How To Talk About Suicide In A Way That’s Actually Helpful

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Trauma-The Rest of Us

I clicked on the New York Times website, planning to make some minor changes in my account there. I saw a video link front and center on the page, arrow ready to click, and was compelled to watch it. What followed was raw, first-hand video footage of the recent school shooting in Parkland, Florida, complete with screams, repeated loud gunfire and a palpable sense of terror that was hard to miss, even via this medium. I watched the opening frames and then had to stop. I could not bear to watch even thirty more seconds of such terrifyingly intimate trauma. I was not there, but in those few seconds I felt an almost uncanny connection to those who were at the center of the tragedy.

You might remember that I wrote a column entitled Emotional Trauma in September last year discussing some of these issues. I felt that the subject needed further attention in light of yet another school shooting and the aftermath of such a horrible event.

Parkland, Florida. Fourteen students and three teachers killed. A dozen more injured. The worst school shooting since Sandy Hook Elementary School in 2012, where twenty children and six teachers died.

There have been two hundred and ninety school shootings since early 2013. The data can be viewed from multiple perspectives, including mass killings, accidental discharge of firearms, after hours fights in parking lots and suicides, but that is not the reason for my revisiting this subject today. No matter how the data for these terrible events are tabulated and categorized, there is a common thread for the public, the rest of us.

We can see the shooting, hear the screams, and experience the terror almost in real time thanks to the ubiquity of portable audio and video devices that make everyone a potential journalist. Even if we are hundreds or thousands of miles away from the event, we can be traumatized repeatedly by viewing and hearing these accounts over and over again. Why are we more exposed to these incidents now than in the past?

Everyone has a cell phone, and many of them are ready to shoot still photographs, video, record audio and stream real time video. We are so used to seeing these devices that they are almost invisible to us. We are also hyperconnected to our friends, families and the world like never before through social media and other outlets. Facebook, Twitter, Periscope, SnapChat, and YouTube keep us messaging, talking, chatting and sharing twenty-four hours a day. There are obvious upsides to this, but one of the downsides is the possibility of live-streaming traumatic events.

While it is true that traditional news media outlets have always brought us graphic images and related content, they were often relegated to specific time slots or print, and one could choose to tune in or pick up the content to watch or read it. Now, exposure can be ongoing and repeated via outlets as diverse as newspapers, phones, television, laptops or other internet providers. Social media also offers unfiltered violent stories and graphic images, without the opportunity to edit content and soften the emotional trauma that results. The web has virtually unlimited reach and scope, with countless sources and a never ending supply of materials to sift through. We have all had the experience of looking for something specific on the internet, only to find ourselves going down the rabbit hole with no shutoff valve for the firehose of information that presents itself to us.

One 2013 study after the Boston Marathon bombing showed that those who were exposed to at least six hours of media coverage of the bombing reported higher levels of acute stress than those with direct exposure to the event itself. Some think that this might be because an acute event is experienced, dealt with and eventually ends, whereas repeated media exposure to the trauma keeps it in mind and much more present in ongoing thoughts.

What symptoms might present as a result of repeated exposure to traumatic events, even in second hand ways? One might become hyper-vigilant to their surroundings, scanning for danger. Feelings of sadness, anger, hopelessness, or guilt may come up, followed by avoidance of certain people, places or circumstances. Social withdrawal may manifest, just at the time that connections are most needed. Sleep and appetite may suffer. We may become not more, but less sensitive to violent acts, with an attitude of “oh, another one” when confronted with the news of a dramatic event such as a shooting. We may become afraid, have a decreased sense of safety and forget to take good care of ourselves.

How should we cope with this new world, when news seems to be increasingly bad, violent acts are frequent and our exposure to trauma is so commonplace?

First, we should realize that there is no right way to deal with stress, trauma and emotional distress. People cope with trauma, loss and grief in many different ways, though there are patterns and similarities. Find someone and talk if you need to; listen if that works better for you. Realize that disasters, be they natural or man made, are often huge in scope materially, physically, financially and emotionally. We, in contrast, are small, and sometimes feel even more so when traumatized. Set realistic expectations for your response to the acute event, and to the pace at which you expect to recover. Deeper hurts often take much longer to heal than we expect them to, and willing ourselves to get past them quicker is not always the best course of action.

Social connections are important, especially in times of tragedy. Stay connected with family, friends and coworkers. If separated by physical or emotional distance, make an effort to reconnect. Remember that time heals. It is not often apparent in the days immediately following a traumatic event, but it is very often true. Focus on getting back to your routine, paying attention to those day to day tasks and activities that ground you. Schedule yourself back to normal. Make time for the mundane, as it gives your life structure and makes its fabric richer over time.

Disconnect from the trauma and its aftermath on social media, the internet and other outlets. Do not let yourself disconnect from information that will help you heal, but don’t subject yourself to repeated traumatization. Schedule positive activities. Manage your emotions by writing, journaling, listening to music, getting out into nature, spending time with those who accept you for who you are and allow you to express yourself in whatever way is healing for you.

Honor losses when they come, as they do for us all, but focus on your future, the positive people, places, and things that you truly care about that will carry you forward into the rest of your life.

This piece was first published in the Aiken (SC) Standard on February 26, 2018.

The Goldwater Rule

You may have heard of the Goldwater rule, given the state of the world and our current American politics.

What is it, how did it come to be, and why was it considered necessary? Is it relevant today, or does it need to be modified or abolished? I will attempt to explain the Goldwater rule, answer these questions, and then put the rule in the context of our current political climate, leaving you to make your own decisions about its relevance.

Barry Goldwater was an American politician and businessman who was the Republican candidate in the 1964 presidential election. He was a staunch conservative from Arizona who had labored in his family business, was a transport pilot in World War II, and was later a member of the Air Force Reserve. He had been elected senator from Arizona twice before the 1964 contest, and went on to be elected to that post three more times after losing the presidential race by a landslide.

In 1964, a publication called Fact published an article entitled “The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater”. In this piece, Fact had asked 12,356 psychiatrists during the political campaign with Lyndon Baines Johnson about Goldwater’s fitness to serve as president. The publication’s cover piece screamed “1189 Psychiatrists Say Goldwater Is Psychologically Unfit to Be President!”

The comments made by many of the psychiatrists who responded were harsh, negative, and sometimes just downright odd. They referred to Goldwater’s state of “chronic psychosis, grandiosity and paranoid schizophrenia”. They compared him to Mao, Hitler, Castro, Stalin, and “other known schizophrenic leaders”. It was thought that some of the responders might well have been couching their political biases in psychiatric terms. Although some of them seemed to be frightened of Goldwater and what he stood for, they could not state in specific terms that he was indeed unfit to be president of the United States.

The piece in Fact may have cost Goldwater a large number of potential votes on the way to his loss. He later sued Fact for libel and won $75,000.

The American Psychiatric Association (APA) is the oldest medical association in the United States, founded in 1844. It was the largest psychiatric organization in the world, with 37,000 physician members who specialize in the diagnosis, treatment, prevention and research of mental illness. The APA quickly responded to this piece and stated that the Fact article was not medically valid, was a hodgepodge of personal political opinions and would be disavowed by the organization. In 1973, a more formal response was formulated in the text and substance of the Goldwater rule. This rule became section 7.3 in the APA’s Principles of Medical Ethics.

It said that it was unethical for a psychiatrist to give a professional opinion about public figures that they had not personally examined, and from whom they had not obtained consent to discuss their mental health in public statements. It was also noted that a psychiatrist could offer expertise about psychiatric issues in general.

Other professional organizations had their own views on this issue. The American Psychological Association had a similar rule in its Ethics Code. The AMA, in the fall of 2017, revisited this concern through its Council on Ethics and Judicial Affairs, revising its own AMA Code of Medical Ethics. In 2016-17, several psychiatrists and clinical psychologists faced criticism by their peers and others for supposedly violating the Goldwater rule.

Related to this, in the APA Newsroom section of their website, Joseph Schachter, MD, PhD, retired and living in New York City, said that “mental health providers and psychiatrists may make political comments as any other citizen, but without selecting a psychiatric diagnosis.”

Fast forward to the presidential campaign of 2016 and the subsequent election of Donald J. Trump as president of the United States. A veritable firestorm of accusations, suppositions, outright guesses and armchair diagnoses have flooded the media in recent months, all concerning themselves with the fitness of the forty fifth president of he United States to occupy his office and carry out his many duties in a rational and professional way.

In March of 2017, the APA modified the Goldwater rule and prohibited any comments on the mental health of a public figure.

In October of 2017, the APA released a statement that reiterated the intent of the Goldwater rule, and also explained the importance of public education about mental illness. As there was already a cohort of professionals who were beginning to feel a sense of urgency about enlightening the public about the dangers of the current presidential administration, the APA also stated that a “duty to warn” was a legal concept that only applied if there was a bonafide physician-patient relationship in place.

On January 6, 2018, a vox.com article by Elizabeth Barclay examined “the case for evaluating the president’s mental capacity-by force if necessary”. At issue for some psychiatrists including Bandy Lee, associate professor in forensic psychiatry at the Yale School of Medicine, was whether the president was really unwell, or sometimes just behaving badly.

Lee and some of her colleagues have been leading the call for an evaluation. She and Judith Herman of Harvard and Robert Jay Lifton of Columbia have previously stated that President Trump was “further unraveling”. Some of her opposition psychiatrists have stated that she is violating the Goldwater rule by speaking and writing on the issue. She counters by stating that her opinions and position are her own. “We are not diagnosing him-we keep with the Goldwater rule.” She maintains that they are concerned with behaviors, tweeting patterns, paranoia, being very susceptible to fawning, denying his own voice on tape, and other behaviors that bode poorly for professional performance and good judgment.

Some prominent psychiatrists, such as Jeffrey Lieberman, former APA president, disagree with Lee and colleagues, although she maintains that she is making an educated assessment of dangerousness based on years of study and experience. She does not purport to make a diagnosis of the president, but says that she and her collaborators are simply “fulfilling a routine, public expectation of duty that comes with our profession”.

A January 10, 2018, Politico article by Bandy Lee and Leonard Glass was titled “We’re Psychiatrists. It’s Our Duty to Question the President’s Mental State”. These authors made the claim that by altering and modifying the Goldwater rule over the last twelve months, the the APA has basally turned it into a gag rule. They posit that “an individual’s dangerousness, however, can be reliably assessed by interviewing coworkers and intimates, reviewing the individuals past statements and behaviors, reviewing police reports, and, crucially, assessing context. While an in-person interview can be quite useful, it is not strictly required to assess danger.”

So, now you know what the Goldwater rule is, how It came about and why, who it impacts, and how it is being modified and challenged in our current political circumstances.

Are some rules made to be broken?
Does the current political climate call for, or even mandate, the injection of psychiatric principles into politics?

As a psychiatrist, I have my own opinion. I hope that by sharing this information with you, I have stimulated you to form your own.

 

 

Calling Dr. Watson

Will there come a time when computers or robots will replace human doctors? I know I’ve thought about it. Have you?

An article in the Sunday, June 4, 2017 Augusta Chronicle (“Researchers use IBM’s Watson to assess tumors’ genetic markers”) addressed the use of IBM’s super computer to help in the diagnosis and treatment of cancer. From that article, we learned that a physician at the Georgia Cancer Center was feeding raw genetic data sequenced from a very rare cancer into IBM Watson for Genomics, a computer system that is endowed with artificial intelligence that has helped it conquer other frontiers such as competing on the game show Jeopardy. Less than one minute after he had finished entering his data, he had a report back from the computer database that not only addressed the particular genetic mutations that he was concerned about, but also told him about ten medication trials that were already underway that might have implications in the treatment of his own patient.

This is astounding. I can remember the days when researching anything meant going to the medical library, looking in card catalogues for physical cards, cross checking references, pulling large, heavy textbooks off of shelves and taking notes or making copies of relevant passages, then taking all of that back to the dorm or apartment or on call room to read and digest and make sense of it all. Even then, there was very little certainty that one had found everything that was known about the topic at hand. This type of research could take hours or even days.

One thing that a computer with artificial intelligence is good at is taking huge data sets and analyzing them, making sense of them and then offering things that are truly helpful to the human who queried the data base in the first place. Another thing that these systems offers is time savings. As I mentioned above, the sheer amount of time that it would take one human, or even a team of humans, to sift through so much data is prohibitive in a normal clinical setting.

You might remember that another activity that Watson and similar computers are good at is playing chess. According to Wikipedia, chess computers were able to beat strong chess players starting in the late 1980s. One of the most famous chess matches between man and machine was when Deep Blue played then world champion Garry Kasparov in 1997, defeating him. Interestingly, what has been found as the years have passed since that match is that man can defeat machine and vice-versa, but the strongest combination of all is what is called a Centaur player, meaning the combination of both man and machine playing together as one. Rather than the mythological half horse-half human, a Centaur chess player combines all the intuition, creativity and feeling of a human player with the brute computational strength of a supercomputer. Centaur chess is not about computers taking the place of humans, but in fact augmenting and strengthening them to the point that they are many times better than before.

Does this play out elsewhere in medicine? You might also be familiar with the da Vinci® machines that are being used in the area to do surgeries of various types. These robotic machines are used not to take advantage of augmented intelligence, but to fine tune minute surgical techniques that a human hand might not be able to accomplish. Through very small incisions, the surgeon, who is in control of the machine at all times, is able to do very complex procedures in very small, tight spaces. The machine is being used not as a replacement for the human surgeon, but as an extension of him.

Are there already automated procedures or robotic elements in use in mental health today? Yes, there are already automated history taking computers and programs, automated treatment planning, and even algorithms that point toward a particular drug or other treatment for a certain disease. Genetic testing is on the rise, both to help make an accurate diagnosis and to target a specific disease with a specific treatment. Computers and computerized diagnosis and treatment are everywhere in medicine, and that includes mental health.

Once again, the role that computers might play going forward is to access and analyze vast databases of information on millions of medical topics, more than a single physician could access and understand in a lifetime. Computers can search this data with lightning speed, and they can test all known hypotheses and possibilities for intervention in mere seconds.

Is there still going to be a need for human empathy, human contact, human touch? Is there still going to be room for the human interactions that we now take for granted to impart hope to patients suffering from illnesses physical and emotional? I would argue yes, as human physicians have a unique perspective, bond and ability to heal that will most likely never be replaced by a machine alone.

Future physicians may be cyborgs, at least in principle, but the computing part of a practicing medical doctor will, like Watson, always be a tool. According to Dr. Kohle in the article above, “the physician will remain responsible for the conduct of patient care and for evaluating the clinical relevance of the information provided by the tool”.

I believe that computers will continue to enhance our ability to provide good care to patients, but that they will not be replacing us any time soon.