Dinah Miller, MD

 

As medicine struggles with rising rates of physician burnout, dissatisfaction, depression, and suicide, one solution comes in the form of Physician Health Programs, or PHPs. These organizations were originally started by volunteer physicians, often doctors in recovery, and funded by medical societies, as a way of providing help while maintaining confidentiality. Now, they are run by independent corporations, by medical societies in some states, and sometimes by hospitals or health systems. The services they offer vary by PHP, and they may have relationships with state licensing boards. While they can provide a gateway to help for a troubled doctor, there has also been concern about the services that are being provided.

ThinkStock

Physicians find their way to PHPs in a number of ways. A doctor whose behavior suggests impairment can be referred to the PHP by his employer, or by a licensing board, following a complaint. In these instances, participation often is a condition of employment or of continued licensure, and the PHP serves as an agent of the hospital or the state. Doctors may also be referred to PHPs for monitoring if they ascribed to having a diagnosis of psychiatric illness or substance abuse, either now or in the past, and are with or without obvious impairment. Finally, PHPs serve as a portal to treatment for physicians who self-identify and self-refer in an effort to get help. Their use is encouraged in an effort to prevent bad outcomes from mental health conditions, stress, and substance abuse, in those who are suffering in ways that would not otherwise call attention to their plights. In these situations, the PHP may serve as the agent of the patient or client, but there may remain dual-agency issues if the physician says something that leads the PHP to be concerned about the doctor’s fitness. Compliance with PHP recommendations, including drug screening, might be mandated, and physicians may resent these requirements.

Louise Andrew, MD, JD, served as the liaison from the American College of Emergency Physicians (ACEP) to the the Federation of State Medical Boards from 2006 to 2014. In an online forum called Collective Wisdom, Andrew talked about the benefits of Physician Health Programs as entities that are helpful to stuggling doctors and urged her colleagues to use them as a safe alternative to suffering in silence.

More recently, Dr. Andrew has become concerned that PHPs may have taken on the role of what is more akin to “diagnosing for dollars.” In her May, 2016 column in Emergency Physician’s Monthly, Andrew noted, “A decade later, and my convictions have changed dramatically. Horror stories that colleagues related to me while I chaired ACEP’s Personal and Professional WellBeing Committee cannot all be isolated events. For example, physicians who self-referred to the PHP for management of stress and depression were reportedly railroaded into incredibly expensive and inconvenient out-of-state drug and alcohol treatment programs, even when there was no coexisting drug or alcohol problem.”

Dr. Andrew is not the only one voicing concerns about PHPs. In “Physician Health Programs: More harm than good?” (Medscape, Aug. 19, 2015), Pauline Anderson wrote about a several problems that have surfaced. In North Carolina, the state audited the PHPs after complaints that they were mandating physicians to lengthy and expensive inpatient programs. The complaints asserted that the physicians had no recourse and were not able to see their records. “The state auditor’s report found no abuse by North Carolina’s PHP. However, there was a caveat – the report determined that abuse could occur and potentially go undetected.

“It also found that the North Carolina PHP created the appearance of conflicts of interest by allowing the centers to provide both patient evaluation and treatments and that procedures did not ensure that physicians receive quality evaluations and treatment because the PHP had no documented criteria for selecting treatment centers and did not adequately monitor them.”

Finally, in a Florida Fox4News story, “Are FL doctors and nurses being sent to rehab unnecessarily? Accusations: Overdiagnosing; overcharging” (Nov. 16, 2017), reporters Katie Lagrone and Matthew Apthorp wrote about financial incentives for evaluators to refer doctors to inpatient substance abuse facilities.

“Medical professionals who enter the programs must pay for all treatment out-of-pocket, which could add up to thousands of dollars each year. There are also no standards on how much treatment can cost.”

The American Psychiatric Association has made it a priority to address physician burnout and mental health. Richard F. Summers, MD, APA Trustee-at-Large noted: “State PHPs are an essential resource for physicians, but there is a tremendous diversity in quality and approach. It is critical that these programs include attention to mental health problems as well as addiction, and that they support individual physicians’ treatment and journey toward well-being. They need to be accessible, private, and high quality, and they should be staffed by excellent psychiatrists and other mental health professionals.”

PHPs provide a much-needed and wanted service. But if the goal is to provide mental health and substance abuse services to physicians who are struggling – to prevent physicians from burning out, leaving medicine, and dying of suicide – then any whiff of corruption and any fear of professional repercussions become a reason not to use these services. If they are to be helpful, physicians must feel safe using them.
 

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).

 

As medicine struggles with rising rates of physician burnout, dissatisfaction, depression, and suicide, one solution comes in the form of Physician Health Programs, or PHPs. These organizations were originally started by volunteer physicians, often doctors in recovery, and funded by medical societies, as a way of providing help while maintaining confidentiality. Now, they are run by independent corporations, by medical societies in some states, and sometimes by hospitals or health systems. The services they offer vary by PHP, and they may have relationships with state licensing boards. While they can provide a gateway to help for a troubled doctor, there has also been concern about the services that are being provided.

ThinkStock

Physicians find their way to PHPs in a number of ways. A doctor whose behavior suggests impairment can be referred to the PHP by his employer, or by a licensing board, following a complaint. In these instances, participation often is a condition of employment or of continued licensure, and the PHP serves as an agent of the hospital or the state. Doctors may also be referred to PHPs for monitoring if they ascribed to having a diagnosis of psychiatric illness or substance abuse, either now or in the past, and are with or without obvious impairment. Finally, PHPs serve as a portal to treatment for physicians who self-identify and self-refer in an effort to get help. Their use is encouraged in an effort to prevent bad outcomes from mental health conditions, stress, and substance abuse, in those who are suffering in ways that would not otherwise call attention to their plights. In these situations, the PHP may serve as the agent of the patient or client, but there may remain dual-agency issues if the physician says something that leads the PHP to be concerned about the doctor’s fitness. Compliance with PHP recommendations, including drug screening, might be mandated, and physicians may resent these requirements.

Louise Andrew, MD, JD, served as the liaison from the American College of Emergency Physicians (ACEP) to the the Federation of State Medical Boards from 2006 to 2014. In an online forum called Collective Wisdom, Andrew talked about the benefits of Physician Health Programs as entities that are helpful to stuggling doctors and urged her colleagues to use them as a safe alternative to suffering in silence.

More recently, Dr. Andrew has become concerned that PHPs may have taken on the role of what is more akin to “diagnosing for dollars.” In her May, 2016 column in Emergency Physician’s Monthly, Andrew noted, “A decade later, and my convictions have changed dramatically. Horror stories that colleagues related to me while I chaired ACEP’s Personal and Professional WellBeing Committee cannot all be isolated events. For example, physicians who self-referred to the PHP for management of stress and depression were reportedly railroaded into incredibly expensive and inconvenient out-of-state drug and alcohol treatment programs, even when there was no coexisting drug or alcohol problem.”

Dr. Andrew is not the only one voicing concerns about PHPs. In “Physician Health Programs: More harm than good?” (Medscape, Aug. 19, 2015), Pauline Anderson wrote about a several problems that have surfaced. In North Carolina, the state audited the PHPs after complaints that they were mandating physicians to lengthy and expensive inpatient programs. The complaints asserted that the physicians had no recourse and were not able to see their records. “The state auditor’s report found no abuse by North Carolina’s PHP. However, there was a caveat – the report determined that abuse could occur and potentially go undetected.

“It also found that the North Carolina PHP created the appearance of conflicts of interest by allowing the centers to provide both patient evaluation and treatments and that procedures did not ensure that physicians receive quality evaluations and treatment because the PHP had no documented criteria for selecting treatment centers and did not adequately monitor them.”

Finally, in a Florida Fox4News story, “Are FL doctors and nurses being sent to rehab unnecessarily? Accusations: Overdiagnosing; overcharging” (Nov. 16, 2017), reporters Katie Lagrone and Matthew Apthorp wrote about financial incentives for evaluators to refer doctors to inpatient substance abuse facilities.

“Medical professionals who enter the programs must pay for all treatment out-of-pocket, which could add up to thousands of dollars each year. There are also no standards on how much treatment can cost.”

The American Psychiatric Association has made it a priority to address physician burnout and mental health. Richard F. Summers, MD, APA Trustee-at-Large noted: “State PHPs are an essential resource for physicians, but there is a tremendous diversity in quality and approach. It is critical that these programs include attention to mental health problems as well as addiction, and that they support individual physicians’ treatment and journey toward well-being. They need to be accessible, private, and high quality, and they should be staffed by excellent psychiatrists and other mental health professionals.”

PHPs provide a much-needed and wanted service. But if the goal is to provide mental health and substance abuse services to physicians who are struggling – to prevent physicians from burning out, leaving medicine, and dying of suicide – then any whiff of corruption and any fear of professional repercussions become a reason not to use these services. If they are to be helpful, physicians must feel safe using them.
 

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).

 

As medicine struggles with rising rates of physician burnout, dissatisfaction, depression, and suicide, one solution comes in the form of Physician Health Programs, or PHPs. These organizations were originally started by volunteer physicians, often doctors in recovery, and funded by medical societies, as a way of providing help while maintaining confidentiality. Now, they are run by independent corporations, by medical societies in some states, and sometimes by hospitals or health systems. The services they offer vary by PHP, and they may have relationships with state licensing boards. While they can provide a gateway to help for a troubled doctor, there has also been concern about the services that are being provided.

ThinkStock

Physicians find their way to PHPs in a number of ways. A doctor whose behavior suggests impairment can be referred to the PHP by his employer, or by a licensing board, following a complaint. In these instances, participation often is a condition of employment or of continued licensure, and the PHP serves as an agent of the hospital or the state. Doctors may also be referred to PHPs for monitoring if they ascribed to having a diagnosis of psychiatric illness or substance abuse, either now or in the past, and are with or without obvious impairment. Finally, PHPs serve as a portal to treatment for physicians who self-identify and self-refer in an effort to get help. Their use is encouraged in an effort to prevent bad outcomes from mental health conditions, stress, and substance abuse, in those who are suffering in ways that would not otherwise call attention to their plights. In these situations, the PHP may serve as the agent of the patient or client, but there may remain dual-agency issues if the physician says something that leads the PHP to be concerned about the doctor’s fitness. Compliance with PHP recommendations, including drug screening, might be mandated, and physicians may resent these requirements.

Louise Andrew, MD, JD, served as the liaison from the American College of Emergency Physicians (ACEP) to the the Federation of State Medical Boards from 2006 to 2014. In an online forum called Collective Wisdom, Andrew talked about the benefits of Physician Health Programs as entities that are helpful to stuggling doctors and urged her colleagues to use them as a safe alternative to suffering in silence.

More recently, Dr. Andrew has become concerned that PHPs may have taken on the role of what is more akin to “diagnosing for dollars.” In her May, 2016 column in Emergency Physician’s Monthly, Andrew noted, “A decade later, and my convictions have changed dramatically. Horror stories that colleagues related to me while I chaired ACEP’s Personal and Professional WellBeing Committee cannot all be isolated events. For example, physicians who self-referred to the PHP for management of stress and depression were reportedly railroaded into incredibly expensive and inconvenient out-of-state drug and alcohol treatment programs, even when there was no coexisting drug or alcohol problem.”

Dr. Andrew is not the only one voicing concerns about PHPs. In “Physician Health Programs: More harm than good?” (Medscape, Aug. 19, 2015), Pauline Anderson wrote about a several problems that have surfaced. In North Carolina, the state audited the PHPs after complaints that they were mandating physicians to lengthy and expensive inpatient programs. The complaints asserted that the physicians had no recourse and were not able to see their records. “The state auditor’s report found no abuse by North Carolina’s PHP. However, there was a caveat – the report determined that abuse could occur and potentially go undetected.

“It also found that the North Carolina PHP created the appearance of conflicts of interest by allowing the centers to provide both patient evaluation and treatments and that procedures did not ensure that physicians receive quality evaluations and treatment because the PHP had no documented criteria for selecting treatment centers and did not adequately monitor them.”

Finally, in a Florida Fox4News story, “Are FL doctors and nurses being sent to rehab unnecessarily? Accusations: Overdiagnosing; overcharging” (Nov. 16, 2017), reporters Katie Lagrone and Matthew Apthorp wrote about financial incentives for evaluators to refer doctors to inpatient substance abuse facilities.

“Medical professionals who enter the programs must pay for all treatment out-of-pocket, which could add up to thousands of dollars each year. There are also no standards on how much treatment can cost.”

The American Psychiatric Association has made it a priority to address physician burnout and mental health. Richard F. Summers, MD, APA Trustee-at-Large noted: “State PHPs are an essential resource for physicians, but there is a tremendous diversity in quality and approach. It is critical that these programs include attention to mental health problems as well as addiction, and that they support individual physicians’ treatment and journey toward well-being. They need to be accessible, private, and high quality, and they should be staffed by excellent psychiatrists and other mental health professionals.”

PHPs provide a much-needed and wanted service. But if the goal is to provide mental health and substance abuse services to physicians who are struggling – to prevent physicians from burning out, leaving medicine, and dying of suicide – then any whiff of corruption and any fear of professional repercussions become a reason not to use these services. If they are to be helpful, physicians must feel safe using them.
 

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).

 

I can still hear my mother saying these words: “Sticks and stones will break your bones but names will never hurt you.” It was a call for resilience, in a world that wasn’t always kind, but where the expectation was clear: I was to let insults roll off me.

We live in a different world now, one in which there are divisions between the good and the bad, where children have the right not to be called names by bullies. Our college students want safe spaces where they won’t hear offensive ideologies and trigger warnings if they are to be exposed to anything that may rekindle a past trauma.

I wish I could find a clear line as to where “good” ends and “bad” starts, but our world has become quite confusing. We elected a man to be our president only days after the release of tapes in which he talked in graphic terms about molesting women, yet earlier this month, NFL quarterback Cam Newton lost his endorsement with a national yogurt company because, during an interview with a female sports reporter, he said,” It’s funny to hear a female talk about ‘routes.’ ” I confess that I am no football expert, so perhaps I’ve just completely missed the egregious nature of this comment, but it does seem that the player was talking about his own feeling that something felt odd, and the response – by the reporter, by the media, and by the yogurt company – it is that it’s not okay to verbalize if one has these feelings about words said by a female reporter.

If you’ve been following social media, then you might be familiar with the #MeToo topic that traveled after the public was made aware of the despicable, sexually aggressive behavior of acclaimed film executive Harvey Weinstein. Actress Alyssa Milano put out a call on social media: “Suggested by a friend: If all the women who have been sexually harassed or assaulted wrote ‘Me too’ as a status, we might give people a sense of the magnitude of the problem.” Others have noted that in medicine, it might well be that 100% of women have been harassed. The hashtag took off, and millions of people wrote #MeToo on their social media sites, including four female U.S. senators who told their stories.

On my personal Facebook page, I voiced a concern about the #MeToo tag. I noted that there were times when men had said some inappropriate things to me and I’d felt uncomfortable. I went on to write, “I don’t feel I was changed, harmed, or victimized by these uncomfortable advances, and I worry that by turning everyone into a victim of sexual harassment, then we detract from the stories of the women who were raped, molested, and those who were the victims of men who were maliciously taking advantage of a power differential. I don’t think we should dilute the message.” One friend (a woman) responded that if I felt uncomfortable, then I was harassed. Another friend (a man) responded that if I did not feel harmed, then I was not harassed.

With no clear definition, this does lead to the question of whether we might be turning everyone into victims and if that is good for our collective psyches. What we don’t seem to say is that if everyone is a victim of something – if not sexual assault or harassment, then something else – then doesn’t that also make everyone a perpetrator? Cam Newton, for instance, has been an advocate of kneeling to oppose institutional racism and, in terms of his own victimization, I would add that he also is the victim of a sport that now knowingly inflicts permanent and disabling brain damage on healthy young men. And now he is not just a victim, he is also a sexist perpetrator, unworthy of endorsing something as wholesome as yogurt.

Other concerns about the #MeToo campaign have also been expressed on social media. Might those who have been victimized feel pressured to publicly announce their victimization? Might the campaign trigger women to recall troubling events that were safely suppressed? While I would not personally use the terms “victimized,” “triggered,” or “harassed,” to describe myself, I would say that the campaign, like many things I see on social media, left me to think about events I had not considered in many years. That’s not necessarily bad: I like revisiting old memories, but others certainly may not. It does leave us to ask how we can live in a society where we can’t openly address our horrors for fear that the victims might be forced to relive them.

And what do we do about these issues with our patients? As a psychotherapist, I don’t live in a comfortable world. Patients often do and say things that make me personally uneasy, and I never considered the idea that I might be entitled to live without such discomfort. The mandate of psychotherapy for the patient is to talk openly about that which is on his or her mind and for the therapist to provide a safe space for thoughts that might be unacceptable in other settings. Patients talk of behaviors that make me worry for their safety. Some talk of sexual fantasies that are demeaning to others. Others are openly sexist, racist, anti-Semitic, or supportive of political ideologies that I strongly oppose. This can be hard work.

Was my mother right? Or was she dismissive? It was good that I always felt she was in my corner cheering me on. Obviously, it’s not just a saying, but a mindset that gets transmitted, sometimes successfully breeding resilience, and sometimes not. Certainly, I have seen that patients feel helped when I have validated their victimization. I have also seen people reassess their values when I have pointed out alternative ways about thinking about situations. I have not found it particularly helpful to tell people that their wounds are not so bad and others have it worse. While I don’t tell patients that sticks and stones will break their bones and names will never hurt them, I do sometimes gently tell them that I wish I could have them dipped in tin so that they would have stronger armor and so that the insensitive words of others might roll off without injuring them so. And as with all communications in our chaotic world, it’s often not the exact words that matter, but rather the context, the tone, and the intention with which they are said.

Sometimes, there really are clear victims and clear perpetrators, but in our world today, one can be both and the sides can be blurry. We are all trying to negotiate a society where words, spoken or unspoken, well-considered or not, have become weapons. Who gets to be comfortable and protected, we might ask, and who does not? Perhaps, in the end, we are left with the possibility that there are no safe spaces.


With thanks to Dr. Emile Bendit for considering the #MeToo hashtag with me.
 

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The battle over involuntary psychiatric care” (Baltimore: Johns Hopkins University Press, 2016).

 

I can still hear my mother saying these words: “Sticks and stones will break your bones but names will never hurt you.” It was a call for resilience, in a world that wasn’t always kind, but where the expectation was clear: I was to let insults roll off me.

We live in a different world now, one in which there are divisions between the good and the bad, where children have the right not to be called names by bullies. Our college students want safe spaces where they won’t hear offensive ideologies and trigger warnings if they are to be exposed to anything that may rekindle a past trauma.

I wish I could find a clear line as to where “good” ends and “bad” starts, but our world has become quite confusing. We elected a man to be our president only days after the release of tapes in which he talked in graphic terms about molesting women, yet earlier this month, NFL quarterback Cam Newton lost his endorsement with a national yogurt company because, during an interview with a female sports reporter, he said,” It’s funny to hear a female talk about ‘routes.’ ” I confess that I am no football expert, so perhaps I’ve just completely missed the egregious nature of this comment, but it does seem that the player was talking about his own feeling that something felt odd, and the response – by the reporter, by the media, and by the yogurt company – it is that it’s not okay to verbalize if one has these feelings about words said by a female reporter.

If you’ve been following social media, then you might be familiar with the #MeToo topic that traveled after the public was made aware of the despicable, sexually aggressive behavior of acclaimed film executive Harvey Weinstein. Actress Alyssa Milano put out a call on social media: “Suggested by a friend: If all the women who have been sexually harassed or assaulted wrote ‘Me too’ as a status, we might give people a sense of the magnitude of the problem.” Others have noted that in medicine, it might well be that 100% of women have been harassed. The hashtag took off, and millions of people wrote #MeToo on their social media sites, including four female U.S. senators who told their stories.

On my personal Facebook page, I voiced a concern about the #MeToo tag. I noted that there were times when men had said some inappropriate things to me and I’d felt uncomfortable. I went on to write, “I don’t feel I was changed, harmed, or victimized by these uncomfortable advances, and I worry that by turning everyone into a victim of sexual harassment, then we detract from the stories of the women who were raped, molested, and those who were the victims of men who were maliciously taking advantage of a power differential. I don’t think we should dilute the message.” One friend (a woman) responded that if I felt uncomfortable, then I was harassed. Another friend (a man) responded that if I did not feel harmed, then I was not harassed.

With no clear definition, this does lead to the question of whether we might be turning everyone into victims and if that is good for our collective psyches. What we don’t seem to say is that if everyone is a victim of something – if not sexual assault or harassment, then something else – then doesn’t that also make everyone a perpetrator? Cam Newton, for instance, has been an advocate of kneeling to oppose institutional racism and, in terms of his own victimization, I would add that he also is the victim of a sport that now knowingly inflicts permanent and disabling brain damage on healthy young men. And now he is not just a victim, he is also a sexist perpetrator, unworthy of endorsing something as wholesome as yogurt.

Other concerns about the #MeToo campaign have also been expressed on social media. Might those who have been victimized feel pressured to publicly announce their victimization? Might the campaign trigger women to recall troubling events that were safely suppressed? While I would not personally use the terms “victimized,” “triggered,” or “harassed,” to describe myself, I would say that the campaign, like many things I see on social media, left me to think about events I had not considered in many years. That’s not necessarily bad: I like revisiting old memories, but others certainly may not. It does leave us to ask how we can live in a society where we can’t openly address our horrors for fear that the victims might be forced to relive them.

And what do we do about these issues with our patients? As a psychotherapist, I don’t live in a comfortable world. Patients often do and say things that make me personally uneasy, and I never considered the idea that I might be entitled to live without such discomfort. The mandate of psychotherapy for the patient is to talk openly about that which is on his or her mind and for the therapist to provide a safe space for thoughts that might be unacceptable in other settings. Patients talk of behaviors that make me worry for their safety. Some talk of sexual fantasies that are demeaning to others. Others are openly sexist, racist, anti-Semitic, or supportive of political ideologies that I strongly oppose. This can be hard work.

Was my mother right? Or was she dismissive? It was good that I always felt she was in my corner cheering me on. Obviously, it’s not just a saying, but a mindset that gets transmitted, sometimes successfully breeding resilience, and sometimes not. Certainly, I have seen that patients feel helped when I have validated their victimization. I have also seen people reassess their values when I have pointed out alternative ways about thinking about situations. I have not found it particularly helpful to tell people that their wounds are not so bad and others have it worse. While I don’t tell patients that sticks and stones will break their bones and names will never hurt them, I do sometimes gently tell them that I wish I could have them dipped in tin so that they would have stronger armor and so that the insensitive words of others might roll off without injuring them so. And as with all communications in our chaotic world, it’s often not the exact words that matter, but rather the context, the tone, and the intention with which they are said.

Sometimes, there really are clear victims and clear perpetrators, but in our world today, one can be both and the sides can be blurry. We are all trying to negotiate a society where words, spoken or unspoken, well-considered or not, have become weapons. Who gets to be comfortable and protected, we might ask, and who does not? Perhaps, in the end, we are left with the possibility that there are no safe spaces.


With thanks to Dr. Emile Bendit for considering the #MeToo hashtag with me.
 

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The battle over involuntary psychiatric care” (Baltimore: Johns Hopkins University Press, 2016).

 

I can still hear my mother saying these words: “Sticks and stones will break your bones but names will never hurt you.” It was a call for resilience, in a world that wasn’t always kind, but where the expectation was clear: I was to let insults roll off me.

We live in a different world now, one in which there are divisions between the good and the bad, where children have the right not to be called names by bullies. Our college students want safe spaces where they won’t hear offensive ideologies and trigger warnings if they are to be exposed to anything that may rekindle a past trauma.

I wish I could find a clear line as to where “good” ends and “bad” starts, but our world has become quite confusing. We elected a man to be our president only days after the release of tapes in which he talked in graphic terms about molesting women, yet earlier this month, NFL quarterback Cam Newton lost his endorsement with a national yogurt company because, during an interview with a female sports reporter, he said,” It’s funny to hear a female talk about ‘routes.’ ” I confess that I am no football expert, so perhaps I’ve just completely missed the egregious nature of this comment, but it does seem that the player was talking about his own feeling that something felt odd, and the response – by the reporter, by the media, and by the yogurt company – it is that it’s not okay to verbalize if one has these feelings about words said by a female reporter.

If you’ve been following social media, then you might be familiar with the #MeToo topic that traveled after the public was made aware of the despicable, sexually aggressive behavior of acclaimed film executive Harvey Weinstein. Actress Alyssa Milano put out a call on social media: “Suggested by a friend: If all the women who have been sexually harassed or assaulted wrote ‘Me too’ as a status, we might give people a sense of the magnitude of the problem.” Others have noted that in medicine, it might well be that 100% of women have been harassed. The hashtag took off, and millions of people wrote #MeToo on their social media sites, including four female U.S. senators who told their stories.

On my personal Facebook page, I voiced a concern about the #MeToo tag. I noted that there were times when men had said some inappropriate things to me and I’d felt uncomfortable. I went on to write, “I don’t feel I was changed, harmed, or victimized by these uncomfortable advances, and I worry that by turning everyone into a victim of sexual harassment, then we detract from the stories of the women who were raped, molested, and those who were the victims of men who were maliciously taking advantage of a power differential. I don’t think we should dilute the message.” One friend (a woman) responded that if I felt uncomfortable, then I was harassed. Another friend (a man) responded that if I did not feel harmed, then I was not harassed.

With no clear definition, this does lead to the question of whether we might be turning everyone into victims and if that is good for our collective psyches. What we don’t seem to say is that if everyone is a victim of something – if not sexual assault or harassment, then something else – then doesn’t that also make everyone a perpetrator? Cam Newton, for instance, has been an advocate of kneeling to oppose institutional racism and, in terms of his own victimization, I would add that he also is the victim of a sport that now knowingly inflicts permanent and disabling brain damage on healthy young men. And now he is not just a victim, he is also a sexist perpetrator, unworthy of endorsing something as wholesome as yogurt.

Other concerns about the #MeToo campaign have also been expressed on social media. Might those who have been victimized feel pressured to publicly announce their victimization? Might the campaign trigger women to recall troubling events that were safely suppressed? While I would not personally use the terms “victimized,” “triggered,” or “harassed,” to describe myself, I would say that the campaign, like many things I see on social media, left me to think about events I had not considered in many years. That’s not necessarily bad: I like revisiting old memories, but others certainly may not. It does leave us to ask how we can live in a society where we can’t openly address our horrors for fear that the victims might be forced to relive them.

And what do we do about these issues with our patients? As a psychotherapist, I don’t live in a comfortable world. Patients often do and say things that make me personally uneasy, and I never considered the idea that I might be entitled to live without such discomfort. The mandate of psychotherapy for the patient is to talk openly about that which is on his or her mind and for the therapist to provide a safe space for thoughts that might be unacceptable in other settings. Patients talk of behaviors that make me worry for their safety. Some talk of sexual fantasies that are demeaning to others. Others are openly sexist, racist, anti-Semitic, or supportive of political ideologies that I strongly oppose. This can be hard work.

Was my mother right? Or was she dismissive? It was good that I always felt she was in my corner cheering me on. Obviously, it’s not just a saying, but a mindset that gets transmitted, sometimes successfully breeding resilience, and sometimes not. Certainly, I have seen that patients feel helped when I have validated their victimization. I have also seen people reassess their values when I have pointed out alternative ways about thinking about situations. I have not found it particularly helpful to tell people that their wounds are not so bad and others have it worse. While I don’t tell patients that sticks and stones will break their bones and names will never hurt them, I do sometimes gently tell them that I wish I could have them dipped in tin so that they would have stronger armor and so that the insensitive words of others might roll off without injuring them so. And as with all communications in our chaotic world, it’s often not the exact words that matter, but rather the context, the tone, and the intention with which they are said.

Sometimes, there really are clear victims and clear perpetrators, but in our world today, one can be both and the sides can be blurry. We are all trying to negotiate a society where words, spoken or unspoken, well-considered or not, have become weapons. Who gets to be comfortable and protected, we might ask, and who does not? Perhaps, in the end, we are left with the possibility that there are no safe spaces.


With thanks to Dr. Emile Bendit for considering the #MeToo hashtag with me.
 

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The battle over involuntary psychiatric care” (Baltimore: Johns Hopkins University Press, 2016).

 

It’s National Suicide Prevention Week (Sept. 10-16, 2017) and few psychiatrists would disagree that suicide is a bad outcome, that it is often preventable, and that the loss and pain that follow an untimely act are nothing short of tragic.

It’s also an epidemic on the rise, with more than 40,000 deaths a year, half of those by self-inflicted gunshot. Because 90% of those who suicide suffer from mental illness, one target becomes clear: We need to identify those at risk and make it easy for them to get help. Still, treatment is not a clear panacea; in the decades since selective serotonin reuptake inhibitors have become so readily available, suicide rates have risen, and many who die have gotten help of some type. The issue is a complicated one that reaches well beyond the arena of mental health.

Still, the suicide of a patient, friend, or family member is shattering, and psychiatrists hope to see this trend reverse. While to many of us, it’s an all-bad thing, society at large has become a bit more ambivalent, if not conflicted, as to how suicide is considered.

Paul Nestadt, MD, a postdoctoral fellow in the Johns Hopkins Psychiatric Epidemiology Training Program, is a researcher on a study that correlated rural suicide rates with the availability of firearms (Am J Public Health. 2017 Oct;107[10]:1548-53). “Suicide can happen when ambivalent suicidal thoughts dip over the threshold into behavior. In those key moments, the lethality of the nearest available method may determine whether someone dies, as illustrated in the United States by the predominance of firearms in the use of completed suicides.” Yet it is not unusual for those who are against gun control to note that most firearm deaths are suicides, and therefore unlikely to be changed with gun regulation; they believe that individuals who want to die will find another way, despite research that indicates otherwise. At moments, it feels like they are saying these deaths don’t count; people who have impulses to harm themselves will do so, and gun control is not an answer. Others, like Nestadt, contend otherwise, and say that limiting access to lethal means will make a difference.

Let’s also consider the words we use. While the familiar term is to “commit suicide,” the current thinking is that this is stigmatizing – people “commit” crimes – and family members of survivors often prefer the phrase “died of suicide.” Is the change necessary? It is true that people commit crimes, but they also commit to relationships, and to any number of positive activities. I had not previously associated the word with criminal behavior, and the now-favored term changes suicide from an active event to a passive one. If changing the words helps lessen the pain of the survivors, then I am all in favor, but the loss and shame remain regardless of the phrasing.

Stigma may be a mixed thing when it comes to ending one’s life. We would all like to see suicidal thoughts and intentions destigmatized so that those who suffer won’t hesitate to get help. It’s not clear, however, whether stigmatizing the completed suicide might serve as a deterrent to the behavior for some. When patients talk of wanting to die and are considering a method, they often add that they could not do this to their families. If suicide is just another nonstigmatized way to die and end an individual’s suffering, perhaps even more people would choose this option? And the question moves to media portrayals where suicide is not only not stigmatized, it is sometimes glamorized, and the deceased becomes the focus of positive attention, especially for young people, and inspires copycat deaths.

Anita Everett, MD, the chief medical officer of the Substance Abuse and Mental Health Services Administration and president of the American Psychiatric Association, notes, “Suicide is a significant problem of national concern that every part of the health care system can play a part in addressing.” Yet in our societal ambivalence, the topic of physician-assisted suicide has become a subject of much contention in our state legislatures. Six states and the District of Columbia allow for “physician-assisted suicide” – also called “aid in dying” or “death with dignity” – terms that distance the association with either suicide or euthanasia. It is available for people with terminal illnesses and a projected life expectancy of less than 6 months. In this scenario, a physician prescribes a lethal dose of medication at the patient’s request, and the patient then obtains the medication and self-administers it. The death is not reported as suicide, but rather as a consequence of the underlying disease, thereby eliminating any concerns with stigma for the family survivors. While this is not obviously an issue for psychiatry, members of our profession have been outspoken about it, and in one state, the issue came to such a head that two district branches of the American Psychiatric Association with differing views could no longer continue to employ a single lobbyist.

Ambivalence is not limited to the United States. Belgium and the Netherlands have extended physician-assisted suicide to include patients with psychiatric illnesses deemed to be intractable. In these countries, the patient may choose to have a psychiatrist administer a lethal injection.

Mark Komrad, MD, is the ethicist-in-residence at Sheppard Pratt Health Systems. Earlier this month, he visited Belgium to speak on the topic. Komrad noted: “The Belgian professionals were quite aware that the majority of the world disagrees with the euthanasia of psychiatric patients. It seemed almost a point of honor that they differed in this way, as if they are on higher moral ground in a bold new era of medical ethics.” It strikes me as tragically ironic that, as we struggle to prevent the blight of suicide, we have colleagues in Europe who are ushering it along and stretching the practice of euthanasia to what many of us might classify more simply as the murder of physically healthy patients who may not have exhausted every possible psychiatric treatment, or who may spontaneously recover in the future.

Finally, I wanted to touch on a rather unusual case of two teenagers in Massachusetts. Michelle Carter was 17 years old when her boyfriend died of suicide from carbon monoxide poisoning. Sometime after the young man’s death, it was discovered that Carter, a troubled young woman with her own psychiatric illnesses, had known of his suicide plans. By text and phone call, she encouraged him to go through with it, although she was never physically present at the scene of his death. The boyfriend had been suicidal prior to meeting Carter and had spoken to her about his wishes to die. The defense contended, unsuccessfully, that the young woman was propelled to such evil because she was taking antidepressants. Carter was convicted of involuntary manslaughter in a juvenile court and sentenced to 15 months in jail for her reckless conduct that was deemed to have caused the young man’s suicide. The case was obviously quite complicated, but I found it to be one more example of our society’s ambivalence about suicide, in that a teenager would be held responsible and incarcerated for inciting another person to die with her words alone.

As suicide rates rise, we are still finding our way here. We don’t know what propels it, and we don’t know how to cure it. We vacillate between trying not to stigmatize suicide and trying not to glamorize it. And we struggle with whether it is the role of the physician to prolong life and continue to proffer hope or to end life when suffering is deemed by the individual to be unbearable.
 

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).

 

It’s National Suicide Prevention Week (Sept. 10-16, 2017) and few psychiatrists would disagree that suicide is a bad outcome, that it is often preventable, and that the loss and pain that follow an untimely act are nothing short of tragic.

It’s also an epidemic on the rise, with more than 40,000 deaths a year, half of those by self-inflicted gunshot. Because 90% of those who suicide suffer from mental illness, one target becomes clear: We need to identify those at risk and make it easy for them to get help. Still, treatment is not a clear panacea; in the decades since selective serotonin reuptake inhibitors have become so readily available, suicide rates have risen, and many who die have gotten help of some type. The issue is a complicated one that reaches well beyond the arena of mental health.

Still, the suicide of a patient, friend, or family member is shattering, and psychiatrists hope to see this trend reverse. While to many of us, it’s an all-bad thing, society at large has become a bit more ambivalent, if not conflicted, as to how suicide is considered.

Paul Nestadt, MD, a postdoctoral fellow in the Johns Hopkins Psychiatric Epidemiology Training Program, is a researcher on a study that correlated rural suicide rates with the availability of firearms (Am J Public Health. 2017 Oct;107[10]:1548-53). “Suicide can happen when ambivalent suicidal thoughts dip over the threshold into behavior. In those key moments, the lethality of the nearest available method may determine whether someone dies, as illustrated in the United States by the predominance of firearms in the use of completed suicides.” Yet it is not unusual for those who are against gun control to note that most firearm deaths are suicides, and therefore unlikely to be changed with gun regulation; they believe that individuals who want to die will find another way, despite research that indicates otherwise. At moments, it feels like they are saying these deaths don’t count; people who have impulses to harm themselves will do so, and gun control is not an answer. Others, like Nestadt, contend otherwise, and say that limiting access to lethal means will make a difference.

Let’s also consider the words we use. While the familiar term is to “commit suicide,” the current thinking is that this is stigmatizing – people “commit” crimes – and family members of survivors often prefer the phrase “died of suicide.” Is the change necessary? It is true that people commit crimes, but they also commit to relationships, and to any number of positive activities. I had not previously associated the word with criminal behavior, and the now-favored term changes suicide from an active event to a passive one. If changing the words helps lessen the pain of the survivors, then I am all in favor, but the loss and shame remain regardless of the phrasing.

Stigma may be a mixed thing when it comes to ending one’s life. We would all like to see suicidal thoughts and intentions destigmatized so that those who suffer won’t hesitate to get help. It’s not clear, however, whether stigmatizing the completed suicide might serve as a deterrent to the behavior for some. When patients talk of wanting to die and are considering a method, they often add that they could not do this to their families. If suicide is just another nonstigmatized way to die and end an individual’s suffering, perhaps even more people would choose this option? And the question moves to media portrayals where suicide is not only not stigmatized, it is sometimes glamorized, and the deceased becomes the focus of positive attention, especially for young people, and inspires copycat deaths.

Anita Everett, MD, the chief medical officer of the Substance Abuse and Mental Health Services Administration and president of the American Psychiatric Association, notes, “Suicide is a significant problem of national concern that every part of the health care system can play a part in addressing.” Yet in our societal ambivalence, the topic of physician-assisted suicide has become a subject of much contention in our state legislatures. Six states and the District of Columbia allow for “physician-assisted suicide” – also called “aid in dying” or “death with dignity” – terms that distance the association with either suicide or euthanasia. It is available for people with terminal illnesses and a projected life expectancy of less than 6 months. In this scenario, a physician prescribes a lethal dose of medication at the patient’s request, and the patient then obtains the medication and self-administers it. The death is not reported as suicide, but rather as a consequence of the underlying disease, thereby eliminating any concerns with stigma for the family survivors. While this is not obviously an issue for psychiatry, members of our profession have been outspoken about it, and in one state, the issue came to such a head that two district branches of the American Psychiatric Association with differing views could no longer continue to employ a single lobbyist.

Ambivalence is not limited to the United States. Belgium and the Netherlands have extended physician-assisted suicide to include patients with psychiatric illnesses deemed to be intractable. In these countries, the patient may choose to have a psychiatrist administer a lethal injection.

Mark Komrad, MD, is the ethicist-in-residence at Sheppard Pratt Health Systems. Earlier this month, he visited Belgium to speak on the topic. Komrad noted: “The Belgian professionals were quite aware that the majority of the world disagrees with the euthanasia of psychiatric patients. It seemed almost a point of honor that they differed in this way, as if they are on higher moral ground in a bold new era of medical ethics.” It strikes me as tragically ironic that, as we struggle to prevent the blight of suicide, we have colleagues in Europe who are ushering it along and stretching the practice of euthanasia to what many of us might classify more simply as the murder of physically healthy patients who may not have exhausted every possible psychiatric treatment, or who may spontaneously recover in the future.

Finally, I wanted to touch on a rather unusual case of two teenagers in Massachusetts. Michelle Carter was 17 years old when her boyfriend died of suicide from carbon monoxide poisoning. Sometime after the young man’s death, it was discovered that Carter, a troubled young woman with her own psychiatric illnesses, had known of his suicide plans. By text and phone call, she encouraged him to go through with it, although she was never physically present at the scene of his death. The boyfriend had been suicidal prior to meeting Carter and had spoken to her about his wishes to die. The defense contended, unsuccessfully, that the young woman was propelled to such evil because she was taking antidepressants. Carter was convicted of involuntary manslaughter in a juvenile court and sentenced to 15 months in jail for her reckless conduct that was deemed to have caused the young man’s suicide. The case was obviously quite complicated, but I found it to be one more example of our society’s ambivalence about suicide, in that a teenager would be held responsible and incarcerated for inciting another person to die with her words alone.

As suicide rates rise, we are still finding our way here. We don’t know what propels it, and we don’t know how to cure it. We vacillate between trying not to stigmatize suicide and trying not to glamorize it. And we struggle with whether it is the role of the physician to prolong life and continue to proffer hope or to end life when suffering is deemed by the individual to be unbearable.
 

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).

 

It’s National Suicide Prevention Week (Sept. 10-16, 2017) and few psychiatrists would disagree that suicide is a bad outcome, that it is often preventable, and that the loss and pain that follow an untimely act are nothing short of tragic.

It’s also an epidemic on the rise, with more than 40,000 deaths a year, half of those by self-inflicted gunshot. Because 90% of those who suicide suffer from mental illness, one target becomes clear: We need to identify those at risk and make it easy for them to get help. Still, treatment is not a clear panacea; in the decades since selective serotonin reuptake inhibitors have become so readily available, suicide rates have risen, and many who die have gotten help of some type. The issue is a complicated one that reaches well beyond the arena of mental health.

Still, the suicide of a patient, friend, or family member is shattering, and psychiatrists hope to see this trend reverse. While to many of us, it’s an all-bad thing, society at large has become a bit more ambivalent, if not conflicted, as to how suicide is considered.

Paul Nestadt, MD, a postdoctoral fellow in the Johns Hopkins Psychiatric Epidemiology Training Program, is a researcher on a study that correlated rural suicide rates with the availability of firearms (Am J Public Health. 2017 Oct;107[10]:1548-53). “Suicide can happen when ambivalent suicidal thoughts dip over the threshold into behavior. In those key moments, the lethality of the nearest available method may determine whether someone dies, as illustrated in the United States by the predominance of firearms in the use of completed suicides.” Yet it is not unusual for those who are against gun control to note that most firearm deaths are suicides, and therefore unlikely to be changed with gun regulation; they believe that individuals who want to die will find another way, despite research that indicates otherwise. At moments, it feels like they are saying these deaths don’t count; people who have impulses to harm themselves will do so, and gun control is not an answer. Others, like Nestadt, contend otherwise, and say that limiting access to lethal means will make a difference.

Let’s also consider the words we use. While the familiar term is to “commit suicide,” the current thinking is that this is stigmatizing – people “commit” crimes – and family members of survivors often prefer the phrase “died of suicide.” Is the change necessary? It is true that people commit crimes, but they also commit to relationships, and to any number of positive activities. I had not previously associated the word with criminal behavior, and the now-favored term changes suicide from an active event to a passive one. If changing the words helps lessen the pain of the survivors, then I am all in favor, but the loss and shame remain regardless of the phrasing.

Stigma may be a mixed thing when it comes to ending one’s life. We would all like to see suicidal thoughts and intentions destigmatized so that those who suffer won’t hesitate to get help. It’s not clear, however, whether stigmatizing the completed suicide might serve as a deterrent to the behavior for some. When patients talk of wanting to die and are considering a method, they often add that they could not do this to their families. If suicide is just another nonstigmatized way to die and end an individual’s suffering, perhaps even more people would choose this option? And the question moves to media portrayals where suicide is not only not stigmatized, it is sometimes glamorized, and the deceased becomes the focus of positive attention, especially for young people, and inspires copycat deaths.

Anita Everett, MD, the chief medical officer of the Substance Abuse and Mental Health Services Administration and president of the American Psychiatric Association, notes, “Suicide is a significant problem of national concern that every part of the health care system can play a part in addressing.” Yet in our societal ambivalence, the topic of physician-assisted suicide has become a subject of much contention in our state legislatures. Six states and the District of Columbia allow for “physician-assisted suicide” – also called “aid in dying” or “death with dignity” – terms that distance the association with either suicide or euthanasia. It is available for people with terminal illnesses and a projected life expectancy of less than 6 months. In this scenario, a physician prescribes a lethal dose of medication at the patient’s request, and the patient then obtains the medication and self-administers it. The death is not reported as suicide, but rather as a consequence of the underlying disease, thereby eliminating any concerns with stigma for the family survivors. While this is not obviously an issue for psychiatry, members of our profession have been outspoken about it, and in one state, the issue came to such a head that two district branches of the American Psychiatric Association with differing views could no longer continue to employ a single lobbyist.

Ambivalence is not limited to the United States. Belgium and the Netherlands have extended physician-assisted suicide to include patients with psychiatric illnesses deemed to be intractable. In these countries, the patient may choose to have a psychiatrist administer a lethal injection.

Mark Komrad, MD, is the ethicist-in-residence at Sheppard Pratt Health Systems. Earlier this month, he visited Belgium to speak on the topic. Komrad noted: “The Belgian professionals were quite aware that the majority of the world disagrees with the euthanasia of psychiatric patients. It seemed almost a point of honor that they differed in this way, as if they are on higher moral ground in a bold new era of medical ethics.” It strikes me as tragically ironic that, as we struggle to prevent the blight of suicide, we have colleagues in Europe who are ushering it along and stretching the practice of euthanasia to what many of us might classify more simply as the murder of physically healthy patients who may not have exhausted every possible psychiatric treatment, or who may spontaneously recover in the future.

Finally, I wanted to touch on a rather unusual case of two teenagers in Massachusetts. Michelle Carter was 17 years old when her boyfriend died of suicide from carbon monoxide poisoning. Sometime after the young man’s death, it was discovered that Carter, a troubled young woman with her own psychiatric illnesses, had known of his suicide plans. By text and phone call, she encouraged him to go through with it, although she was never physically present at the scene of his death. The boyfriend had been suicidal prior to meeting Carter and had spoken to her about his wishes to die. The defense contended, unsuccessfully, that the young woman was propelled to such evil because she was taking antidepressants. Carter was convicted of involuntary manslaughter in a juvenile court and sentenced to 15 months in jail for her reckless conduct that was deemed to have caused the young man’s suicide. The case was obviously quite complicated, but I found it to be one more example of our society’s ambivalence about suicide, in that a teenager would be held responsible and incarcerated for inciting another person to die with her words alone.

As suicide rates rise, we are still finding our way here. We don’t know what propels it, and we don’t know how to cure it. We vacillate between trying not to stigmatize suicide and trying not to glamorize it. And we struggle with whether it is the role of the physician to prolong life and continue to proffer hope or to end life when suffering is deemed by the individual to be unbearable.
 

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).

 

Physician burnout is rampant, and every seat was taken at a workshop on physician burnout and depression at this year’s APA annual meeting in San Diego.

In his book, “Why Physicians Die By Suicide” (Amazon, 2017), Michael F. Myers, MD, describes “burnout.”

Darrin Klimek/Thinkstock

“It is a state of emotional exhaustion, depersonalization (a lack of feeling for others), and a diminished sense of personal accomplishment. Put another way, doctors who are burned out complain that they are used up emotionally and have nothing left to give their patients, medical colleagues, and staff. They are running on empty. They have become numb and feel detached from the symptoms and the suffering of their patients.”

Myers notes that there is no stigma to having burnout, as there is to having major depression – a condition that may have remarkably similar symptoms.

What stops physicians from getting help? It’s a complex question – especially in a group that has the means to access medical services – but one factor is that most state licensing boards specifically ask about mental illnesses and substance abuse in intrusive and stigmatizing ways. States vary both with their questions and with their responses to a box checked “yes.”

Katherine Gold, MD, MSW, MS, a family physician at the University of Michigan, Ann Arbor, has studied the topic extensively. Her review of licensing questions from all 50 states revealed that most states ask for information about mental health, and there is tremendous variation as to what is asked (Fam Med. 2017 Jun;49[6]:464-7).

“Some states are very specific and very intrusive,” Gold noted. “They may ask if a physician has a specific diagnosis, a history of treatment or hospitalization. The questions may ask about current impairment, or they may ask about mental health conditions back to age 18 years. There may be very specific questions about diagnosis that are not asked about medical conditions, such as whether the applicant has kleptomania, pyromania, or seasonal affective disorder.”

Gold conducted an online survey of physician-mothers. Nearly half believed they had met criteria for an episode of mental illness at some point during their lives. Of those who did have a diagnosis, only 6% of physicians reported this on licensing forms, though she was quick to say that not all states ask for this information, and some may just ask about current impairment. “The people who are self-disclosing are probably not the physicians we need to be worrying about,” she said.

There is no research that supports the idea that asking physicians about mental illness improves patient safety. Not every state licensing board asks about psychiatric history, but many do ask these questions in a way that violates the Americans with Disabilities Act (Acad Med. 2009;84[6]:776-81). This is not a new issue: In 1993, The State Medical Society of New Jersey filed an injunction against the New Jersey medical board (Medical Society vs. Jacobs et al.) and questions asked on the licensing forms were changed.

Dr. Gold noted that if a physician checks yes to a question about a mental health history, the board response also varies. The doctor can be asked to provide a letter from his physician stating he is fit to work, or can be required to release all of his psychiatric record, or even to appear before the board to justify his fitness to practice.

Chae Kwak, LCSW-C, is the director of the Maryland Physician Health Program for Maryland MedChi. In the fall 2016 Board of Physicians newsletter, Kwak wrote, “An applicant has to affirmatively answer this question only if a current condition affects their ability to practice medicine. Diagnosis and/or treatment of mental health issues such as depression or anxiety is not the same as ‘impairment’ in the practice of medicine.”

Kwak was pleased that the board published his letter. “We want physicians to get the help they need. But this is not just about licensing boards, it’s an issue with hospital credentialing and applications for malpractice insurance as well.”

“We need to advocate on the level of the Federation of State Medical Boards on this subject, and there is a sense of increasing awareness that this is a problem, said Richard Summers, MD, who cochaired the American Psychiatric Association workshop on physician burnout and depression. “The increased salience and awareness of physician burnout, and its relationship to stigma might help this organization and the various state boards become more sympathetic and open to questioning the stigmatizing element of their questions. So, we’ve got to work on this situation both nationally and at the level of the state boards. Hopefully, some successes will stimulate others and will begin to help to change the culture of secrecy and shame.”

Nathaniel Morris, MD, is doing his psychiatry residency at Stanford (Calif.) University. He wrote about this issue in a Washington Post article, “Why doctors are leery about seeking mental health care for themselves” (Jan. 7, 2017). Morris wrote, “When I was a medical student, I suffered an episode of depression and refused to seek treatment for weeks. My fears about licensing applications were a major reason I kept quiet. I didn’t want a mark on my record. I didn’t want to check “yes” on those forms.”

Questions about mental health on licensing board applications were recently addressed by the American Medical Association’s House of Delegates meeting as part of Resolution 301. The AMA concluded with a suggestion that state medical boards inquire about mental health and physical health in a similar way and went on to suggest that boards not request psychotherapy records if the psychotherapy were a requirement of training. This is a profoundly disappointing and inadequate response from the AMA, and my hope is that the APA will move ahead with both words and actions that condemn stigmatizing inquiries.

Questions that differentiate other medical disabilities from psychiatric disabilities need to be stricken from licensing and credentialing forms. Our treatments work, and the cost of not getting care can be catastrophic for both physicians and for their patients. Why ask intrusive and detailed questions about mental illness or substance abuse, and not about diabetes control, seizures, hypotension, atrial fibrillation, or any illness that may cause impairment? It would seem enough to simply ask if the applicant suffers from any condition that impairs ability to function as a physician. Furthermore, it is unreasonable to ask for a full release of psychiatric records following an affirmative statement if detailed records of other illnesses are not required to confirm competency to practice and may prevent psychiatrists from being honest with their therapists. Self-report has limited value on applications, and questions about past sanctions, employment history, and criminal records are more likely to identify physicians who are impaired for any reason.
 

Dr. Miller, who practices in Baltimore, is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016).

 

 

Physician burnout is rampant, and every seat was taken at a workshop on physician burnout and depression at this year’s APA annual meeting in San Diego.

In his book, “Why Physicians Die By Suicide” (Amazon, 2017), Michael F. Myers, MD, describes “burnout.”

Darrin Klimek/Thinkstock

“It is a state of emotional exhaustion, depersonalization (a lack of feeling for others), and a diminished sense of personal accomplishment. Put another way, doctors who are burned out complain that they are used up emotionally and have nothing left to give their patients, medical colleagues, and staff. They are running on empty. They have become numb and feel detached from the symptoms and the suffering of their patients.”

Myers notes that there is no stigma to having burnout, as there is to having major depression – a condition that may have remarkably similar symptoms.

What stops physicians from getting help? It’s a complex question – especially in a group that has the means to access medical services – but one factor is that most state licensing boards specifically ask about mental illnesses and substance abuse in intrusive and stigmatizing ways. States vary both with their questions and with their responses to a box checked “yes.”

Katherine Gold, MD, MSW, MS, a family physician at the University of Michigan, Ann Arbor, has studied the topic extensively. Her review of licensing questions from all 50 states revealed that most states ask for information about mental health, and there is tremendous variation as to what is asked (Fam Med. 2017 Jun;49[6]:464-7).

“Some states are very specific and very intrusive,” Gold noted. “They may ask if a physician has a specific diagnosis, a history of treatment or hospitalization. The questions may ask about current impairment, or they may ask about mental health conditions back to age 18 years. There may be very specific questions about diagnosis that are not asked about medical conditions, such as whether the applicant has kleptomania, pyromania, or seasonal affective disorder.”

Gold conducted an online survey of physician-mothers. Nearly half believed they had met criteria for an episode of mental illness at some point during their lives. Of those who did have a diagnosis, only 6% of physicians reported this on licensing forms, though she was quick to say that not all states ask for this information, and some may just ask about current impairment. “The people who are self-disclosing are probably not the physicians we need to be worrying about,” she said.

There is no research that supports the idea that asking physicians about mental illness improves patient safety. Not every state licensing board asks about psychiatric history, but many do ask these questions in a way that violates the Americans with Disabilities Act (Acad Med. 2009;84[6]:776-81). This is not a new issue: In 1993, The State Medical Society of New Jersey filed an injunction against the New Jersey medical board (Medical Society vs. Jacobs et al.) and questions asked on the licensing forms were changed.

Dr. Gold noted that if a physician checks yes to a question about a mental health history, the board response also varies. The doctor can be asked to provide a letter from his physician stating he is fit to work, or can be required to release all of his psychiatric record, or even to appear before the board to justify his fitness to practice.

Chae Kwak, LCSW-C, is the director of the Maryland Physician Health Program for Maryland MedChi. In the fall 2016 Board of Physicians newsletter, Kwak wrote, “An applicant has to affirmatively answer this question only if a current condition affects their ability to practice medicine. Diagnosis and/or treatment of mental health issues such as depression or anxiety is not the same as ‘impairment’ in the practice of medicine.”

Kwak was pleased that the board published his letter. “We want physicians to get the help they need. But this is not just about licensing boards, it’s an issue with hospital credentialing and applications for malpractice insurance as well.”

“We need to advocate on the level of the Federation of State Medical Boards on this subject, and there is a sense of increasing awareness that this is a problem, said Richard Summers, MD, who cochaired the American Psychiatric Association workshop on physician burnout and depression. “The increased salience and awareness of physician burnout, and its relationship to stigma might help this organization and the various state boards become more sympathetic and open to questioning the stigmatizing element of their questions. So, we’ve got to work on this situation both nationally and at the level of the state boards. Hopefully, some successes will stimulate others and will begin to help to change the culture of secrecy and shame.”

Nathaniel Morris, MD, is doing his psychiatry residency at Stanford (Calif.) University. He wrote about this issue in a Washington Post article, “Why doctors are leery about seeking mental health care for themselves” (Jan. 7, 2017). Morris wrote, “When I was a medical student, I suffered an episode of depression and refused to seek treatment for weeks. My fears about licensing applications were a major reason I kept quiet. I didn’t want a mark on my record. I didn’t want to check “yes” on those forms.”

Questions about mental health on licensing board applications were recently addressed by the American Medical Association’s House of Delegates meeting as part of Resolution 301. The AMA concluded with a suggestion that state medical boards inquire about mental health and physical health in a similar way and went on to suggest that boards not request psychotherapy records if the psychotherapy were a requirement of training. This is a profoundly disappointing and inadequate response from the AMA, and my hope is that the APA will move ahead with both words and actions that condemn stigmatizing inquiries.

Questions that differentiate other medical disabilities from psychiatric disabilities need to be stricken from licensing and credentialing forms. Our treatments work, and the cost of not getting care can be catastrophic for both physicians and for their patients. Why ask intrusive and detailed questions about mental illness or substance abuse, and not about diabetes control, seizures, hypotension, atrial fibrillation, or any illness that may cause impairment? It would seem enough to simply ask if the applicant suffers from any condition that impairs ability to function as a physician. Furthermore, it is unreasonable to ask for a full release of psychiatric records following an affirmative statement if detailed records of other illnesses are not required to confirm competency to practice and may prevent psychiatrists from being honest with their therapists. Self-report has limited value on applications, and questions about past sanctions, employment history, and criminal records are more likely to identify physicians who are impaired for any reason.
 

Dr. Miller, who practices in Baltimore, is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016).

 

 

Physician burnout is rampant, and every seat was taken at a workshop on physician burnout and depression at this year’s APA annual meeting in San Diego.

In his book, “Why Physicians Die By Suicide” (Amazon, 2017), Michael F. Myers, MD, describes “burnout.”

Darrin Klimek/Thinkstock

“It is a state of emotional exhaustion, depersonalization (a lack of feeling for others), and a diminished sense of personal accomplishment. Put another way, doctors who are burned out complain that they are used up emotionally and have nothing left to give their patients, medical colleagues, and staff. They are running on empty. They have become numb and feel detached from the symptoms and the suffering of their patients.”

Myers notes that there is no stigma to having burnout, as there is to having major depression – a condition that may have remarkably similar symptoms.

What stops physicians from getting help? It’s a complex question – especially in a group that has the means to access medical services – but one factor is that most state licensing boards specifically ask about mental illnesses and substance abuse in intrusive and stigmatizing ways. States vary both with their questions and with their responses to a box checked “yes.”

Katherine Gold, MD, MSW, MS, a family physician at the University of Michigan, Ann Arbor, has studied the topic extensively. Her review of licensing questions from all 50 states revealed that most states ask for information about mental health, and there is tremendous variation as to what is asked (Fam Med. 2017 Jun;49[6]:464-7).

“Some states are very specific and very intrusive,” Gold noted. “They may ask if a physician has a specific diagnosis, a history of treatment or hospitalization. The questions may ask about current impairment, or they may ask about mental health conditions back to age 18 years. There may be very specific questions about diagnosis that are not asked about medical conditions, such as whether the applicant has kleptomania, pyromania, or seasonal affective disorder.”

Gold conducted an online survey of physician-mothers. Nearly half believed they had met criteria for an episode of mental illness at some point during their lives. Of those who did have a diagnosis, only 6% of physicians reported this on licensing forms, though she was quick to say that not all states ask for this information, and some may just ask about current impairment. “The people who are self-disclosing are probably not the physicians we need to be worrying about,” she said.

There is no research that supports the idea that asking physicians about mental illness improves patient safety. Not every state licensing board asks about psychiatric history, but many do ask these questions in a way that violates the Americans with Disabilities Act (Acad Med. 2009;84[6]:776-81). This is not a new issue: In 1993, The State Medical Society of New Jersey filed an injunction against the New Jersey medical board (Medical Society vs. Jacobs et al.) and questions asked on the licensing forms were changed.

Dr. Gold noted that if a physician checks yes to a question about a mental health history, the board response also varies. The doctor can be asked to provide a letter from his physician stating he is fit to work, or can be required to release all of his psychiatric record, or even to appear before the board to justify his fitness to practice.

Chae Kwak, LCSW-C, is the director of the Maryland Physician Health Program for Maryland MedChi. In the fall 2016 Board of Physicians newsletter, Kwak wrote, “An applicant has to affirmatively answer this question only if a current condition affects their ability to practice medicine. Diagnosis and/or treatment of mental health issues such as depression or anxiety is not the same as ‘impairment’ in the practice of medicine.”

Kwak was pleased that the board published his letter. “We want physicians to get the help they need. But this is not just about licensing boards, it’s an issue with hospital credentialing and applications for malpractice insurance as well.”

“We need to advocate on the level of the Federation of State Medical Boards on this subject, and there is a sense of increasing awareness that this is a problem, said Richard Summers, MD, who cochaired the American Psychiatric Association workshop on physician burnout and depression. “The increased salience and awareness of physician burnout, and its relationship to stigma might help this organization and the various state boards become more sympathetic and open to questioning the stigmatizing element of their questions. So, we’ve got to work on this situation both nationally and at the level of the state boards. Hopefully, some successes will stimulate others and will begin to help to change the culture of secrecy and shame.”

Nathaniel Morris, MD, is doing his psychiatry residency at Stanford (Calif.) University. He wrote about this issue in a Washington Post article, “Why doctors are leery about seeking mental health care for themselves” (Jan. 7, 2017). Morris wrote, “When I was a medical student, I suffered an episode of depression and refused to seek treatment for weeks. My fears about licensing applications were a major reason I kept quiet. I didn’t want a mark on my record. I didn’t want to check “yes” on those forms.”

Questions about mental health on licensing board applications were recently addressed by the American Medical Association’s House of Delegates meeting as part of Resolution 301. The AMA concluded with a suggestion that state medical boards inquire about mental health and physical health in a similar way and went on to suggest that boards not request psychotherapy records if the psychotherapy were a requirement of training. This is a profoundly disappointing and inadequate response from the AMA, and my hope is that the APA will move ahead with both words and actions that condemn stigmatizing inquiries.

Questions that differentiate other medical disabilities from psychiatric disabilities need to be stricken from licensing and credentialing forms. Our treatments work, and the cost of not getting care can be catastrophic for both physicians and for their patients. Why ask intrusive and detailed questions about mental illness or substance abuse, and not about diabetes control, seizures, hypotension, atrial fibrillation, or any illness that may cause impairment? It would seem enough to simply ask if the applicant suffers from any condition that impairs ability to function as a physician. Furthermore, it is unreasonable to ask for a full release of psychiatric records following an affirmative statement if detailed records of other illnesses are not required to confirm competency to practice and may prevent psychiatrists from being honest with their therapists. Self-report has limited value on applications, and questions about past sanctions, employment history, and criminal records are more likely to identify physicians who are impaired for any reason.
 

Dr. Miller, who practices in Baltimore, is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016).

 

 

Robert Lowell knew civic valor. Sixteen times and more he had been down on his knees in madness, he said. Sixteen times and more he had gotten up. He had gone back to his work, entered back into life. He had faced down uncertainty and madness, had created new forms when pushed to stay with the old, had brought back imaginative order from chaos. It was a different kind of courage, this civic courage, and the rules of engagement were unclear. Lowell’s life, as his daughter observed, was a messy one, difficult for him and for those who knew him. But it was lived with iron, and often with grace. He kept always in the front of his mind what he thought he ought to be, even when he couldn’t be it; he believed in what his country could be, even if it wasn’t. He worked hard at his art.

–Kay Redfield Jamison, PhD, in “Robert Lowell, Setting the River on Fire: A Study of Genius, Mania, and Character” (New York: Alfred A. Knopf, 2017).

Kay Jamison starts her newest book by telling the reader, up front, this is not a biography of the great poet, Robert Lowell. It is, instead, a psychological account of his life and of his mind. Her magnificent study is an unconventional way of approaching the life of another human being, taken in the context of both Lowell’s personal struggle with mental illness and as the culmination of generations of genius and mania in a long and complicated family history. There have been many reviews of Jamison’s book, and for the reader who is interested in a more conventional read, I will steer you to Elizabeth Bosworth’s review in The New York Times (“A poet’s pathologies: Inside Robert Lowell’s restless mind,” March 1, 2017) or Helen Vendler’s review in The New York Review of Books (“The two Robert Lowells,” April 20, 2017). Instead, of a review, per se, I’d like to recount what I thought about as I read “Setting The River On Fire.”

Lowell, who lived from 1917 to 1977, was a two-time Pulitzer Prize winner, deemed to be the greatest American poet of his time. He studied the classics and was obsessed with Napoleon as a child, and he drew on the work of other great poets and classicists as influences for his own work. I must confess, I came to this psychological study having never read the work of Robert Lowell. My only familiarity with the poet came directly from the author. I heard Dr. Jamison, a professor of psychiatry at Johns Hopkins University, Baltimore, speak several years ago at the Johns Hopkins Annual Mood Disorders Symposium about her then work-in-progress as she was researching this book. What I heard was intriguing enough that I was eager to read and review a long and solid book about a great poet whose work I had never read.

As I began “Setting The River On Fire,” my first thought was that the writing itself was astounding. Dr. Jamison’s words flow, her metaphors never fall flat or feel artificial, the ride itself is lovely. I looked for a few lines to quote as an example, and I was left at a standstill. One line was more gracious than the next. I finally settled on the quote I used at the beginning of this piece, benignly chosen from page 403 because it encapsulated not just the beautiful writing but a synopsis of who Lowell was and what he had achieved, set in the context of attempted differentiation between the man, the madness, and the interplay of the two.

Dr. Jamison’s research on Lowell’s life is nothing short of astounding and was clearly a labor that took both sustained passion and years of her time. Dr. Jamison quoted the poet at length. She is an expert on his many volumes of poetry and prose, as well as his life and loves – three marriages and many intimate friendships – documented through letters and conversations. In addition, she quoted many other poets as examples of how their work influenced Lowell. Beyond the literature and correspondence, Dr. Jamison interviewed those who knew Lowell well. She unearthed his medical and psychiatric records, and she plotted out the course of his life in an uncanny way, linking so much of his work to the ebbs and flows of his illness. My only “criticism” of the book would be in how extensive it is. She sometimes makes a point by quoting several sources, each of whom drive at the same idea. It makes for very strong rhetoric.

Lowell lived through the heyday of psychoanalysis, a time when psychiatry focused on the idea that mental aberration was a result of unconscious conflicts and issues left unaddressed from childhood. Lowell’s life was certainly ripe for the psychoanalyst, as Dr. Jamison documented his mother’s psychopathology and his father’s passive distance from his own emotions . In fact, Robert Lowell was treated at some of the great institutions steeped in psychoanalytic learning: Payne Whitney Clinic, McLean Hospital, and Massachusetts Mental Health Center (formerly Boston Psychopathic Hospital), where his treatments included electroconvulsive therapy, chlorpromazine, and eventually lithium.

His second wife, Elizabeth Hardwick, had a striking understanding of his illness as a biological disorder beyond his control. Her sympathy for his behavior as a product of illness allowed her to tolerate actions that many people would not, even with our current day emphasis on disease states, including sexual indiscretions. His friends, too, saw the uncharacteristic chaos of his manias as the result of a state of illness, and, as such, as forgivable. These were often not subtle indiscretions: Jamison describes intense delusional states, combative behavior, police with straightjackets, often at very public and professional events worldwide. If psychoanalytic thinking weighed in on an understanding of Lowell’s motivations, Dr. Jamison did not include it in her study of Lowell, and she makes a point at the end of saying that she focused on his illness and did not include the content of psychotherapy notes. Still, I was struck by the understanding of his depressions and manias as a state of illness by lay people in his life and thought that, given the time period, it was noteworthy.

On a similar vein, I wondered if Lowell could live his life now as he lived his life then. A crucial arena for his career was Harvard College, where he returned over and over to teach. Dr. Jamison says that Lowell lectured in an acutely psychotic and disorganized state. She says that, while students clamored to take his classes, so, too, they were afraid of him. I cannot quite imagine that, in our world of “trigger warnings,” microaggressions, and college safe spaces, we might ever allow an openly ill genius to reign in a classroom of students. I am never certain if we are aimed forward or backward in our struggle against stigma, and “Setting The River On Fire” may be one more example in which we have lost ground in a quest for tolerance.

Once again, Dr. Jamison pulled me into her world. “Setting The River On Fire” is no one’s version of a light or happy read, it is a serious study of an intensely brilliant and often desperately ill poet – and it does not disappoint.

 

Dr. Miller, who practices in Baltimore, is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016).

 

Robert Lowell knew civic valor. Sixteen times and more he had been down on his knees in madness, he said. Sixteen times and more he had gotten up. He had gone back to his work, entered back into life. He had faced down uncertainty and madness, had created new forms when pushed to stay with the old, had brought back imaginative order from chaos. It was a different kind of courage, this civic courage, and the rules of engagement were unclear. Lowell’s life, as his daughter observed, was a messy one, difficult for him and for those who knew him. But it was lived with iron, and often with grace. He kept always in the front of his mind what he thought he ought to be, even when he couldn’t be it; he believed in what his country could be, even if it wasn’t. He worked hard at his art.

–Kay Redfield Jamison, PhD, in “Robert Lowell, Setting the River on Fire: A Study of Genius, Mania, and Character” (New York: Alfred A. Knopf, 2017).

Kay Jamison starts her newest book by telling the reader, up front, this is not a biography of the great poet, Robert Lowell. It is, instead, a psychological account of his life and of his mind. Her magnificent study is an unconventional way of approaching the life of another human being, taken in the context of both Lowell’s personal struggle with mental illness and as the culmination of generations of genius and mania in a long and complicated family history. There have been many reviews of Jamison’s book, and for the reader who is interested in a more conventional read, I will steer you to Elizabeth Bosworth’s review in The New York Times (“A poet’s pathologies: Inside Robert Lowell’s restless mind,” March 1, 2017) or Helen Vendler’s review in The New York Review of Books (“The two Robert Lowells,” April 20, 2017). Instead, of a review, per se, I’d like to recount what I thought about as I read “Setting The River On Fire.”

Lowell, who lived from 1917 to 1977, was a two-time Pulitzer Prize winner, deemed to be the greatest American poet of his time. He studied the classics and was obsessed with Napoleon as a child, and he drew on the work of other great poets and classicists as influences for his own work. I must confess, I came to this psychological study having never read the work of Robert Lowell. My only familiarity with the poet came directly from the author. I heard Dr. Jamison, a professor of psychiatry at Johns Hopkins University, Baltimore, speak several years ago at the Johns Hopkins Annual Mood Disorders Symposium about her then work-in-progress as she was researching this book. What I heard was intriguing enough that I was eager to read and review a long and solid book about a great poet whose work I had never read.

As I began “Setting The River On Fire,” my first thought was that the writing itself was astounding. Dr. Jamison’s words flow, her metaphors never fall flat or feel artificial, the ride itself is lovely. I looked for a few lines to quote as an example, and I was left at a standstill. One line was more gracious than the next. I finally settled on the quote I used at the beginning of this piece, benignly chosen from page 403 because it encapsulated not just the beautiful writing but a synopsis of who Lowell was and what he had achieved, set in the context of attempted differentiation between the man, the madness, and the interplay of the two.

Dr. Jamison’s research on Lowell’s life is nothing short of astounding and was clearly a labor that took both sustained passion and years of her time. Dr. Jamison quoted the poet at length. She is an expert on his many volumes of poetry and prose, as well as his life and loves – three marriages and many intimate friendships – documented through letters and conversations. In addition, she quoted many other poets as examples of how their work influenced Lowell. Beyond the literature and correspondence, Dr. Jamison interviewed those who knew Lowell well. She unearthed his medical and psychiatric records, and she plotted out the course of his life in an uncanny way, linking so much of his work to the ebbs and flows of his illness. My only “criticism” of the book would be in how extensive it is. She sometimes makes a point by quoting several sources, each of whom drive at the same idea. It makes for very strong rhetoric.

Lowell lived through the heyday of psychoanalysis, a time when psychiatry focused on the idea that mental aberration was a result of unconscious conflicts and issues left unaddressed from childhood. Lowell’s life was certainly ripe for the psychoanalyst, as Dr. Jamison documented his mother’s psychopathology and his father’s passive distance from his own emotions . In fact, Robert Lowell was treated at some of the great institutions steeped in psychoanalytic learning: Payne Whitney Clinic, McLean Hospital, and Massachusetts Mental Health Center (formerly Boston Psychopathic Hospital), where his treatments included electroconvulsive therapy, chlorpromazine, and eventually lithium.

His second wife, Elizabeth Hardwick, had a striking understanding of his illness as a biological disorder beyond his control. Her sympathy for his behavior as a product of illness allowed her to tolerate actions that many people would not, even with our current day emphasis on disease states, including sexual indiscretions. His friends, too, saw the uncharacteristic chaos of his manias as the result of a state of illness, and, as such, as forgivable. These were often not subtle indiscretions: Jamison describes intense delusional states, combative behavior, police with straightjackets, often at very public and professional events worldwide. If psychoanalytic thinking weighed in on an understanding of Lowell’s motivations, Dr. Jamison did not include it in her study of Lowell, and she makes a point at the end of saying that she focused on his illness and did not include the content of psychotherapy notes. Still, I was struck by the understanding of his depressions and manias as a state of illness by lay people in his life and thought that, given the time period, it was noteworthy.

On a similar vein, I wondered if Lowell could live his life now as he lived his life then. A crucial arena for his career was Harvard College, where he returned over and over to teach. Dr. Jamison says that Lowell lectured in an acutely psychotic and disorganized state. She says that, while students clamored to take his classes, so, too, they were afraid of him. I cannot quite imagine that, in our world of “trigger warnings,” microaggressions, and college safe spaces, we might ever allow an openly ill genius to reign in a classroom of students. I am never certain if we are aimed forward or backward in our struggle against stigma, and “Setting The River On Fire” may be one more example in which we have lost ground in a quest for tolerance.

Once again, Dr. Jamison pulled me into her world. “Setting The River On Fire” is no one’s version of a light or happy read, it is a serious study of an intensely brilliant and often desperately ill poet – and it does not disappoint.

 

Dr. Miller, who practices in Baltimore, is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016).

 

Robert Lowell knew civic valor. Sixteen times and more he had been down on his knees in madness, he said. Sixteen times and more he had gotten up. He had gone back to his work, entered back into life. He had faced down uncertainty and madness, had created new forms when pushed to stay with the old, had brought back imaginative order from chaos. It was a different kind of courage, this civic courage, and the rules of engagement were unclear. Lowell’s life, as his daughter observed, was a messy one, difficult for him and for those who knew him. But it was lived with iron, and often with grace. He kept always in the front of his mind what he thought he ought to be, even when he couldn’t be it; he believed in what his country could be, even if it wasn’t. He worked hard at his art.

–Kay Redfield Jamison, PhD, in “Robert Lowell, Setting the River on Fire: A Study of Genius, Mania, and Character” (New York: Alfred A. Knopf, 2017).

Kay Jamison starts her newest book by telling the reader, up front, this is not a biography of the great poet, Robert Lowell. It is, instead, a psychological account of his life and of his mind. Her magnificent study is an unconventional way of approaching the life of another human being, taken in the context of both Lowell’s personal struggle with mental illness and as the culmination of generations of genius and mania in a long and complicated family history. There have been many reviews of Jamison’s book, and for the reader who is interested in a more conventional read, I will steer you to Elizabeth Bosworth’s review in The New York Times (“A poet’s pathologies: Inside Robert Lowell’s restless mind,” March 1, 2017) or Helen Vendler’s review in The New York Review of Books (“The two Robert Lowells,” April 20, 2017). Instead, of a review, per se, I’d like to recount what I thought about as I read “Setting The River On Fire.”

Lowell, who lived from 1917 to 1977, was a two-time Pulitzer Prize winner, deemed to be the greatest American poet of his time. He studied the classics and was obsessed with Napoleon as a child, and he drew on the work of other great poets and classicists as influences for his own work. I must confess, I came to this psychological study having never read the work of Robert Lowell. My only familiarity with the poet came directly from the author. I heard Dr. Jamison, a professor of psychiatry at Johns Hopkins University, Baltimore, speak several years ago at the Johns Hopkins Annual Mood Disorders Symposium about her then work-in-progress as she was researching this book. What I heard was intriguing enough that I was eager to read and review a long and solid book about a great poet whose work I had never read.

As I began “Setting The River On Fire,” my first thought was that the writing itself was astounding. Dr. Jamison’s words flow, her metaphors never fall flat or feel artificial, the ride itself is lovely. I looked for a few lines to quote as an example, and I was left at a standstill. One line was more gracious than the next. I finally settled on the quote I used at the beginning of this piece, benignly chosen from page 403 because it encapsulated not just the beautiful writing but a synopsis of who Lowell was and what he had achieved, set in the context of attempted differentiation between the man, the madness, and the interplay of the two.

Dr. Jamison’s research on Lowell’s life is nothing short of astounding and was clearly a labor that took both sustained passion and years of her time. Dr. Jamison quoted the poet at length. She is an expert on his many volumes of poetry and prose, as well as his life and loves – three marriages and many intimate friendships – documented through letters and conversations. In addition, she quoted many other poets as examples of how their work influenced Lowell. Beyond the literature and correspondence, Dr. Jamison interviewed those who knew Lowell well. She unearthed his medical and psychiatric records, and she plotted out the course of his life in an uncanny way, linking so much of his work to the ebbs and flows of his illness. My only “criticism” of the book would be in how extensive it is. She sometimes makes a point by quoting several sources, each of whom drive at the same idea. It makes for very strong rhetoric.

Lowell lived through the heyday of psychoanalysis, a time when psychiatry focused on the idea that mental aberration was a result of unconscious conflicts and issues left unaddressed from childhood. Lowell’s life was certainly ripe for the psychoanalyst, as Dr. Jamison documented his mother’s psychopathology and his father’s passive distance from his own emotions . In fact, Robert Lowell was treated at some of the great institutions steeped in psychoanalytic learning: Payne Whitney Clinic, McLean Hospital, and Massachusetts Mental Health Center (formerly Boston Psychopathic Hospital), where his treatments included electroconvulsive therapy, chlorpromazine, and eventually lithium.

His second wife, Elizabeth Hardwick, had a striking understanding of his illness as a biological disorder beyond his control. Her sympathy for his behavior as a product of illness allowed her to tolerate actions that many people would not, even with our current day emphasis on disease states, including sexual indiscretions. His friends, too, saw the uncharacteristic chaos of his manias as the result of a state of illness, and, as such, as forgivable. These were often not subtle indiscretions: Jamison describes intense delusional states, combative behavior, police with straightjackets, often at very public and professional events worldwide. If psychoanalytic thinking weighed in on an understanding of Lowell’s motivations, Dr. Jamison did not include it in her study of Lowell, and she makes a point at the end of saying that she focused on his illness and did not include the content of psychotherapy notes. Still, I was struck by the understanding of his depressions and manias as a state of illness by lay people in his life and thought that, given the time period, it was noteworthy.

On a similar vein, I wondered if Lowell could live his life now as he lived his life then. A crucial arena for his career was Harvard College, where he returned over and over to teach. Dr. Jamison says that Lowell lectured in an acutely psychotic and disorganized state. She says that, while students clamored to take his classes, so, too, they were afraid of him. I cannot quite imagine that, in our world of “trigger warnings,” microaggressions, and college safe spaces, we might ever allow an openly ill genius to reign in a classroom of students. I am never certain if we are aimed forward or backward in our struggle against stigma, and “Setting The River On Fire” may be one more example in which we have lost ground in a quest for tolerance.

Once again, Dr. Jamison pulled me into her world. “Setting The River On Fire” is no one’s version of a light or happy read, it is a serious study of an intensely brilliant and often desperately ill poet – and it does not disappoint.

 

Dr. Miller, who practices in Baltimore, is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016).

 

Involuntary treatment is an everyday event in the emergency department and on the inpatient unit, but, for both patients and advocates, it remains the most distressing and controversial aspect of psychiatric care. We all value medical autonomy, and, even when people may be too ill to make decisions about their own care, the issue of whether to force treatment gets sticky. On the other hand, the decision not to force someone to get care when they are very sick has its own risks and distresses, and sometimes groups clash.

If you don’t believe me, check outside the convention center during the upcoming American Psychiatric Association’s annual meeting in San Diego this May. Every year, there are protesters: antipsychiatry groups who feel our treatments offer more harm than good. For those who believe the field is sullied by the pharmaceutical companies and that the treatments are harmful, forcing those treatments upon people is all the more egregious. Most years, protesters come from the Church of Scientology and MindFreedom International to make their feelings known. The pitch of the protests varies, as does the length of time they stay, but, some years, there are marchers, megaphones, and jumbotrons.

I’ve spent the last few years talking with a wide variety of patients and professionals about their views on psychiatry and on involuntary care in particular. The culmination of that project was the publication of a book I wrote with forensic psychiatrist, Annette Hanson, MD, “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). With the battlefield defined, we’ve put together two symposia on involuntary care with presenters from around the country.

“The Battle Over Involuntary Psychiatric Care” will be held Wednesday, May 24, from 2 to 5 p.m. As the title suggests, the “combatants” will represent all sides. Roger Peele, MD, has been part of the APA’s governance since 1975. He will be traveling from Maryland to discuss why involuntary treatment is a good thing, an option that should be used more liberally with legislation that should be less restrictive. Former APA President Paul Appelbaum, MD, a forensic psychiatrist, will be coming from Columbia University in New York to talk about the APA’s stance on involuntary treatment over time.

On the other side of the debate, Elyn Saks, JD, PhD, will be talking about patient rights. Dr. Saks is the author of “The Center Cannot Hold: My Journey Through Madness” (New York: Hyperion, 2007), a memoir of her own experiences with treatment for schizophrenia. She is the founder of the Saks Institute for Mental Health Law, Policy, and Ethics at the University of Southern California in Los Angeles.

Finally, Al Galves, PhD, is on the board of directors of MindFreedom International, one of the groups that traditionally has picketed our meeting. He will be traveling from New Mexico to represent that group’s viewpoint. Dr. Galves also has a fascinating background: He holds degrees in government administration, as well as a doctorate in clinical psychology. He is the author of “Harness Your Dark Side: Mastering Jealousy, Rage, Frustration, and Other Negative Emotions” (Falls Hills, N.J.: New Horizon Press, 2012), and he has a long history of treatment for depression. I believe this is the first time that a member of MFI has spoken at an APA meeting.

Dr. Hanson will be the discussant who sums up what we learn from these diverse and esteemed speakers. I invite you to come for what is certain to be a lively symposium, but please leave your picket signs at the door. Our hope is not to fuel the battle but to provide an arena where diverse viewpoints can be expressed and heard. In our increasingly polarized world, we’d like to think that it is still possible to consider a variety of ideas without firing any artillery.

To add to the controversy, outpatient civil commitment continues to be held out as a panacea to get people treatment before they become dangerous. Still, each state handles outpatient care differently, if at all, so a symposium, “Outpatient Commitment: A Tour Across the States,” will be held on Tuesday, May 23, from 8 to 11 a.m. Two speakers will be coming from New York state, Ryan Bell, JD, MD, and Kimberly Butler, LCSW, MS, to talk about their experiences running an assisted outpatient treatment program in Rochester, N.Y. Erin Klekot, MD, will be talking about her experiences in Ohio. Adam Nelson, MD, will discuss the programs in California that are starting to be implemented.

Finally, Mustafa Mufti, MD, will be talking about the experience in Delaware, where they have had a great deal of experience with outpatient commitment – not without some contention – and where the state hospital and outpatient programs have been investigated by the Department of Justice. Our discussant will be Marvin Swartz, MD, from North Carolina. Dr. Swartz has coauthored the seminal studies on outpatient civil commitment results from both New York City and North Carolina.

If you’re coming to the APA, do join us. If not, both sessions are slated to be part of APA’s Meeting On Demand. Dr. Hanson will try to stream parts of the Battleground session on Periscope (wifi permitting) – follow her on Twitter if you’re interested in updates.

Finally, if you’d like to look up any session, either by topic or by presenter, the APA has provided a useful search function.

See you in San Diego!
 

 

To learn more about the latest book by Dr. Miller and Dr. Hanson, “Committed: The Battle Over Involuntary Psychiatric Care,” visit https://jhupbooks.press.jhu.edu/content/committed.

 

Involuntary treatment is an everyday event in the emergency department and on the inpatient unit, but, for both patients and advocates, it remains the most distressing and controversial aspect of psychiatric care. We all value medical autonomy, and, even when people may be too ill to make decisions about their own care, the issue of whether to force treatment gets sticky. On the other hand, the decision not to force someone to get care when they are very sick has its own risks and distresses, and sometimes groups clash.

If you don’t believe me, check outside the convention center during the upcoming American Psychiatric Association’s annual meeting in San Diego this May. Every year, there are protesters: antipsychiatry groups who feel our treatments offer more harm than good. For those who believe the field is sullied by the pharmaceutical companies and that the treatments are harmful, forcing those treatments upon people is all the more egregious. Most years, protesters come from the Church of Scientology and MindFreedom International to make their feelings known. The pitch of the protests varies, as does the length of time they stay, but, some years, there are marchers, megaphones, and jumbotrons.

I’ve spent the last few years talking with a wide variety of patients and professionals about their views on psychiatry and on involuntary care in particular. The culmination of that project was the publication of a book I wrote with forensic psychiatrist, Annette Hanson, MD, “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). With the battlefield defined, we’ve put together two symposia on involuntary care with presenters from around the country.

“The Battle Over Involuntary Psychiatric Care” will be held Wednesday, May 24, from 2 to 5 p.m. As the title suggests, the “combatants” will represent all sides. Roger Peele, MD, has been part of the APA’s governance since 1975. He will be traveling from Maryland to discuss why involuntary treatment is a good thing, an option that should be used more liberally with legislation that should be less restrictive. Former APA President Paul Appelbaum, MD, a forensic psychiatrist, will be coming from Columbia University in New York to talk about the APA’s stance on involuntary treatment over time.

On the other side of the debate, Elyn Saks, JD, PhD, will be talking about patient rights. Dr. Saks is the author of “The Center Cannot Hold: My Journey Through Madness” (New York: Hyperion, 2007), a memoir of her own experiences with treatment for schizophrenia. She is the founder of the Saks Institute for Mental Health Law, Policy, and Ethics at the University of Southern California in Los Angeles.

Finally, Al Galves, PhD, is on the board of directors of MindFreedom International, one of the groups that traditionally has picketed our meeting. He will be traveling from New Mexico to represent that group’s viewpoint. Dr. Galves also has a fascinating background: He holds degrees in government administration, as well as a doctorate in clinical psychology. He is the author of “Harness Your Dark Side: Mastering Jealousy, Rage, Frustration, and Other Negative Emotions” (Falls Hills, N.J.: New Horizon Press, 2012), and he has a long history of treatment for depression. I believe this is the first time that a member of MFI has spoken at an APA meeting.

Dr. Hanson will be the discussant who sums up what we learn from these diverse and esteemed speakers. I invite you to come for what is certain to be a lively symposium, but please leave your picket signs at the door. Our hope is not to fuel the battle but to provide an arena where diverse viewpoints can be expressed and heard. In our increasingly polarized world, we’d like to think that it is still possible to consider a variety of ideas without firing any artillery.

To add to the controversy, outpatient civil commitment continues to be held out as a panacea to get people treatment before they become dangerous. Still, each state handles outpatient care differently, if at all, so a symposium, “Outpatient Commitment: A Tour Across the States,” will be held on Tuesday, May 23, from 8 to 11 a.m. Two speakers will be coming from New York state, Ryan Bell, JD, MD, and Kimberly Butler, LCSW, MS, to talk about their experiences running an assisted outpatient treatment program in Rochester, N.Y. Erin Klekot, MD, will be talking about her experiences in Ohio. Adam Nelson, MD, will discuss the programs in California that are starting to be implemented.

Finally, Mustafa Mufti, MD, will be talking about the experience in Delaware, where they have had a great deal of experience with outpatient commitment – not without some contention – and where the state hospital and outpatient programs have been investigated by the Department of Justice. Our discussant will be Marvin Swartz, MD, from North Carolina. Dr. Swartz has coauthored the seminal studies on outpatient civil commitment results from both New York City and North Carolina.

If you’re coming to the APA, do join us. If not, both sessions are slated to be part of APA’s Meeting On Demand. Dr. Hanson will try to stream parts of the Battleground session on Periscope (wifi permitting) – follow her on Twitter if you’re interested in updates.

Finally, if you’d like to look up any session, either by topic or by presenter, the APA has provided a useful search function.

See you in San Diego!
 

 

To learn more about the latest book by Dr. Miller and Dr. Hanson, “Committed: The Battle Over Involuntary Psychiatric Care,” visit https://jhupbooks.press.jhu.edu/content/committed.

 

Involuntary treatment is an everyday event in the emergency department and on the inpatient unit, but, for both patients and advocates, it remains the most distressing and controversial aspect of psychiatric care. We all value medical autonomy, and, even when people may be too ill to make decisions about their own care, the issue of whether to force treatment gets sticky. On the other hand, the decision not to force someone to get care when they are very sick has its own risks and distresses, and sometimes groups clash.

If you don’t believe me, check outside the convention center during the upcoming American Psychiatric Association’s annual meeting in San Diego this May. Every year, there are protesters: antipsychiatry groups who feel our treatments offer more harm than good. For those who believe the field is sullied by the pharmaceutical companies and that the treatments are harmful, forcing those treatments upon people is all the more egregious. Most years, protesters come from the Church of Scientology and MindFreedom International to make their feelings known. The pitch of the protests varies, as does the length of time they stay, but, some years, there are marchers, megaphones, and jumbotrons.

I’ve spent the last few years talking with a wide variety of patients and professionals about their views on psychiatry and on involuntary care in particular. The culmination of that project was the publication of a book I wrote with forensic psychiatrist, Annette Hanson, MD, “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). With the battlefield defined, we’ve put together two symposia on involuntary care with presenters from around the country.

“The Battle Over Involuntary Psychiatric Care” will be held Wednesday, May 24, from 2 to 5 p.m. As the title suggests, the “combatants” will represent all sides. Roger Peele, MD, has been part of the APA’s governance since 1975. He will be traveling from Maryland to discuss why involuntary treatment is a good thing, an option that should be used more liberally with legislation that should be less restrictive. Former APA President Paul Appelbaum, MD, a forensic psychiatrist, will be coming from Columbia University in New York to talk about the APA’s stance on involuntary treatment over time.

On the other side of the debate, Elyn Saks, JD, PhD, will be talking about patient rights. Dr. Saks is the author of “The Center Cannot Hold: My Journey Through Madness” (New York: Hyperion, 2007), a memoir of her own experiences with treatment for schizophrenia. She is the founder of the Saks Institute for Mental Health Law, Policy, and Ethics at the University of Southern California in Los Angeles.

Finally, Al Galves, PhD, is on the board of directors of MindFreedom International, one of the groups that traditionally has picketed our meeting. He will be traveling from New Mexico to represent that group’s viewpoint. Dr. Galves also has a fascinating background: He holds degrees in government administration, as well as a doctorate in clinical psychology. He is the author of “Harness Your Dark Side: Mastering Jealousy, Rage, Frustration, and Other Negative Emotions” (Falls Hills, N.J.: New Horizon Press, 2012), and he has a long history of treatment for depression. I believe this is the first time that a member of MFI has spoken at an APA meeting.

Dr. Hanson will be the discussant who sums up what we learn from these diverse and esteemed speakers. I invite you to come for what is certain to be a lively symposium, but please leave your picket signs at the door. Our hope is not to fuel the battle but to provide an arena where diverse viewpoints can be expressed and heard. In our increasingly polarized world, we’d like to think that it is still possible to consider a variety of ideas without firing any artillery.

To add to the controversy, outpatient civil commitment continues to be held out as a panacea to get people treatment before they become dangerous. Still, each state handles outpatient care differently, if at all, so a symposium, “Outpatient Commitment: A Tour Across the States,” will be held on Tuesday, May 23, from 8 to 11 a.m. Two speakers will be coming from New York state, Ryan Bell, JD, MD, and Kimberly Butler, LCSW, MS, to talk about their experiences running an assisted outpatient treatment program in Rochester, N.Y. Erin Klekot, MD, will be talking about her experiences in Ohio. Adam Nelson, MD, will discuss the programs in California that are starting to be implemented.

Finally, Mustafa Mufti, MD, will be talking about the experience in Delaware, where they have had a great deal of experience with outpatient commitment – not without some contention – and where the state hospital and outpatient programs have been investigated by the Department of Justice. Our discussant will be Marvin Swartz, MD, from North Carolina. Dr. Swartz has coauthored the seminal studies on outpatient civil commitment results from both New York City and North Carolina.

If you’re coming to the APA, do join us. If not, both sessions are slated to be part of APA’s Meeting On Demand. Dr. Hanson will try to stream parts of the Battleground session on Periscope (wifi permitting) – follow her on Twitter if you’re interested in updates.

Finally, if you’d like to look up any session, either by topic or by presenter, the APA has provided a useful search function.

See you in San Diego!
 

 

To learn more about the latest book by Dr. Miller and Dr. Hanson, “Committed: The Battle Over Involuntary Psychiatric Care,” visit https://jhupbooks.press.jhu.edu/content/committed.

 

In the course of researching our book, “Committed: The Battle Over Involuntary Psychiatric Care,” I came to a few very important conclusions. Involuntary commitment can be traumatizing to patients, and it should be done as a last resort when patients are dangerous (generally to themselves, but sometimes toward others) or tormented, and when they can’t be persuaded to get voluntary care. That may sound obvious, but in practice, it doesn’t always work that way. Furthermore, if there is no choice but to hold people against their will, there should be no use of physical force unless it is absolutely necessary to maintain safety, and patients should be treated with kindness and respect. It’s what we’d all want if we were the patient, and it’s not what all patients get.

Knowing that, you can imagine my shock when I saw reporter Mike Anderson’s article “Jail cells await mentally ill in Rapid City” in the Feb. 8, 2017, edition of the Rapid City Journal. Mr. Anderson noted that the Rapid City Regional Hospital was changing its policy on psychiatric admissions. The South Dakota city of 60,000 has a 44-bed psychiatric hospital located 1.5 miles from the main hospital. It is the only inpatient facility for at least 250 miles and serves a total population of approximately 250,000 people. If the unit is full – either because all beds are full or because staffing and acuity issues limit capacity – its policy always has been to admit overflow psychiatric patients to medical beds.

That policy changed recently. The interim director of Rapid City Regional Hospital, Dennis Millirons, reportedly wrote a letter on Jan. 23, 2017, to the Pennington County Board of Mental Health defining a new policy. The letter stated:



Effective Feb. 1, 2017, we will no longer admit behavioral health patients who do not have acute medical needs to the main hospital when the Behavioral Health facility is at capacity. In these instances, we will expect the County to take custody of patients who are subject to the involuntary mental commitment process, pending an opening at the Behavioral Health unit. It is simply no longer feasible for us to care for behavioral health patients who do not have acute medical needs outside of the Behavioral Health facility. Unless we hear differently, we will contact the Sheriff’s Office to take custody of involuntarily detained persons when the Behavioral Health facility is at capacity.

Also, by way of information, we will no longer admit patients to the Behavioral Health facility who have neurodevelopmental/cognitive disorders such as dementia, Alzheimer’s disease, or Autism Spectrum Disorders. We believe it is in the best interest of all patients to limit the conditions which are appropriate for treatment in our facility.



In other words, if there are no open beds in a psychiatric facility, patients would be transported from the emergency deparment to the Pennington County Jail. The fate of patients with psychiatric issues and dementia or autism was not at all clear.

I spoke with Stephen Manlove, MD, DFAPA. Dr. Manlove has a psychiatric outpatient practice but worked for the Rapid City Regional Hospital for 26 years. He left this past September because he felt the facility had lost sight of its mission to give psychiatric patients excellent care. He also works two mornings a week providing psychiatric treatment at the local jail, a 600-bed facility where 1 in 6 inmates is on psychotropic medications, and an average of 25 inmates at any given time suffer from severe and persistent mental disorders.

“This is obviously a complicated story,” Dr. Manlove noted. “The hospital gave the jail only a few days’ notice. The hospital doesn’t seem to want to invest in this population. They are investing millions of dollars in other projects but can’t find the money to fund psychiatry. Surprisingly, the medical community seems to have accepted this.”

Dr. Manlove noted that the jail is not equipped to offer comprehensive psychiatric treatment, and that inmates are held in cinder block cells with very limited medical supervision.

Kevin Thom, the Pennington County sheriff, was quick to say, “We shouldn’t be criminalizing mental health problems.” While he noted that local statute allows for patients to be held in a jail cell for up to 24 hours if a hospital bed is not available, he commented on the inappropriateness of this and on the brief notice his office was given: “There was no time to figure out a process or alternatives. It’s frustrating.”

Dr. Manlove said he believes that a few patients may have been taken to the jail since the new policy was instituted, but the jail has turned some away. Sheriff Thom said his office had been called to transport a patient and had refused.

I asked what happens when a voluntary patient needs a bed and there is no room. Dr. Manlove replied: “If they are not considered acutely dangerous, I assume they will be told to go to another hospital. If they are acutely dangerous to themselves or others, then a mental health hold would be placed, and they would be sent to jail.”

Of note, the closest hospital with a psychiatric unit is 253 miles away, in Casper, Wyo.

One reason for limiting the type of patients the psychiatric facility will admit may have to do with an effort by the hospital to lower its use of seclusion and restraint. In an article in the Rapid City Journal on Feb. 19, 2017, reporter Chris Huber noted that between July 2015 and July 2016, Rapid City Behavioral Health had seclusion rates 300 times higher than the national average, a fact the hospital attributes to the high acuity needs of autistic patients. Rather than improving its ability to treat these patients, the facility has decided not to accept them.

In June 2016, the Boston Globe Spotlight team began a series called “The Desperate and the Dead” as a way to highlight deficiencies in the Massachusetts public mental health system. The first article was a sensationalized piece about psychiatric patients who kill their family members. The backlash to the stigmatization of psychiatric patients as murderers was huge; a Facebook page set up to accept comments soon had more than 1,300 members, and the entrance to the Globe was blocked by 150 protesters. The response to the Rapid City hospital’s decision to jail people with psychiatric disorders who have committed no crime has been surprisingly quiet; there have been no stories of protests or advocacy outrage. In this egregious stigmatization of those with psychiatric disorders, I had to wonder what they do when the medical beds overflow: Do they send those patients to jail? Of course not. And why would anyone think this is okay?

We know that involuntary care can be traumatizing and that psychiatric care can feel demeaning. On the one hand, there is a call to pass laws to make it easier to treat patients involuntarily. In our polarized world with rising suicide rates, should we be doing everything possible to engage patients in voluntary care? How do we reconcile the fact that a hospital administration can decide that if distressed people seek care, having broken no law, they can be sent to jail? And finally, since suicide rates among physicians remain so high, I’d like to ask this: Would you go to a hospital for treatment if you knew you might end up desperate and alone, receiving no treatment, in a jail cell?
 

 

My thanks to Mr. Anderson of the Rapid City Journal, Dr. Manlove, and Sheriff Thom for their help with this article.

Dr. Miller wrote “Committed: The Battle Over Involuntary Psychiatric Care” with Annette Hanson, MD (Baltimore: Johns Hopkins University Press, 2016).

 

In the course of researching our book, “Committed: The Battle Over Involuntary Psychiatric Care,” I came to a few very important conclusions. Involuntary commitment can be traumatizing to patients, and it should be done as a last resort when patients are dangerous (generally to themselves, but sometimes toward others) or tormented, and when they can’t be persuaded to get voluntary care. That may sound obvious, but in practice, it doesn’t always work that way. Furthermore, if there is no choice but to hold people against their will, there should be no use of physical force unless it is absolutely necessary to maintain safety, and patients should be treated with kindness and respect. It’s what we’d all want if we were the patient, and it’s not what all patients get.

Knowing that, you can imagine my shock when I saw reporter Mike Anderson’s article “Jail cells await mentally ill in Rapid City” in the Feb. 8, 2017, edition of the Rapid City Journal. Mr. Anderson noted that the Rapid City Regional Hospital was changing its policy on psychiatric admissions. The South Dakota city of 60,000 has a 44-bed psychiatric hospital located 1.5 miles from the main hospital. It is the only inpatient facility for at least 250 miles and serves a total population of approximately 250,000 people. If the unit is full – either because all beds are full or because staffing and acuity issues limit capacity – its policy always has been to admit overflow psychiatric patients to medical beds.

That policy changed recently. The interim director of Rapid City Regional Hospital, Dennis Millirons, reportedly wrote a letter on Jan. 23, 2017, to the Pennington County Board of Mental Health defining a new policy. The letter stated:



Effective Feb. 1, 2017, we will no longer admit behavioral health patients who do not have acute medical needs to the main hospital when the Behavioral Health facility is at capacity. In these instances, we will expect the County to take custody of patients who are subject to the involuntary mental commitment process, pending an opening at the Behavioral Health unit. It is simply no longer feasible for us to care for behavioral health patients who do not have acute medical needs outside of the Behavioral Health facility. Unless we hear differently, we will contact the Sheriff’s Office to take custody of involuntarily detained persons when the Behavioral Health facility is at capacity.

Also, by way of information, we will no longer admit patients to the Behavioral Health facility who have neurodevelopmental/cognitive disorders such as dementia, Alzheimer’s disease, or Autism Spectrum Disorders. We believe it is in the best interest of all patients to limit the conditions which are appropriate for treatment in our facility.



In other words, if there are no open beds in a psychiatric facility, patients would be transported from the emergency deparment to the Pennington County Jail. The fate of patients with psychiatric issues and dementia or autism was not at all clear.

I spoke with Stephen Manlove, MD, DFAPA. Dr. Manlove has a psychiatric outpatient practice but worked for the Rapid City Regional Hospital for 26 years. He left this past September because he felt the facility had lost sight of its mission to give psychiatric patients excellent care. He also works two mornings a week providing psychiatric treatment at the local jail, a 600-bed facility where 1 in 6 inmates is on psychotropic medications, and an average of 25 inmates at any given time suffer from severe and persistent mental disorders.

“This is obviously a complicated story,” Dr. Manlove noted. “The hospital gave the jail only a few days’ notice. The hospital doesn’t seem to want to invest in this population. They are investing millions of dollars in other projects but can’t find the money to fund psychiatry. Surprisingly, the medical community seems to have accepted this.”

Dr. Manlove noted that the jail is not equipped to offer comprehensive psychiatric treatment, and that inmates are held in cinder block cells with very limited medical supervision.

Kevin Thom, the Pennington County sheriff, was quick to say, “We shouldn’t be criminalizing mental health problems.” While he noted that local statute allows for patients to be held in a jail cell for up to 24 hours if a hospital bed is not available, he commented on the inappropriateness of this and on the brief notice his office was given: “There was no time to figure out a process or alternatives. It’s frustrating.”

Dr. Manlove said he believes that a few patients may have been taken to the jail since the new policy was instituted, but the jail has turned some away. Sheriff Thom said his office had been called to transport a patient and had refused.

I asked what happens when a voluntary patient needs a bed and there is no room. Dr. Manlove replied: “If they are not considered acutely dangerous, I assume they will be told to go to another hospital. If they are acutely dangerous to themselves or others, then a mental health hold would be placed, and they would be sent to jail.”

Of note, the closest hospital with a psychiatric unit is 253 miles away, in Casper, Wyo.

One reason for limiting the type of patients the psychiatric facility will admit may have to do with an effort by the hospital to lower its use of seclusion and restraint. In an article in the Rapid City Journal on Feb. 19, 2017, reporter Chris Huber noted that between July 2015 and July 2016, Rapid City Behavioral Health had seclusion rates 300 times higher than the national average, a fact the hospital attributes to the high acuity needs of autistic patients. Rather than improving its ability to treat these patients, the facility has decided not to accept them.

In June 2016, the Boston Globe Spotlight team began a series called “The Desperate and the Dead” as a way to highlight deficiencies in the Massachusetts public mental health system. The first article was a sensationalized piece about psychiatric patients who kill their family members. The backlash to the stigmatization of psychiatric patients as murderers was huge; a Facebook page set up to accept comments soon had more than 1,300 members, and the entrance to the Globe was blocked by 150 protesters. The response to the Rapid City hospital’s decision to jail people with psychiatric disorders who have committed no crime has been surprisingly quiet; there have been no stories of protests or advocacy outrage. In this egregious stigmatization of those with psychiatric disorders, I had to wonder what they do when the medical beds overflow: Do they send those patients to jail? Of course not. And why would anyone think this is okay?

We know that involuntary care can be traumatizing and that psychiatric care can feel demeaning. On the one hand, there is a call to pass laws to make it easier to treat patients involuntarily. In our polarized world with rising suicide rates, should we be doing everything possible to engage patients in voluntary care? How do we reconcile the fact that a hospital administration can decide that if distressed people seek care, having broken no law, they can be sent to jail? And finally, since suicide rates among physicians remain so high, I’d like to ask this: Would you go to a hospital for treatment if you knew you might end up desperate and alone, receiving no treatment, in a jail cell?
 

 

My thanks to Mr. Anderson of the Rapid City Journal, Dr. Manlove, and Sheriff Thom for their help with this article.

Dr. Miller wrote “Committed: The Battle Over Involuntary Psychiatric Care” with Annette Hanson, MD (Baltimore: Johns Hopkins University Press, 2016).

 

In the course of researching our book, “Committed: The Battle Over Involuntary Psychiatric Care,” I came to a few very important conclusions. Involuntary commitment can be traumatizing to patients, and it should be done as a last resort when patients are dangerous (generally to themselves, but sometimes toward others) or tormented, and when they can’t be persuaded to get voluntary care. That may sound obvious, but in practice, it doesn’t always work that way. Furthermore, if there is no choice but to hold people against their will, there should be no use of physical force unless it is absolutely necessary to maintain safety, and patients should be treated with kindness and respect. It’s what we’d all want if we were the patient, and it’s not what all patients get.

Knowing that, you can imagine my shock when I saw reporter Mike Anderson’s article “Jail cells await mentally ill in Rapid City” in the Feb. 8, 2017, edition of the Rapid City Journal. Mr. Anderson noted that the Rapid City Regional Hospital was changing its policy on psychiatric admissions. The South Dakota city of 60,000 has a 44-bed psychiatric hospital located 1.5 miles from the main hospital. It is the only inpatient facility for at least 250 miles and serves a total population of approximately 250,000 people. If the unit is full – either because all beds are full or because staffing and acuity issues limit capacity – its policy always has been to admit overflow psychiatric patients to medical beds.

That policy changed recently. The interim director of Rapid City Regional Hospital, Dennis Millirons, reportedly wrote a letter on Jan. 23, 2017, to the Pennington County Board of Mental Health defining a new policy. The letter stated:



Effective Feb. 1, 2017, we will no longer admit behavioral health patients who do not have acute medical needs to the main hospital when the Behavioral Health facility is at capacity. In these instances, we will expect the County to take custody of patients who are subject to the involuntary mental commitment process, pending an opening at the Behavioral Health unit. It is simply no longer feasible for us to care for behavioral health patients who do not have acute medical needs outside of the Behavioral Health facility. Unless we hear differently, we will contact the Sheriff’s Office to take custody of involuntarily detained persons when the Behavioral Health facility is at capacity.

Also, by way of information, we will no longer admit patients to the Behavioral Health facility who have neurodevelopmental/cognitive disorders such as dementia, Alzheimer’s disease, or Autism Spectrum Disorders. We believe it is in the best interest of all patients to limit the conditions which are appropriate for treatment in our facility.



In other words, if there are no open beds in a psychiatric facility, patients would be transported from the emergency deparment to the Pennington County Jail. The fate of patients with psychiatric issues and dementia or autism was not at all clear.

I spoke with Stephen Manlove, MD, DFAPA. Dr. Manlove has a psychiatric outpatient practice but worked for the Rapid City Regional Hospital for 26 years. He left this past September because he felt the facility had lost sight of its mission to give psychiatric patients excellent care. He also works two mornings a week providing psychiatric treatment at the local jail, a 600-bed facility where 1 in 6 inmates is on psychotropic medications, and an average of 25 inmates at any given time suffer from severe and persistent mental disorders.

“This is obviously a complicated story,” Dr. Manlove noted. “The hospital gave the jail only a few days’ notice. The hospital doesn’t seem to want to invest in this population. They are investing millions of dollars in other projects but can’t find the money to fund psychiatry. Surprisingly, the medical community seems to have accepted this.”

Dr. Manlove noted that the jail is not equipped to offer comprehensive psychiatric treatment, and that inmates are held in cinder block cells with very limited medical supervision.

Kevin Thom, the Pennington County sheriff, was quick to say, “We shouldn’t be criminalizing mental health problems.” While he noted that local statute allows for patients to be held in a jail cell for up to 24 hours if a hospital bed is not available, he commented on the inappropriateness of this and on the brief notice his office was given: “There was no time to figure out a process or alternatives. It’s frustrating.”

Dr. Manlove said he believes that a few patients may have been taken to the jail since the new policy was instituted, but the jail has turned some away. Sheriff Thom said his office had been called to transport a patient and had refused.

I asked what happens when a voluntary patient needs a bed and there is no room. Dr. Manlove replied: “If they are not considered acutely dangerous, I assume they will be told to go to another hospital. If they are acutely dangerous to themselves or others, then a mental health hold would be placed, and they would be sent to jail.”

Of note, the closest hospital with a psychiatric unit is 253 miles away, in Casper, Wyo.

One reason for limiting the type of patients the psychiatric facility will admit may have to do with an effort by the hospital to lower its use of seclusion and restraint. In an article in the Rapid City Journal on Feb. 19, 2017, reporter Chris Huber noted that between July 2015 and July 2016, Rapid City Behavioral Health had seclusion rates 300 times higher than the national average, a fact the hospital attributes to the high acuity needs of autistic patients. Rather than improving its ability to treat these patients, the facility has decided not to accept them.

In June 2016, the Boston Globe Spotlight team began a series called “The Desperate and the Dead” as a way to highlight deficiencies in the Massachusetts public mental health system. The first article was a sensationalized piece about psychiatric patients who kill their family members. The backlash to the stigmatization of psychiatric patients as murderers was huge; a Facebook page set up to accept comments soon had more than 1,300 members, and the entrance to the Globe was blocked by 150 protesters. The response to the Rapid City hospital’s decision to jail people with psychiatric disorders who have committed no crime has been surprisingly quiet; there have been no stories of protests or advocacy outrage. In this egregious stigmatization of those with psychiatric disorders, I had to wonder what they do when the medical beds overflow: Do they send those patients to jail? Of course not. And why would anyone think this is okay?

We know that involuntary care can be traumatizing and that psychiatric care can feel demeaning. On the one hand, there is a call to pass laws to make it easier to treat patients involuntarily. In our polarized world with rising suicide rates, should we be doing everything possible to engage patients in voluntary care? How do we reconcile the fact that a hospital administration can decide that if distressed people seek care, having broken no law, they can be sent to jail? And finally, since suicide rates among physicians remain so high, I’d like to ask this: Would you go to a hospital for treatment if you knew you might end up desperate and alone, receiving no treatment, in a jail cell?
 

 

My thanks to Mr. Anderson of the Rapid City Journal, Dr. Manlove, and Sheriff Thom for their help with this article.

Dr. Miller wrote “Committed: The Battle Over Involuntary Psychiatric Care” with Annette Hanson, MD (Baltimore: Johns Hopkins University Press, 2016).

Nurse Jackie is an amazing woman: She’s a fantastically competent and compassionate ER nurse who will do anything for her patients, and she is far better than the caricature ER docs she works with who all care more about their designer shoes and designer egos then about their jobs. She’s a wife – at least in the early episodes – and mother to two adorable girls with a life that includes Mommy and Me tap dancing classes. She somehow juggles it all.

In her fictional life as the star of a Showtime series, “Jackie Peyton” – played by actress Edie Falco, formerly known for her role as Tony Soprano’s wife, Carmela – manages even more: She does it all while popping pain pills by the handful throughout the work day and snorting whatever there is to snort. The interesting thing about Jackie is that her drug habit never interferes with her ability to function. There are no episodes where she makes mistakes or falls asleep. She doesn’t get too wired and is rarely irritable, and she certainly doesn’t pass out from overdoses. She shows up at work on time and never falls off her tightrope of responsibilities in the busy All Saints Hospital ER of New York City.

Without the drugs, she gets ill, but with them, she just functions. And she doesn’t just hold her own with a busy life; she also juggles the secret life of what it takes to get her daily fix, including daily lunchtime sex with the hospital pharmacist, who provides her with pain medicines for her aching back and doesn’t initially know that she’s married with children.

By Season 6, her personal life has broken down, and her daughter Grace, now an angry teenager with her own difficulties and secret life, notes that mom Jackie is incredibly good at hiding her drug use, and that no one can tell when she’s using.

With each season, Jackie’s personal life unwinds a little more, but it’s not because of the effects constant pill-popping has on her behavior; it’s because of the difficulties she has obtaining the drugs. If she could go to the store and buy large amounts of oxycontin and whatever else she takes, she’d have no problem. Her cauldron, however, is filled with constant lies and deception and the secret lives she lives to obtain drugs and to avoid boiling in her own self-made addictive mess.

I’m only at the end of Season 6, and Jackie already has had a year of sobriety – broken on her 1-year anniversary – and perhaps things will change in the final season, but so far, I’m struck by how well she manages to consistently function while living life high. It’s the perfect series to watch at the gym – entertaining, but it doesn’t ask much of the viewer.

You wouldn’t expect a review of a dark comedy TV series together with a review of a very serious memoir written by former Rep. Patrick J. Kennedy, but somehow, the two fit together for me.

In “A Common Struggle,” Patrick Kennedy and author Stephen Fried march through Kennedy’s long history of mental illness and substance abuse. Kennedy talks about his life in psychotherapy starting in childhood, related to his parents’ separation. He talks about the treatment he received in college and during his time as a state legislator in Providence, R.I., and how he parked far from his psychiatrist’s office so no one would learn he was in treatment.

Unfortunately, while he found treatment to be very helpful, he stopped when his doctor, Peter Kramer, became a celebrity in his own right after the publication of “Listening to Prozac” (New York: Penguin Books, 1997), and Kennedy became “spooked.” He goes on to talk about the many treatments – including lists of medications – he received over the years and his diagnosis of bipolar disorder, type II. But he doesn’t document what symptoms or episodes led to this diagnosis, and I couldn’t help but wonder how much of his mood disorder was part and parcel of his substance abuse problem. I imagine his doctors may have had the same problem.

So while Kennedy is vague about his psychiatric illness, he is much more forthcoming with his substance abuse problem. Like Nurse Jackie, he has the constant flow of pills – prescribed opiates starting with the diagnosis of a spinal tumor, a handful of Adderall here, some benzodiazepines there, and an enormous issue with alcohol on top of all that. Unlike Nurse Jackie, Kennedy wears the results of his addictions openly. He sleeps through mornings, and his schedulers know to accommodate this. He says things he otherwise wouldn’t while intoxicated, and he embarrasses himself and has others on edge. His mentor in the House of Representatives was Dick Gephardt, and Gephardt’s chief of staff summoned Kennedy to ask him to become chairman of the Democratic Congressional Campaign Committee – a tremendous honor for a 31-year-old congressman.

“There was, however, one catch,” the authors wrote. “ ‘If you do this,’ he said, ‘you can’t drink.’ ” Kennedy notes that he didn’t have the insight to realize how odd this was, and in reflection calls it his first intervention.

While most of his difficulties remained relatively private, one night he mixed Ambien and Phenergan, and in a state of confusion, he went for a drive and crashed into a Capitol Hill concrete barrier – an event that led to media coverage, scandal, and, as his chief of staff put it, “ ‘Patrick,’ he said, ‘we have a problem.’ ” While his father, Sen. Ted Kennedy, dismissed this as “a little fendah bendah,” the son made a public statement and checked himself into a rehab unit at the Mayo Clinic. It was to be the second of many attempts at rehab, his first having been in high school.

What makes “A Common Struggle” (New York: Blue Rider Press, 2015) so special is not just that it is a strikingly candid memoir of addiction and illness in a successful congressman, nor that the congressman happens to be a Kennedy with all the glamour and tragedy that come with being born into that family. What makes it special is the way that Kennedy and Fried weave so much more into this riveting book. It’s the story of one man’s life, taken in the full context of a family bound by tragedies: the assassinations of two of his uncles before his birth, an aunt who’d had a lobotomy and inspired a whole advocacy organization for developmental disabilities, two siblings who struggled with cancer, and two parents with their own addictions and scandalous behaviors. His mother’s psychiatric illness was severe enough that her children obtained guardianship, and that’s just a smattering of all the Kennedy family events that are reported here.

The story unfolds against the backdrop of major news events in America, and combines itself with the complex story of parity legislation and the struggle to legitimize brain diseases as worthy of funding, awareness, and destigmatization. And if that’s not enough for one book to do, it all takes place within Patrick Kennedy’s poignant and powerful desire to gain his father’s approval. Ultimately, the son achieves an extended period of sobriety in the context of falling in love and starting a family, well into his 40s.

Nurse Jackie, despite her drug use and personal woes, is fictional and entertaining. “A Common Struggle” is a serious book and heartfelt look at how addiction and mental illness destroy lives; there is little doubt here that without the Kennedy machine for support and privilege, a 20-year-old compromised college student would not have been able to start or maintain a successful political career. Kudos to Mr. Kennedy for sharing his pain and for helping to break the stereotype that those with mental illness and substance abuse can only be found in jails or under bridges.
 

 

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Care,” which was released last fall (Baltimore: Johns Hopkins University Press).

Nurse Jackie is an amazing woman: She’s a fantastically competent and compassionate ER nurse who will do anything for her patients, and she is far better than the caricature ER docs she works with who all care more about their designer shoes and designer egos then about their jobs. She’s a wife – at least in the early episodes – and mother to two adorable girls with a life that includes Mommy and Me tap dancing classes. She somehow juggles it all.

In her fictional life as the star of a Showtime series, “Jackie Peyton” – played by actress Edie Falco, formerly known for her role as Tony Soprano’s wife, Carmela – manages even more: She does it all while popping pain pills by the handful throughout the work day and snorting whatever there is to snort. The interesting thing about Jackie is that her drug habit never interferes with her ability to function. There are no episodes where she makes mistakes or falls asleep. She doesn’t get too wired and is rarely irritable, and she certainly doesn’t pass out from overdoses. She shows up at work on time and never falls off her tightrope of responsibilities in the busy All Saints Hospital ER of New York City.

Without the drugs, she gets ill, but with them, she just functions. And she doesn’t just hold her own with a busy life; she also juggles the secret life of what it takes to get her daily fix, including daily lunchtime sex with the hospital pharmacist, who provides her with pain medicines for her aching back and doesn’t initially know that she’s married with children.

By Season 6, her personal life has broken down, and her daughter Grace, now an angry teenager with her own difficulties and secret life, notes that mom Jackie is incredibly good at hiding her drug use, and that no one can tell when she’s using.

With each season, Jackie’s personal life unwinds a little more, but it’s not because of the effects constant pill-popping has on her behavior; it’s because of the difficulties she has obtaining the drugs. If she could go to the store and buy large amounts of oxycontin and whatever else she takes, she’d have no problem. Her cauldron, however, is filled with constant lies and deception and the secret lives she lives to obtain drugs and to avoid boiling in her own self-made addictive mess.

I’m only at the end of Season 6, and Jackie already has had a year of sobriety – broken on her 1-year anniversary – and perhaps things will change in the final season, but so far, I’m struck by how well she manages to consistently function while living life high. It’s the perfect series to watch at the gym – entertaining, but it doesn’t ask much of the viewer.

You wouldn’t expect a review of a dark comedy TV series together with a review of a very serious memoir written by former Rep. Patrick J. Kennedy, but somehow, the two fit together for me.

In “A Common Struggle,” Patrick Kennedy and author Stephen Fried march through Kennedy’s long history of mental illness and substance abuse. Kennedy talks about his life in psychotherapy starting in childhood, related to his parents’ separation. He talks about the treatment he received in college and during his time as a state legislator in Providence, R.I., and how he parked far from his psychiatrist’s office so no one would learn he was in treatment.

Unfortunately, while he found treatment to be very helpful, he stopped when his doctor, Peter Kramer, became a celebrity in his own right after the publication of “Listening to Prozac” (New York: Penguin Books, 1997), and Kennedy became “spooked.” He goes on to talk about the many treatments – including lists of medications – he received over the years and his diagnosis of bipolar disorder, type II. But he doesn’t document what symptoms or episodes led to this diagnosis, and I couldn’t help but wonder how much of his mood disorder was part and parcel of his substance abuse problem. I imagine his doctors may have had the same problem.

So while Kennedy is vague about his psychiatric illness, he is much more forthcoming with his substance abuse problem. Like Nurse Jackie, he has the constant flow of pills – prescribed opiates starting with the diagnosis of a spinal tumor, a handful of Adderall here, some benzodiazepines there, and an enormous issue with alcohol on top of all that. Unlike Nurse Jackie, Kennedy wears the results of his addictions openly. He sleeps through mornings, and his schedulers know to accommodate this. He says things he otherwise wouldn’t while intoxicated, and he embarrasses himself and has others on edge. His mentor in the House of Representatives was Dick Gephardt, and Gephardt’s chief of staff summoned Kennedy to ask him to become chairman of the Democratic Congressional Campaign Committee – a tremendous honor for a 31-year-old congressman.

“There was, however, one catch,” the authors wrote. “ ‘If you do this,’ he said, ‘you can’t drink.’ ” Kennedy notes that he didn’t have the insight to realize how odd this was, and in reflection calls it his first intervention.

While most of his difficulties remained relatively private, one night he mixed Ambien and Phenergan, and in a state of confusion, he went for a drive and crashed into a Capitol Hill concrete barrier – an event that led to media coverage, scandal, and, as his chief of staff put it, “ ‘Patrick,’ he said, ‘we have a problem.’ ” While his father, Sen. Ted Kennedy, dismissed this as “a little fendah bendah,” the son made a public statement and checked himself into a rehab unit at the Mayo Clinic. It was to be the second of many attempts at rehab, his first having been in high school.

What makes “A Common Struggle” (New York: Blue Rider Press, 2015) so special is not just that it is a strikingly candid memoir of addiction and illness in a successful congressman, nor that the congressman happens to be a Kennedy with all the glamour and tragedy that come with being born into that family. What makes it special is the way that Kennedy and Fried weave so much more into this riveting book. It’s the story of one man’s life, taken in the full context of a family bound by tragedies: the assassinations of two of his uncles before his birth, an aunt who’d had a lobotomy and inspired a whole advocacy organization for developmental disabilities, two siblings who struggled with cancer, and two parents with their own addictions and scandalous behaviors. His mother’s psychiatric illness was severe enough that her children obtained guardianship, and that’s just a smattering of all the Kennedy family events that are reported here.

The story unfolds against the backdrop of major news events in America, and combines itself with the complex story of parity legislation and the struggle to legitimize brain diseases as worthy of funding, awareness, and destigmatization. And if that’s not enough for one book to do, it all takes place within Patrick Kennedy’s poignant and powerful desire to gain his father’s approval. Ultimately, the son achieves an extended period of sobriety in the context of falling in love and starting a family, well into his 40s.

Nurse Jackie, despite her drug use and personal woes, is fictional and entertaining. “A Common Struggle” is a serious book and heartfelt look at how addiction and mental illness destroy lives; there is little doubt here that without the Kennedy machine for support and privilege, a 20-year-old compromised college student would not have been able to start or maintain a successful political career. Kudos to Mr. Kennedy for sharing his pain and for helping to break the stereotype that those with mental illness and substance abuse can only be found in jails or under bridges.
 

 

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Care,” which was released last fall (Baltimore: Johns Hopkins University Press).

Nurse Jackie is an amazing woman: She’s a fantastically competent and compassionate ER nurse who will do anything for her patients, and she is far better than the caricature ER docs she works with who all care more about their designer shoes and designer egos then about their jobs. She’s a wife – at least in the early episodes – and mother to two adorable girls with a life that includes Mommy and Me tap dancing classes. She somehow juggles it all.

In her fictional life as the star of a Showtime series, “Jackie Peyton” – played by actress Edie Falco, formerly known for her role as Tony Soprano’s wife, Carmela – manages even more: She does it all while popping pain pills by the handful throughout the work day and snorting whatever there is to snort. The interesting thing about Jackie is that her drug habit never interferes with her ability to function. There are no episodes where she makes mistakes or falls asleep. She doesn’t get too wired and is rarely irritable, and she certainly doesn’t pass out from overdoses. She shows up at work on time and never falls off her tightrope of responsibilities in the busy All Saints Hospital ER of New York City.

Without the drugs, she gets ill, but with them, she just functions. And she doesn’t just hold her own with a busy life; she also juggles the secret life of what it takes to get her daily fix, including daily lunchtime sex with the hospital pharmacist, who provides her with pain medicines for her aching back and doesn’t initially know that she’s married with children.

By Season 6, her personal life has broken down, and her daughter Grace, now an angry teenager with her own difficulties and secret life, notes that mom Jackie is incredibly good at hiding her drug use, and that no one can tell when she’s using.

With each season, Jackie’s personal life unwinds a little more, but it’s not because of the effects constant pill-popping has on her behavior; it’s because of the difficulties she has obtaining the drugs. If she could go to the store and buy large amounts of oxycontin and whatever else she takes, she’d have no problem. Her cauldron, however, is filled with constant lies and deception and the secret lives she lives to obtain drugs and to avoid boiling in her own self-made addictive mess.

I’m only at the end of Season 6, and Jackie already has had a year of sobriety – broken on her 1-year anniversary – and perhaps things will change in the final season, but so far, I’m struck by how well she manages to consistently function while living life high. It’s the perfect series to watch at the gym – entertaining, but it doesn’t ask much of the viewer.

You wouldn’t expect a review of a dark comedy TV series together with a review of a very serious memoir written by former Rep. Patrick J. Kennedy, but somehow, the two fit together for me.

In “A Common Struggle,” Patrick Kennedy and author Stephen Fried march through Kennedy’s long history of mental illness and substance abuse. Kennedy talks about his life in psychotherapy starting in childhood, related to his parents’ separation. He talks about the treatment he received in college and during his time as a state legislator in Providence, R.I., and how he parked far from his psychiatrist’s office so no one would learn he was in treatment.

Unfortunately, while he found treatment to be very helpful, he stopped when his doctor, Peter Kramer, became a celebrity in his own right after the publication of “Listening to Prozac” (New York: Penguin Books, 1997), and Kennedy became “spooked.” He goes on to talk about the many treatments – including lists of medications – he received over the years and his diagnosis of bipolar disorder, type II. But he doesn’t document what symptoms or episodes led to this diagnosis, and I couldn’t help but wonder how much of his mood disorder was part and parcel of his substance abuse problem. I imagine his doctors may have had the same problem.

So while Kennedy is vague about his psychiatric illness, he is much more forthcoming with his substance abuse problem. Like Nurse Jackie, he has the constant flow of pills – prescribed opiates starting with the diagnosis of a spinal tumor, a handful of Adderall here, some benzodiazepines there, and an enormous issue with alcohol on top of all that. Unlike Nurse Jackie, Kennedy wears the results of his addictions openly. He sleeps through mornings, and his schedulers know to accommodate this. He says things he otherwise wouldn’t while intoxicated, and he embarrasses himself and has others on edge. His mentor in the House of Representatives was Dick Gephardt, and Gephardt’s chief of staff summoned Kennedy to ask him to become chairman of the Democratic Congressional Campaign Committee – a tremendous honor for a 31-year-old congressman.

“There was, however, one catch,” the authors wrote. “ ‘If you do this,’ he said, ‘you can’t drink.’ ” Kennedy notes that he didn’t have the insight to realize how odd this was, and in reflection calls it his first intervention.

While most of his difficulties remained relatively private, one night he mixed Ambien and Phenergan, and in a state of confusion, he went for a drive and crashed into a Capitol Hill concrete barrier – an event that led to media coverage, scandal, and, as his chief of staff put it, “ ‘Patrick,’ he said, ‘we have a problem.’ ” While his father, Sen. Ted Kennedy, dismissed this as “a little fendah bendah,” the son made a public statement and checked himself into a rehab unit at the Mayo Clinic. It was to be the second of many attempts at rehab, his first having been in high school.

What makes “A Common Struggle” (New York: Blue Rider Press, 2015) so special is not just that it is a strikingly candid memoir of addiction and illness in a successful congressman, nor that the congressman happens to be a Kennedy with all the glamour and tragedy that come with being born into that family. What makes it special is the way that Kennedy and Fried weave so much more into this riveting book. It’s the story of one man’s life, taken in the full context of a family bound by tragedies: the assassinations of two of his uncles before his birth, an aunt who’d had a lobotomy and inspired a whole advocacy organization for developmental disabilities, two siblings who struggled with cancer, and two parents with their own addictions and scandalous behaviors. His mother’s psychiatric illness was severe enough that her children obtained guardianship, and that’s just a smattering of all the Kennedy family events that are reported here.

The story unfolds against the backdrop of major news events in America, and combines itself with the complex story of parity legislation and the struggle to legitimize brain diseases as worthy of funding, awareness, and destigmatization. And if that’s not enough for one book to do, it all takes place within Patrick Kennedy’s poignant and powerful desire to gain his father’s approval. Ultimately, the son achieves an extended period of sobriety in the context of falling in love and starting a family, well into his 40s.

Nurse Jackie, despite her drug use and personal woes, is fictional and entertaining. “A Common Struggle” is a serious book and heartfelt look at how addiction and mental illness destroy lives; there is little doubt here that without the Kennedy machine for support and privilege, a 20-year-old compromised college student would not have been able to start or maintain a successful political career. Kudos to Mr. Kennedy for sharing his pain and for helping to break the stereotype that those with mental illness and substance abuse can only be found in jails or under bridges.
 

 

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Care,” which was released last fall (Baltimore: Johns Hopkins University Press).

 

“Still Down: What to Do When Antidepressants Fail” by Dean F. MacKinnon, MD, is a compact little book that recently was released by Johns Hopkins University Press. The title, “Still Down,” says it all. At 152 pages, the book is short, but not because it isn’t jammed full of information, but because – like the title – the writing is succinct and straight to the point; there’s no flowery detail, and Dr. MacKinnon doesn’t parse words. He tells the reader up front what his mission is, how the book is organized, and who his audience is. He’s an organized writer who captures the reader while getting his point across.

So how organized is Dr. MacKinnon? Each chapter is a clinical vignette, and the patients and doctors are given pseudonyms in alphabetical order: Ann sees Dr. Abernathy in chapter 1; then Bob sees Dr. Beasly in chapter 2. While “Still Down” is a series of nine short stories that make for a quick and interesting read, it provides enough information for a book twice the size. And in case the reader misses the point of the story (which is hard to imagine), each chapter ends with a summary of bullet points followed by case notes to clarify and expand on the points that were made during the vignette, and to add important commentary on the variety of decisions that might have been made for that particular patient’s story. Each chapter is short – a matter of pages, and there is no opportunity for the reader to get bored or tune out.

The book is divided into three distinct parts. In chapter 1, Ann suffers from “textbook depression.” Dr. MacKinnon uses this as an opportunity to educate the reader on the signs and symptoms of major depression, and the fact that treatment takes several weeks, during which side effects may occur before the resolution of symptoms. He talks about depression as a recurring medical illness, lists the available antidepressants by their class, and mentions that depression can be a result of other medical illnesses such as thyroid disease. In chapter 2, college student Bob remains depressed until he takes the medications as prescribed at a steady dose on a daily basis. This involves some coaxing, education, and even outreach by the school nurse, all while being cognizant of things that can go wrong in a young person on antidepressants.

In chapter 3, Carla is a patient of both Dr. Cohen and Dr. Clark, and she is a sensitive soul who sees herself as beyond help. In addition, she has difficulty tolerating medications, and it is only with much support that she is able to get an antidepressant up to a therapeutic dose that gives her relief from her distress. In fact, Dr. Clark resorts to using an older tricyclic antidepressant so he can monitor levels, and he discovers that Carla’s levels run much higher than expected from the dose she’s on, explaining some of her sensitivity to medication and propensity to side effects.

Part 2 of “Still Down” takes on the sticky issue of misdiagnosis. Darius sees Dr. Dennis for treatment of depression during a distressing period of his life when treatment with another doctor had already failed. After careful assessment, Dr. Dennis concludes that while antidepressants weren’t unreasonable to try, Darius is actually suffering from demoralization from losing his business, a miserable divorce, and a child custody battle. Dr. Dennis suggests therapy instead of medications at this point. This was where I found that, I, as a clinician, swayed from Dr. MacKinnon’s treatment approach: He emphasizes an inability to function and to feel pleasure as necessary elements of major depression, and Darius could do both to some extent. But still, his sleep was poor from shift work. He’d gained 30 pounds; he had little energy for activities besides work; and he was in a rut, unhappy, and having trouble entertaining his children when they visited and feeling too lazy to make changes. I thought Darius was depressed and demoralized, and while I agreed with the author that he needed psychotherapy, I also would have continued with medication trials. Dr. MacKinnon certainly doesn’t dismiss the idea of medication, and I found it helpful to revisit demoralization as a state responsible for many psychiatric symptoms.

Moving on in the section on misdiagnoses, the author talks about Evelyn, who turns out to have bipolar versus unipolar depression, and Frances, who carries an incorrect diagnosis of bipolar disorder, and has been overmedicated into a state of delirium. They both do well with time, thoughtful assessment, and treatment. Clinical pearls are threaded through these chapters.

“Depression-plus” is the title of the final section. Gary has major depression superimposed on his dysthymia, or persistent depressive disorder, and Dr. MacKinnon notes that people with constitutionally gloomy moods may have persistent sadness even after successful treatment of major depression. Here, there is a need for accommodation to a given personality state, and therapy can be helpful. Hannah, a patient of Dr. Hernandez, has what the author calls “depressed functioning.” This part I found most interesting, because I see this often in practice – a patient with a long history of being unmotivated and underfunctioning does not get fully (or any) better with antidepressants. Here, the functioning must improve before mood and self-esteem lift, and this is not an easy task. Finally, Irma has treatment-resistant depression, and with her doctor, considers a variety of augmentation medications as well as more novel strategies.

Simply stated, this book is a gem. It’s a very understandable guide to a very complex and frustrating issue, one that needs more time-consuming and thoughtful evaluation, and more intensive resources than a simple episode of depression usually entails.

Finally, I have to admit that I enjoyed Dr. MacKinnon’s quiet jabs at electronic medical records.
 

 

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has known Dr. MacKinnon for many years.

 

“Still Down: What to Do When Antidepressants Fail” by Dean F. MacKinnon, MD, is a compact little book that recently was released by Johns Hopkins University Press. The title, “Still Down,” says it all. At 152 pages, the book is short, but not because it isn’t jammed full of information, but because – like the title – the writing is succinct and straight to the point; there’s no flowery detail, and Dr. MacKinnon doesn’t parse words. He tells the reader up front what his mission is, how the book is organized, and who his audience is. He’s an organized writer who captures the reader while getting his point across.

So how organized is Dr. MacKinnon? Each chapter is a clinical vignette, and the patients and doctors are given pseudonyms in alphabetical order: Ann sees Dr. Abernathy in chapter 1; then Bob sees Dr. Beasly in chapter 2. While “Still Down” is a series of nine short stories that make for a quick and interesting read, it provides enough information for a book twice the size. And in case the reader misses the point of the story (which is hard to imagine), each chapter ends with a summary of bullet points followed by case notes to clarify and expand on the points that were made during the vignette, and to add important commentary on the variety of decisions that might have been made for that particular patient’s story. Each chapter is short – a matter of pages, and there is no opportunity for the reader to get bored or tune out.

The book is divided into three distinct parts. In chapter 1, Ann suffers from “textbook depression.” Dr. MacKinnon uses this as an opportunity to educate the reader on the signs and symptoms of major depression, and the fact that treatment takes several weeks, during which side effects may occur before the resolution of symptoms. He talks about depression as a recurring medical illness, lists the available antidepressants by their class, and mentions that depression can be a result of other medical illnesses such as thyroid disease. In chapter 2, college student Bob remains depressed until he takes the medications as prescribed at a steady dose on a daily basis. This involves some coaxing, education, and even outreach by the school nurse, all while being cognizant of things that can go wrong in a young person on antidepressants.

In chapter 3, Carla is a patient of both Dr. Cohen and Dr. Clark, and she is a sensitive soul who sees herself as beyond help. In addition, she has difficulty tolerating medications, and it is only with much support that she is able to get an antidepressant up to a therapeutic dose that gives her relief from her distress. In fact, Dr. Clark resorts to using an older tricyclic antidepressant so he can monitor levels, and he discovers that Carla’s levels run much higher than expected from the dose she’s on, explaining some of her sensitivity to medication and propensity to side effects.

Part 2 of “Still Down” takes on the sticky issue of misdiagnosis. Darius sees Dr. Dennis for treatment of depression during a distressing period of his life when treatment with another doctor had already failed. After careful assessment, Dr. Dennis concludes that while antidepressants weren’t unreasonable to try, Darius is actually suffering from demoralization from losing his business, a miserable divorce, and a child custody battle. Dr. Dennis suggests therapy instead of medications at this point. This was where I found that, I, as a clinician, swayed from Dr. MacKinnon’s treatment approach: He emphasizes an inability to function and to feel pleasure as necessary elements of major depression, and Darius could do both to some extent. But still, his sleep was poor from shift work. He’d gained 30 pounds; he had little energy for activities besides work; and he was in a rut, unhappy, and having trouble entertaining his children when they visited and feeling too lazy to make changes. I thought Darius was depressed and demoralized, and while I agreed with the author that he needed psychotherapy, I also would have continued with medication trials. Dr. MacKinnon certainly doesn’t dismiss the idea of medication, and I found it helpful to revisit demoralization as a state responsible for many psychiatric symptoms.

Moving on in the section on misdiagnoses, the author talks about Evelyn, who turns out to have bipolar versus unipolar depression, and Frances, who carries an incorrect diagnosis of bipolar disorder, and has been overmedicated into a state of delirium. They both do well with time, thoughtful assessment, and treatment. Clinical pearls are threaded through these chapters.

“Depression-plus” is the title of the final section. Gary has major depression superimposed on his dysthymia, or persistent depressive disorder, and Dr. MacKinnon notes that people with constitutionally gloomy moods may have persistent sadness even after successful treatment of major depression. Here, there is a need for accommodation to a given personality state, and therapy can be helpful. Hannah, a patient of Dr. Hernandez, has what the author calls “depressed functioning.” This part I found most interesting, because I see this often in practice – a patient with a long history of being unmotivated and underfunctioning does not get fully (or any) better with antidepressants. Here, the functioning must improve before mood and self-esteem lift, and this is not an easy task. Finally, Irma has treatment-resistant depression, and with her doctor, considers a variety of augmentation medications as well as more novel strategies.

Simply stated, this book is a gem. It’s a very understandable guide to a very complex and frustrating issue, one that needs more time-consuming and thoughtful evaluation, and more intensive resources than a simple episode of depression usually entails.

Finally, I have to admit that I enjoyed Dr. MacKinnon’s quiet jabs at electronic medical records.
 

 

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has known Dr. MacKinnon for many years.

 

“Still Down: What to Do When Antidepressants Fail” by Dean F. MacKinnon, MD, is a compact little book that recently was released by Johns Hopkins University Press. The title, “Still Down,” says it all. At 152 pages, the book is short, but not because it isn’t jammed full of information, but because – like the title – the writing is succinct and straight to the point; there’s no flowery detail, and Dr. MacKinnon doesn’t parse words. He tells the reader up front what his mission is, how the book is organized, and who his audience is. He’s an organized writer who captures the reader while getting his point across.

So how organized is Dr. MacKinnon? Each chapter is a clinical vignette, and the patients and doctors are given pseudonyms in alphabetical order: Ann sees Dr. Abernathy in chapter 1; then Bob sees Dr. Beasly in chapter 2. While “Still Down” is a series of nine short stories that make for a quick and interesting read, it provides enough information for a book twice the size. And in case the reader misses the point of the story (which is hard to imagine), each chapter ends with a summary of bullet points followed by case notes to clarify and expand on the points that were made during the vignette, and to add important commentary on the variety of decisions that might have been made for that particular patient’s story. Each chapter is short – a matter of pages, and there is no opportunity for the reader to get bored or tune out.

The book is divided into three distinct parts. In chapter 1, Ann suffers from “textbook depression.” Dr. MacKinnon uses this as an opportunity to educate the reader on the signs and symptoms of major depression, and the fact that treatment takes several weeks, during which side effects may occur before the resolution of symptoms. He talks about depression as a recurring medical illness, lists the available antidepressants by their class, and mentions that depression can be a result of other medical illnesses such as thyroid disease. In chapter 2, college student Bob remains depressed until he takes the medications as prescribed at a steady dose on a daily basis. This involves some coaxing, education, and even outreach by the school nurse, all while being cognizant of things that can go wrong in a young person on antidepressants.

In chapter 3, Carla is a patient of both Dr. Cohen and Dr. Clark, and she is a sensitive soul who sees herself as beyond help. In addition, she has difficulty tolerating medications, and it is only with much support that she is able to get an antidepressant up to a therapeutic dose that gives her relief from her distress. In fact, Dr. Clark resorts to using an older tricyclic antidepressant so he can monitor levels, and he discovers that Carla’s levels run much higher than expected from the dose she’s on, explaining some of her sensitivity to medication and propensity to side effects.

Part 2 of “Still Down” takes on the sticky issue of misdiagnosis. Darius sees Dr. Dennis for treatment of depression during a distressing period of his life when treatment with another doctor had already failed. After careful assessment, Dr. Dennis concludes that while antidepressants weren’t unreasonable to try, Darius is actually suffering from demoralization from losing his business, a miserable divorce, and a child custody battle. Dr. Dennis suggests therapy instead of medications at this point. This was where I found that, I, as a clinician, swayed from Dr. MacKinnon’s treatment approach: He emphasizes an inability to function and to feel pleasure as necessary elements of major depression, and Darius could do both to some extent. But still, his sleep was poor from shift work. He’d gained 30 pounds; he had little energy for activities besides work; and he was in a rut, unhappy, and having trouble entertaining his children when they visited and feeling too lazy to make changes. I thought Darius was depressed and demoralized, and while I agreed with the author that he needed psychotherapy, I also would have continued with medication trials. Dr. MacKinnon certainly doesn’t dismiss the idea of medication, and I found it helpful to revisit demoralization as a state responsible for many psychiatric symptoms.

Moving on in the section on misdiagnoses, the author talks about Evelyn, who turns out to have bipolar versus unipolar depression, and Frances, who carries an incorrect diagnosis of bipolar disorder, and has been overmedicated into a state of delirium. They both do well with time, thoughtful assessment, and treatment. Clinical pearls are threaded through these chapters.

“Depression-plus” is the title of the final section. Gary has major depression superimposed on his dysthymia, or persistent depressive disorder, and Dr. MacKinnon notes that people with constitutionally gloomy moods may have persistent sadness even after successful treatment of major depression. Here, there is a need for accommodation to a given personality state, and therapy can be helpful. Hannah, a patient of Dr. Hernandez, has what the author calls “depressed functioning.” This part I found most interesting, because I see this often in practice – a patient with a long history of being unmotivated and underfunctioning does not get fully (or any) better with antidepressants. Here, the functioning must improve before mood and self-esteem lift, and this is not an easy task. Finally, Irma has treatment-resistant depression, and with her doctor, considers a variety of augmentation medications as well as more novel strategies.

Simply stated, this book is a gem. It’s a very understandable guide to a very complex and frustrating issue, one that needs more time-consuming and thoughtful evaluation, and more intensive resources than a simple episode of depression usually entails.

Finally, I have to admit that I enjoyed Dr. MacKinnon’s quiet jabs at electronic medical records.
 

 

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has known Dr. MacKinnon for many years.

I have to start this column with a disclaimer: I live in Maryland, and like most Marylanders, I am a Democrat. We’re one of the bluest states – today, you’re welcome to give that statement two meanings – and as such, I live in what today has been somewhat pejoratively called the educated, liberal, elitist, East Coast, “Hillary bubble,” where I can be one of the first to admit that I’m not in touch with the country as a whole. I’ll add one more disclaimer: I married a man I fell in love with during my freshman year of college.

As a teenager, I didn’t care much about politics, but my then-boyfriend was a political science major who was a Republican and spent a summer on Capitol Hill. So my blue world is just a bit influenced by decades of living, quite happily, in a bipartisan household. The adult children seem to have settled in as Democrats; the dogs have split parties.

My election anxiety started in late winter. I was watching the news, and there were reports of polls putting Donald Trump in first place among the 17 Republican candidates. I called my husband at work.

“I thought Donald Trump was a joke, a reality TV thing.”

I hadn’t been paying much attention, and my husband, who remains calm and wise, reassured me that it was months until the primaries, and that Trump would not be the Republican nominee.

Time went on, and my anxiety grew. I found myself caught up in Facebook posts, and I mostly read like-minded rhetoric. In March, I was on vacation and found myself terribly distraught about a colleague’s post. He talked about his anxiety about the election, likened Trump to Hitler or Stalin, and asked what people would do if they found out their friends supported Trump. Should one end their friendship? I have strong viewpoints, and if I limited my friends only to those who agree with me on controversial issues, I would be rather lonely. I started to argue with my colleague’s friends – they likened voting for Trump to being anti-Semitic, and many felt one should end friendships with people who supported him. I decided I didn’t want to be Facebook friends with people who made their friendships contingent on how I vote. This was different, I was told, because of Trump’s xenophobia, and I ended up “unfriending” my colleague (only on Facebook), and turning off all my social media for a while.

When Trump won the Republican nomination, my husband told me I should be happy: This ensured that Hillary Clinton would win the election. He would not vote for Trump; our Republican governor, Larry Hogan, was not supporting Trump; it seemed that neither the Republicans nor the Democrats were enthusiastic about his nomination, and my anxiety waned.

A colleague noted he was having trouble listening to Trump supporters in therapy sessions. In my entire practice, only one patient mentioned being a Trump supporter, a transplant from a Southern state. It was not a major focus of therapy, except that he used it as an example of how he felt out of place in Maryland, and I had sympathy for his sense of isolation here.

My anxiety waned in the weeks before the election, though my patients talked more and more about it. I posted a countdown on Facebook – this nightmare of an election has divided our country, and given a voice to vulgarity and hate speech. While I still would not end a good friendship over a vote, I see Trump as unkind and undignified. He invests energy in being purposely cruel. And since I apparently don’t understand the “non-elitist” voter, it doesn’t make sense to me that disenfranchised blue collar workers hope a privileged billionaire with a history of deceit and mistreating others will be anyone’s savior. At one point, The New York Times’ The Upshot gave Trump a 9% chance of winning. If you are a Trump supporter, please don’t feel insulted, and I would be happy to try to understand your enthusiasm for his presidency.

On Tuesday night, my husband had to be out of town. My friend, psychiatrist Anne Hanson, came to “babysit” me as I didn’t want to be alone as the returns came in – perhaps I had some sense that Clinton could possibly lose. We ordered Indian food, and together, we sat in front of the television, completely dumbfounded.

The morning after came, and Maryland psychiatrists started posting about their despair on our listserv. Others offered support; one suggested that Trump might be just what our country needs; and numerous psychiatrists have said this a call to action, a time to get more involved. On Thursday morning, one psychiatrist noted: “Seeing my patients the day after the election this week felt very much like seeing patients the day after 9/11. What was different though was that on 9/11, we were all in high distress, sadness, and fear. However, unlike 9/11, this time I have the uncanny experience of a few patients that were rejoicing or simply glad that Trump had won.”

My social media sites looked the same – disbelief, distress, obscenities, words of comfort, calls to action. Journalist Andrew Solomon posted on Twitter this morning: “It’s begun. A friend was walking in NYC and someone driving a U-Haul yelled, ‘Hey, homo. So what do you think of President Donald Trump?’” Meanwhile, Trump supporters were reportedly attacked with punches, eggs, and bottles at a protest rally in California. The country remains divided: President Obama and Hillary Clinton remind us that we should give Mr. Trump a chance and support his efforts as we are all one country, while thousands protest his victory in cities across the country.

What will President Trump’s election mean for psychiatry? The American Psychiatric Association gave money to support both candidates, and in the spirit of working together, President Maria A. Oquendo has sent him a letter of congratulations. There is nothing to be gained by having an antagonistic relationship with our country’s leader.

Trump has promised to repeal the Affordable Care Act on his first day in office. What will that mean? Will those covered by ACA policies suddenly lose their coverage? I can’t imagine that would be the case, or at least I hope not. And what about all the time, money, and effort that have been invested in Meaningful Use and the planned transition to MACRA to collect data? Do those systems vanish? I have a son who is about to turn 26 and works as a freelance writer for a fantasy sports website. Will he be able to get health insurance?

And Mr. Trump is a bit unpredictable. He has changed his political party affiliation seven times over the last 2 decades, and until 3 years ago, he was a registered Democrat. Perhaps he won’t repeal the ACA on day 1. Or day 2. We’ll have to wait and see, but in the long run, I think we all have to worry that there might be people with health insurance now who won’t have it in the future.

The mystery of Trump is that he ran a campaign without exposing any strategies. His health care plan boiled down to, We’ll get rid of the lines around the states; there will be open competition with health insurers; and it will be a beautiful thing. (My quote may be inexact, but I took careful note of it during one of the debates.)

Finally, we can ask what will happen with the Mental Health Reform Act of 2016, originally known as the Murphy bill or The Helping Families in Mental Health Crisis Act. The bill, calling for major mental health reforms, passed in the House by a vote of 422-2, and awaits a vote in the Senate during the lame duck session. While the APA supports passage of the bill, there is a great deal of controversy surrounding it, and in a Politico article, former congressman and current mental advocate Patrick Kennedy is quoted as saying that in its current form, the bill should not be passed. The latest version is “‘watered down’ and does nothing more than ‘reallocate money around block grants’ when it should instead ‘try for higher reimbursement rates’ for behavioral health providers. ‘Passing that bill will take the wind out of the sails for real reform,’” he added. “‘Kick it to the next Congress and the new administration to do this the right way.’” How the new administration will react to mental health reform is anyone’s guess.

Anne and I were scheduled to be on NPR’s Diane Rehm radio show this morning to talk about our new book; the unexpected election results led to a postponement while coverage of the election continues. My countdown until the end of this nightmare election reached 0, and I had planned to extend a Facebook re-friend request to my colleague and see if he’d have me back, but election coverage and speculation continue. It may be time for me to take another social media break.

The sun is shining in Baltimore today, and we certainly live in interesting times.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” which was released Nov. 1 by Johns Hopkins University Press.

I have to start this column with a disclaimer: I live in Maryland, and like most Marylanders, I am a Democrat. We’re one of the bluest states – today, you’re welcome to give that statement two meanings – and as such, I live in what today has been somewhat pejoratively called the educated, liberal, elitist, East Coast, “Hillary bubble,” where I can be one of the first to admit that I’m not in touch with the country as a whole. I’ll add one more disclaimer: I married a man I fell in love with during my freshman year of college.

As a teenager, I didn’t care much about politics, but my then-boyfriend was a political science major who was a Republican and spent a summer on Capitol Hill. So my blue world is just a bit influenced by decades of living, quite happily, in a bipartisan household. The adult children seem to have settled in as Democrats; the dogs have split parties.

My election anxiety started in late winter. I was watching the news, and there were reports of polls putting Donald Trump in first place among the 17 Republican candidates. I called my husband at work.

“I thought Donald Trump was a joke, a reality TV thing.”

I hadn’t been paying much attention, and my husband, who remains calm and wise, reassured me that it was months until the primaries, and that Trump would not be the Republican nominee.

Time went on, and my anxiety grew. I found myself caught up in Facebook posts, and I mostly read like-minded rhetoric. In March, I was on vacation and found myself terribly distraught about a colleague’s post. He talked about his anxiety about the election, likened Trump to Hitler or Stalin, and asked what people would do if they found out their friends supported Trump. Should one end their friendship? I have strong viewpoints, and if I limited my friends only to those who agree with me on controversial issues, I would be rather lonely. I started to argue with my colleague’s friends – they likened voting for Trump to being anti-Semitic, and many felt one should end friendships with people who supported him. I decided I didn’t want to be Facebook friends with people who made their friendships contingent on how I vote. This was different, I was told, because of Trump’s xenophobia, and I ended up “unfriending” my colleague (only on Facebook), and turning off all my social media for a while.

When Trump won the Republican nomination, my husband told me I should be happy: This ensured that Hillary Clinton would win the election. He would not vote for Trump; our Republican governor, Larry Hogan, was not supporting Trump; it seemed that neither the Republicans nor the Democrats were enthusiastic about his nomination, and my anxiety waned.

A colleague noted he was having trouble listening to Trump supporters in therapy sessions. In my entire practice, only one patient mentioned being a Trump supporter, a transplant from a Southern state. It was not a major focus of therapy, except that he used it as an example of how he felt out of place in Maryland, and I had sympathy for his sense of isolation here.

My anxiety waned in the weeks before the election, though my patients talked more and more about it. I posted a countdown on Facebook – this nightmare of an election has divided our country, and given a voice to vulgarity and hate speech. While I still would not end a good friendship over a vote, I see Trump as unkind and undignified. He invests energy in being purposely cruel. And since I apparently don’t understand the “non-elitist” voter, it doesn’t make sense to me that disenfranchised blue collar workers hope a privileged billionaire with a history of deceit and mistreating others will be anyone’s savior. At one point, The New York Times’ The Upshot gave Trump a 9% chance of winning. If you are a Trump supporter, please don’t feel insulted, and I would be happy to try to understand your enthusiasm for his presidency.

On Tuesday night, my husband had to be out of town. My friend, psychiatrist Anne Hanson, came to “babysit” me as I didn’t want to be alone as the returns came in – perhaps I had some sense that Clinton could possibly lose. We ordered Indian food, and together, we sat in front of the television, completely dumbfounded.

The morning after came, and Maryland psychiatrists started posting about their despair on our listserv. Others offered support; one suggested that Trump might be just what our country needs; and numerous psychiatrists have said this a call to action, a time to get more involved. On Thursday morning, one psychiatrist noted: “Seeing my patients the day after the election this week felt very much like seeing patients the day after 9/11. What was different though was that on 9/11, we were all in high distress, sadness, and fear. However, unlike 9/11, this time I have the uncanny experience of a few patients that were rejoicing or simply glad that Trump had won.”

My social media sites looked the same – disbelief, distress, obscenities, words of comfort, calls to action. Journalist Andrew Solomon posted on Twitter this morning: “It’s begun. A friend was walking in NYC and someone driving a U-Haul yelled, ‘Hey, homo. So what do you think of President Donald Trump?’” Meanwhile, Trump supporters were reportedly attacked with punches, eggs, and bottles at a protest rally in California. The country remains divided: President Obama and Hillary Clinton remind us that we should give Mr. Trump a chance and support his efforts as we are all one country, while thousands protest his victory in cities across the country.

What will President Trump’s election mean for psychiatry? The American Psychiatric Association gave money to support both candidates, and in the spirit of working together, President Maria A. Oquendo has sent him a letter of congratulations. There is nothing to be gained by having an antagonistic relationship with our country’s leader.

Trump has promised to repeal the Affordable Care Act on his first day in office. What will that mean? Will those covered by ACA policies suddenly lose their coverage? I can’t imagine that would be the case, or at least I hope not. And what about all the time, money, and effort that have been invested in Meaningful Use and the planned transition to MACRA to collect data? Do those systems vanish? I have a son who is about to turn 26 and works as a freelance writer for a fantasy sports website. Will he be able to get health insurance?

And Mr. Trump is a bit unpredictable. He has changed his political party affiliation seven times over the last 2 decades, and until 3 years ago, he was a registered Democrat. Perhaps he won’t repeal the ACA on day 1. Or day 2. We’ll have to wait and see, but in the long run, I think we all have to worry that there might be people with health insurance now who won’t have it in the future.

The mystery of Trump is that he ran a campaign without exposing any strategies. His health care plan boiled down to, We’ll get rid of the lines around the states; there will be open competition with health insurers; and it will be a beautiful thing. (My quote may be inexact, but I took careful note of it during one of the debates.)

Finally, we can ask what will happen with the Mental Health Reform Act of 2016, originally known as the Murphy bill or The Helping Families in Mental Health Crisis Act. The bill, calling for major mental health reforms, passed in the House by a vote of 422-2, and awaits a vote in the Senate during the lame duck session. While the APA supports passage of the bill, there is a great deal of controversy surrounding it, and in a Politico article, former congressman and current mental advocate Patrick Kennedy is quoted as saying that in its current form, the bill should not be passed. The latest version is “‘watered down’ and does nothing more than ‘reallocate money around block grants’ when it should instead ‘try for higher reimbursement rates’ for behavioral health providers. ‘Passing that bill will take the wind out of the sails for real reform,’” he added. “‘Kick it to the next Congress and the new administration to do this the right way.’” How the new administration will react to mental health reform is anyone’s guess.

Anne and I were scheduled to be on NPR’s Diane Rehm radio show this morning to talk about our new book; the unexpected election results led to a postponement while coverage of the election continues. My countdown until the end of this nightmare election reached 0, and I had planned to extend a Facebook re-friend request to my colleague and see if he’d have me back, but election coverage and speculation continue. It may be time for me to take another social media break.

The sun is shining in Baltimore today, and we certainly live in interesting times.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” which was released Nov. 1 by Johns Hopkins University Press.

I have to start this column with a disclaimer: I live in Maryland, and like most Marylanders, I am a Democrat. We’re one of the bluest states – today, you’re welcome to give that statement two meanings – and as such, I live in what today has been somewhat pejoratively called the educated, liberal, elitist, East Coast, “Hillary bubble,” where I can be one of the first to admit that I’m not in touch with the country as a whole. I’ll add one more disclaimer: I married a man I fell in love with during my freshman year of college.

As a teenager, I didn’t care much about politics, but my then-boyfriend was a political science major who was a Republican and spent a summer on Capitol Hill. So my blue world is just a bit influenced by decades of living, quite happily, in a bipartisan household. The adult children seem to have settled in as Democrats; the dogs have split parties.

My election anxiety started in late winter. I was watching the news, and there were reports of polls putting Donald Trump in first place among the 17 Republican candidates. I called my husband at work.

“I thought Donald Trump was a joke, a reality TV thing.”

I hadn’t been paying much attention, and my husband, who remains calm and wise, reassured me that it was months until the primaries, and that Trump would not be the Republican nominee.

Time went on, and my anxiety grew. I found myself caught up in Facebook posts, and I mostly read like-minded rhetoric. In March, I was on vacation and found myself terribly distraught about a colleague’s post. He talked about his anxiety about the election, likened Trump to Hitler or Stalin, and asked what people would do if they found out their friends supported Trump. Should one end their friendship? I have strong viewpoints, and if I limited my friends only to those who agree with me on controversial issues, I would be rather lonely. I started to argue with my colleague’s friends – they likened voting for Trump to being anti-Semitic, and many felt one should end friendships with people who supported him. I decided I didn’t want to be Facebook friends with people who made their friendships contingent on how I vote. This was different, I was told, because of Trump’s xenophobia, and I ended up “unfriending” my colleague (only on Facebook), and turning off all my social media for a while.

When Trump won the Republican nomination, my husband told me I should be happy: This ensured that Hillary Clinton would win the election. He would not vote for Trump; our Republican governor, Larry Hogan, was not supporting Trump; it seemed that neither the Republicans nor the Democrats were enthusiastic about his nomination, and my anxiety waned.

A colleague noted he was having trouble listening to Trump supporters in therapy sessions. In my entire practice, only one patient mentioned being a Trump supporter, a transplant from a Southern state. It was not a major focus of therapy, except that he used it as an example of how he felt out of place in Maryland, and I had sympathy for his sense of isolation here.

My anxiety waned in the weeks before the election, though my patients talked more and more about it. I posted a countdown on Facebook – this nightmare of an election has divided our country, and given a voice to vulgarity and hate speech. While I still would not end a good friendship over a vote, I see Trump as unkind and undignified. He invests energy in being purposely cruel. And since I apparently don’t understand the “non-elitist” voter, it doesn’t make sense to me that disenfranchised blue collar workers hope a privileged billionaire with a history of deceit and mistreating others will be anyone’s savior. At one point, The New York Times’ The Upshot gave Trump a 9% chance of winning. If you are a Trump supporter, please don’t feel insulted, and I would be happy to try to understand your enthusiasm for his presidency.

On Tuesday night, my husband had to be out of town. My friend, psychiatrist Anne Hanson, came to “babysit” me as I didn’t want to be alone as the returns came in – perhaps I had some sense that Clinton could possibly lose. We ordered Indian food, and together, we sat in front of the television, completely dumbfounded.

The morning after came, and Maryland psychiatrists started posting about their despair on our listserv. Others offered support; one suggested that Trump might be just what our country needs; and numerous psychiatrists have said this a call to action, a time to get more involved. On Thursday morning, one psychiatrist noted: “Seeing my patients the day after the election this week felt very much like seeing patients the day after 9/11. What was different though was that on 9/11, we were all in high distress, sadness, and fear. However, unlike 9/11, this time I have the uncanny experience of a few patients that were rejoicing or simply glad that Trump had won.”

My social media sites looked the same – disbelief, distress, obscenities, words of comfort, calls to action. Journalist Andrew Solomon posted on Twitter this morning: “It’s begun. A friend was walking in NYC and someone driving a U-Haul yelled, ‘Hey, homo. So what do you think of President Donald Trump?’” Meanwhile, Trump supporters were reportedly attacked with punches, eggs, and bottles at a protest rally in California. The country remains divided: President Obama and Hillary Clinton remind us that we should give Mr. Trump a chance and support his efforts as we are all one country, while thousands protest his victory in cities across the country.

What will President Trump’s election mean for psychiatry? The American Psychiatric Association gave money to support both candidates, and in the spirit of working together, President Maria A. Oquendo has sent him a letter of congratulations. There is nothing to be gained by having an antagonistic relationship with our country’s leader.

Trump has promised to repeal the Affordable Care Act on his first day in office. What will that mean? Will those covered by ACA policies suddenly lose their coverage? I can’t imagine that would be the case, or at least I hope not. And what about all the time, money, and effort that have been invested in Meaningful Use and the planned transition to MACRA to collect data? Do those systems vanish? I have a son who is about to turn 26 and works as a freelance writer for a fantasy sports website. Will he be able to get health insurance?

And Mr. Trump is a bit unpredictable. He has changed his political party affiliation seven times over the last 2 decades, and until 3 years ago, he was a registered Democrat. Perhaps he won’t repeal the ACA on day 1. Or day 2. We’ll have to wait and see, but in the long run, I think we all have to worry that there might be people with health insurance now who won’t have it in the future.

The mystery of Trump is that he ran a campaign without exposing any strategies. His health care plan boiled down to, We’ll get rid of the lines around the states; there will be open competition with health insurers; and it will be a beautiful thing. (My quote may be inexact, but I took careful note of it during one of the debates.)

Finally, we can ask what will happen with the Mental Health Reform Act of 2016, originally known as the Murphy bill or The Helping Families in Mental Health Crisis Act. The bill, calling for major mental health reforms, passed in the House by a vote of 422-2, and awaits a vote in the Senate during the lame duck session. While the APA supports passage of the bill, there is a great deal of controversy surrounding it, and in a Politico article, former congressman and current mental advocate Patrick Kennedy is quoted as saying that in its current form, the bill should not be passed. The latest version is “‘watered down’ and does nothing more than ‘reallocate money around block grants’ when it should instead ‘try for higher reimbursement rates’ for behavioral health providers. ‘Passing that bill will take the wind out of the sails for real reform,’” he added. “‘Kick it to the next Congress and the new administration to do this the right way.’” How the new administration will react to mental health reform is anyone’s guess.

Anne and I were scheduled to be on NPR’s Diane Rehm radio show this morning to talk about our new book; the unexpected election results led to a postponement while coverage of the election continues. My countdown until the end of this nightmare election reached 0, and I had planned to extend a Facebook re-friend request to my colleague and see if he’d have me back, but election coverage and speculation continue. It may be time for me to take another social media break.

The sun is shining in Baltimore today, and we certainly live in interesting times.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” which was released Nov. 1 by Johns Hopkins University Press.