I hadn’t previously thought about this issue and was glad to offer certain possibilities. After the phone call I kept reflecting on this issue. 33 men cut off from their families and the world  in a relatively small space. Except for telephone communication and thin tube which could bring them food and water as well as  whatever small items could fit through the small opening, they were isolated captives. I don’t know what trauma they experienced at the time of mine collapse and whether they had some moments where they felt their life was in immediate damage. We also don’t know whether they still continually fearful for their lives and safety. After all, they are miners and they know the potential pitfalls of the rescue mission being undertaken.

An Event Outside The Usual Human Experience

When people experience a traumatic event that is out of the usual human experience, especially when it is life threatening to themselves or others, that is the major ingredient for developing a post traumatic stress disorder. If they are trained as to what to expect and how to protect themselves, that may help mitigate the trauma. However, as our soldiers have learned, there is no way to guarantee immunity from post traumatic stress. Sensory and sleep deprivation can intensify their response to trauma . The continued presence of the threat to themselves will also exacerbate the psychological symptoms as will the reintroduction of the trauma or something that reminds the person of the trauma.

While the isolation in a mine for this long  duration of time appears to be unprecedented, there are certain situations  where observations have been made on people isolated for long periods of time even with the ability to communicate to the outside world.

Space Travel Provides Model of Prolonged Isolation

The Space program comes immediately to mind where astronauts and cosmonauts were isolated on space stations for long periods of time. Several years ago after one such space trip a Russian cosmonaut wryly remarked, “All the conditions necessary for murder are met if you shut two men in a cabin measuring 5 meters by 6 and leave them together for two months.” With a larger group there is less likely to be intense reactions between two individuals but it certainly can happen.  One report divided the various  psychological responses during prolonged periods in space  into three phases. During the first, which usually lasted about two months, people were busy adapting, usually successfully, to their new environment. In the second phase, there were clear signs of fatigue and low motivation. In the final phase the people could become hypersensitive, nervous and irritable.  In discussing the anticipated expedition to Mars experts have been concerned the ever-present possibility of death by small breach of the space ship by a meteorite or sun flare and how that will effect them. As mentioned above, the trapped miners may very well be attuned to the possibility of some dangerous event where no help could be offered to them

Life on Submerged Submarine or in the Antarctica for Long Periods

Other examples of people being isolated for prolonged periods of time are life aboard a submarine which is on a mission requiring prolonged submersion or life in a remote scientific camp in the Antarctica. The psychological problems which have been noted in these environments include concerns about a limited amount of resources, the unchanging social group, social isolation, limited communication with the outside world, a self-contained ecosystem, the constant sense of danger, physical confinement, lack of privacy, lack of separation between work and non-work, limited opportunity for variety and change, limited sensory deprivation, and dependence on machine-dominated environment. This pretty well defines the anticipated psychological challenges facing the trapped minors. One big difference with those people isolated in the Antarctica  – if one member of an Antarctica team got annoyed with another, he or she would have the whole continent to walk away and be separate for a while. Astronauts and the trapped miners, however, would be very confined with no escape from each other, and they would be very worried about the supply of air and water.

Provide Basic Necessities Plus a Little Extra and More if Possible

The first rule for treating people who may be potentially traumatized is to give them the basic necessities of life plus a little extra when possible. This means food, water, warm dry clothes (or in this case since it is warm down there, dry comfortable cool clothes). The next things that they need are information and communication. They have to have confidence in the people talking to them and know they are receiving honest information. People in a crisis, whether it is on a airliner having difficulty, being in a flood, hurricane or the target of an ongoing  terrorist attack all  want to know what is going on and what is planned for the immediate and near  term future. While they will respond best to truthful information, sometimes it doesn’t help them to give bad news if there is nothing they can do about it.  So for example, sometimes the death of family members is withheld if practical, from a trapped or isolated person until they are rescued. It goes without saying that speaking to loved ones during separation or during an ordeal is usually quite supportive. If a telephone line or radio signal is available a video link usually  can be set up. Providing music, tv shows and broadcasts of sporting events or other entertainment can be psychologically healthy for them also . I understand that some computer games, which are very small and can fit in the small opening, are also being provided. A particular social environment naturally develops with certain people becoming leaders. A 63 year old miner among those down there  has become the spiritual leader according to reports that I read. Recommendations can be made to the miners, which may be helpful. For example it is very important that they maintain a regular sleep cycle, which will be based on the clock rather than on seeing daylight outside. Another recommendation that I heard was being given to them to help maintain their civility and sociability is that they wait before starting their meals until the food for all the miners has been lowered.

Psychological Help During and After Being Trapped in the Mine

It will be feasible for the miners to have individual or group counseling session with mental health experts even while they are in the mine through the communication set up. If needed, psychotropic medications can be prescribed for various individuals and lowered into the mine. Regular chats with mental health professional while they trapped underground even if informal and brief will allow assessment of potential problems, which might require more intensive discussions or medication. I have read about the development of technology to help determine when someone on a phone line is in psychological distress just by their voice characteristics For example, computers can now discern the emotional inflection in a person’s voice to look for signs of emotional trouble. If the computer does find that someone is in need of help, it is programmed to suggest ways to alleviate the problem, such as recommending extra rest, extra food, or possibly medications or the live counselor could do so at that point. Unexpected crisis situations may occur and will have to be dealt with as they occur. One situation, which occurred recently in the Chile mine incident, was similar to situations I have occasionally seen when someone was unexpectedly brought to the hospital. A worried spouse and a girl friend meet each other for the first time as they rushed to the bedside (or in this case to the site of the mine collapse).

It is difficult to anticipate which members of the trapped group of miners will have more psychological issues than the others, both while in the mine and in the aftermath. Perhaps the best indication is whether they have had previous traumas and how they have dealt with them. This is certainly no guaranteed predictor of the future. Even the presence of severe mental illness doesn’t predict problems in this situation. During World War II in Europe there was   a diminished amount of exacerbation of existing mental disease as compared to during peacetime. One of the almost universal responses to an overwhelming trauma is to try to block it out, either by isolating the emotional reactions and/or the memory of traumatic event. People in the midst of traumatic event will report that it seemed as if it were happening to someone else. The degree to which they keep these memories and feelings out of their consciousness can be related to subsequent symptoms, which they may have. Most prominent among post traumatic symptoms are flashback, nightmares, being easily reminded of the trauma with reoccurring feelings or going out of the way to avoid such reminders. Some people resort to alcohol or drugs to try to avoid such painful feelings. Suicidal behavior is sometimes seen in people who feel overwhelmed by their experience and see no way for improvement. These problems when they do occur can be very brief and transient. They may not occur until after a period of weeks or several month from the time of rescue. They can persist for several months or even a lifetime if not treated.

CBT ( Cognitive Behavior Therapy ) has been used successfully in treating PTSD. This is a therapy which consists of correcting negative misperceptions about the experience but also teaching the patient various relaxation techniques at the same time as they mentally re-experience some of their traumatic memories. Other patients will benefit from therapy, which helps them explore the psychological meaning of this experience as well as deal with relationship issues and any resultant drug or alcohol problems.

Resiliency and The Joy of Being Alive

A few years ago I put together a conference of leading experts in psychological trauma and then edited a book with chapters by them on various aspects of disaster. Independently, in each of their presentations and in their book chapter they all made a point of discussing  the resiliency that most people have in dealing with traumatic events. Although many victims of such events greatly benefit by treatment and may have lingering symptoms, the major of  of people in such a situation will have the resiliency, to put this event into some perspective and return to their previous functioning.

Jose Luis Inciarte

Despite clinical experience that mental health professionals might have with people who have been through other traumatic situations, it is still hard to really imagine or empathize how these people are feeling. When I worked as consultant to a burn unit we would sometimes arrange a visit to a patient with a severe burn by a someone who had survived the ordeal that they had been through.

Just this week a Uruguayan rugby player who survived more than two month of isolation in the Andes with 15 others after a 1971 plane crash brought a message of hope for the miners. This survivor, Jose Luis Inciarte said, “They are in the process of discovering the joy of being alive and the will to survive.”

A 46 year old man was in psychotherapy with me for one and a half  years.  He originally came for treatment after his boss told him that he wasn’t aggressive enough with his management style. He did not have a psychiatric history or evidence of depression or other symptoms. He worked well in treatment around his interpersonal relationships which were related to his childhood family dynamics. He had a good marriage and shared many interests with his wife. They had one two year old son. His family history was positive for mental illness in that his maternal uncle had a bipolar disorder. The patient was pleased that his wife became pregnant but 6 weeks after the birth of his daughter he became increasingly depressed for no apparent reason. He had periods of sadness, tension headaches and the a loss of excitement that he had about his new child. His wife was handling things well but  his depression progressed to point where he had insomnia, decreased appetite. He began to worry that he would not be able to provide for his family. The patient was put on Sertraline 50 /day and the dosage was titrated up to 125 mg/day. His depression went into  remission within 6-8 weeks and he began to do well in all phases of his home and work.  He did have some mild sexual side effects and the medication was discontinued after 4 months. The patient was doing well at one year follow-up.

Research Identifies Paternal Depression

Depression in women related to pregnancy is a well known phenomena with an incidence rate between 10-30%. Most clinicians do not usually consider the possibility of depression in men related to the partner’s pregnancy. A  meta analysis was published in a recent issue of the  Journal of the American Medical Association which looked at 43 studies involving 28,004 participant studies which took place over the past 30 years. They used modern approved statistical methods and found that prenatal and postpartum depression was present in 10% of the subjects studied and that this was statistically significant.

Closer Look at The Data

The one year prevalence rate in men for depression would be expected to be 4.8% whereas the paternal depression rate between the first trimester and one year post partum was 10.1%. When the results were analyzed by location, the paternal depression in the United States was 14.1% compared to 8.2% internationally. In regard to timing, fathers experienced the highest rate of depression 3-6 months post partum although there were not enough studies that made this distinction to make conclusions that were statistically significant. The research data was not able to draw any conclusions about trends distinguishing prediction of severe depression from minor depression . The correlation between between paternal and maternal depression was positive and moderate in size. It has been shown that marital satisfaction in women is a close correlation of depression and is among the strongest predictors of maternal depression. However while the data showed some association between materal and paternal depression it was not established as a causal influence.

Further Discussion

Maternal depression may be related to changing hormone levels  and/or well known psychological factors related to the mother child bond and /or related to sleep deprivation as well as the impact of the long, difficult at times child care. It seems unlikely that hormonal levels are  a key factor with men ( although I wouldn’t rule out the power of certain mind-body mechanisms,  especially through the pituitary-adrenal axis ) until research studies are done. There obviously is a great deal of psychological meaning to men about becoming a father. Most fathers will take pride in producing a child  and achieving this role but to some there may be concerns about no longer being young and free of responsibilities. The financial obligations of being a parent can be a burden on some men ( as well on on some women). All of these issues can trigger feeling of loss and depression. The modern man more than his father is likely to be sharing in some child care responsibilities . This can mean getting up at night to give the baby a bottle and change the diaper with the potential of sleep deprivation as well as frustration by infants who are not easily soothed. Finally pre-existing conditions of depression or bipolar disorders can be present in both men and women and can be exacerbated by a major life event such as a pregnancy .

Prenatal and Postpartum Screening for Depression Should Not be Limited to Women

Good prenatal and postpartum care of women should include some type of screening for depression. This may be in the form of a brief questionnaire or in the form of a distinct assessment by the clinician who sees the patient. Both  methods may be used. This should be repeated periodically in followup visits. One needs to be particularly diligent  if there is a previous history of depression or bipolar disorder . Now that there is data to support the concept that men can have depression related to pregnancy and childbirth , every effort should be made to extend the screening net to include the fathers. The easiest method would be to add screening questions to any written or verbal questionnaires that are utilized and include an appropriate question in the interpersonal examination by the clinician. It would also be a good idea for the clinician  to invite the father in for a brief chat when he is available and even suggest that he should make an effort to be present for some of pre and postnatal visits.

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We Are Not More Dangerous to Ourselves Than The Enemy

As statistics such as these continue to emerge there is a continued outcry that something should be done about this. A report  issued by the US Army, in my opinion minimized the fact that these psychological causalities are a result combat and the realities of war. The Army review concluded “simply stated, we are often more dangerous to ourselves than the enemy” It went on to say that commanders have failed to identify and monitor soldiers prone to risk taking behavior and as a result suicides among soldier have soared. I believe that this is a misguided view that some somehow if we did the right thing we could prevent these events. There were 250 recommendations in the recent report and the Army has already implanted 240 of them. While these are positive things done to provide good mental health care, they  won’t prevent  PTSD and sadly it won’t eliminate suicides.

We haven’t been able to prevent the increasing number of Americans being killed by IEDs. War is hell and soldiers get killed. We train them the best way that we know how but inevitably soldiers die when there is a war. Maybe one soldiers, despite the best training available isn’t quite as good in a combat zone as another one. Some may be able to know when to zig rather than zag . Some have better instincts than others and that may make them more likely to survive. Some inherently may be able to handle the stress of war better than others.  However, the best training in the world and all the preventive measures in the world will not eliminate combat injuries and death. Nor can PTSD and suicides be avoided.   The most combat savvy soldiers in our military cannot hide from a  bullet with their name on it nor can the most well adjusted soldiers avoid  being  affected by extraordinary human experiences in a war zone.

Of course , we should always strive to improve our training, safety and efficiency in the battle field. Of course we should always strive to provide the best medical care (which includes psychological care) to our soldiers.

Soldiers Injured With  PTSD Deserves to Receive a Purple Heart

Families Deserve Presidential Condolence After Soldier Suicide

We honor our soldiers who are injured serving their country. We give “Purple Hearts“ to soldiers who have been wounded and bury with honor those who have given their lives for their country with the exception of those soldiers who suffer psychological injuries. There is no Purple Heart for them. There is no letter of condolence from the President to the families of those who died from suicide. This is outrageous!  These men and women have all volunteered and knew they could be in harms way. There is no basis for treating them as if they purposefully became psychological causalities. There is no way to minimize the grief of their loved ones but this failure to acknowledge their loss only compounds it.

After treating  patients with psychoanalytic or psychodynamic psychotherapy for a period of time we usually have a fairly good understanding of their personal and family dynamics. We come to understand their  relationships as well as their culture and customs which may be quite different than our own. If the the therapy has gone on for several years, we have seen how the patient and his or her environment interacts with important life events such as going to college, pregnancy, tragedies and even epic historical events such as war and 9/11. This is one of the privileges and great pleasures of being a therapist. In addition to helping our patients  have a more gratifying and forfilling life, we have learned a great deal, been enriched all the while sitting in our offices ( hopefully remembering to take time for exercise and other things.)

As Well As Reading A Good Novel

I recently was reminded how we can get a similar rewarding experience by reading a good novel.  I just completed such a book titled Shanghai Girls by Lisa See . As best I can tell  from supplementary reading, the author is not explicitly writing about her own life and family. She has researched her subject and her characters quite well by conducting many interviews and reviewing  oral histories in order to convey a very authentic story.  She also appears to have very good insight and empathic understanding of the emotions that the protagonists of novel could have.

Shanghai Girls

As the story opens the reader is introduced to two “beautiful” sisters age 18 and 21 who are living somewhat of an upper class exciting city life in Shanghai, China in 1937. We get a feel for their family dynamics which are embedded in the Chinese customs and culture of the time. We see devotion to parents but yet a struggle when an arranged marriage is imposed upon the sisters. We follow these girls and their family as they confront the Japanese invasion of their country, their attempt to flee, the death of family members and most poignantly, a brutal rape and the consequences of it. The story covers a time span of about twenty years which allows for a maturation and evolution of the characters as well as the effect of new historical events. The sisters come to the United States and struggle with the problems that  immigrants had to face in trying to make this transition. They confront cruel discrimination against the Chinese. Family secrets fester. We see the impact of parental values surface. Religious views, issues of conscience, teenage rebellion , the effects of previous traumatic experiences are all interwoven in this story. There are insights into the thoughts and feelings of immigrants trying to live in a new culture which can easily be reapplied when we look at the plight of the undocumented Latinos in the US today or reflect back on the experiences of the Jews as well as other groups who have tried to become part of the melting pot which is America.

I strongly recommend this book and contend it will  provide useful clinical insights for therapists as well as good reading for everyone.

Ron Artest

I was watching the TV of the celebration after the LA Lakers won the National Basketball Association championship by defeating the Boston Celtics.. A TV reporter thrust the microphone in front of ebullient LA player Ron Artest and asked him how he felt. Among the words that the elated basketball player blurted out on national television was  that he would  like to thank his  psychiatrist! He went on to say ” There is so much commotion going on in the playoffs. She helped me relax.” Granted this was not an Academy Award acceptance speech but is seemed quite unusual and remarkable that we are now hearing such a public acknowledgment.

Ron Artest has had outbursts of temper in the past  and one time a few years ago he ran into the stands and pummeled a fan. However, it is not known if his psychiatric treatment involved psychotherapy, psychopharmacology or some type of relaxation therapy concerning this crucial series. It is significant that more celebrities  in recent years have been comfortable in talking about  their own mental health issues and their treatment with psychiatrists and other mental health professionals.

Brooke Shield

When the Boston Celtics started winning their championships in the 1960′s  such a public statement was nearly unheard of. In 1972 a vice presidential candidate was revealed to have had depression with ECT treatment and he had to resign from the  ticket. While I suspect that  that a modern day politician could still not survive such a public revelation today, there has been a steady flow of celebrities who choose to talk about the their mental problems and psychiatric treatment without any discernible harm to their careers.

Carrie Fisher

For example this list would include Richard Dreyfus, Uma Thurman, Ben Stiller , Jim Carey, George Michael, Adam Ant, Sinead O’Connor, Wionnal Ryder with some becoming spokespersons for mental health issues and even appearing at psychiatric meetings such as Mike Wallace, Brooke Shield and Carrie Fisher.

These public revelations demonstrate how far we have come in the fight against stigma in regard to mental illness. Even the fictional roles of therapists on televsion have evolved. In the 1970s there was a situation comedy  where comedian Bob Newhart played a therapist. It was good for a lot of laughs and lasted for seven years . Television’s depiction of therapy today is a much more realist one. For example In Treatment is an HBO drama   about a fictionalized psychotherapist 53-year-old Dr. Paul Weston  and his weekly sessions with patients. The program, which stars Gabriel Byrne  as Paul, debuted on January 28, 2008, as a five-night-a-week show and now is beginning it’s third year. The therapist certainly is shown with human flaws but as somebody who has genuinely helped his patients. Another somewhat more sensational type of TV production  is the reality TV show Celebrity Rehab and subsequent spinoffs  with Dr. Drew Pinsky who is an internist and addicition specialist who treats various celebrities on each show . The participants are obviously comfortable revealing their addiction problems and how they are trying to get help. When world famous golfer Tiger Woods had marital problems and sexual issues, he was shown going to some kind of a treatment facility.  Psychiatrists and other mental health professionals  have appeared as characters  on  television medical dramas such as ER as well as in some the popular police and crime dramas. They are   usually shown in a very positive light. The evolution of the depiction of psychiatry and mental illness  in the cinema is a fascinating and important story which  has greatly influenced the public’s attitude on these subjects. Two worthwhile books which discuss this subject are Psychiatry and the Cinema by Krin and Glen Gabbard and Reel Psychiatry by David Robinson.

The wide spread use of computers and the Internet has surely contributed also to the changes in the  attitude towards mental illness and therapy. Information about mental illness and treatment is available within a few clicks as is information about any physical condition. Blogs and web sites are easily found on any subject including those that deal with some aspect of mental health. Organizations which have traditionally tried to address the stigma of mental illness such as the Mental Health America ( MHA) ,  National Alliance On Mental Illness (NAMI), the American Psychiatric Association (APA) and many other reputable groups now have very popular web sites which are seen by millions of people. The social media on the Internet such as Facebook and Twitter are facilitating a freer communication which does brings into  the open  psychological concerns along with everything else. It seems to discourage people from allowing painful secrets to fester in a harmful manner. On this blog I recently wrote about a website called Postsecrets where people anonymously post their secrets in the form of an artistic postcard. When a San Francisco resident told of his or her discouragement about life and plan to jump off the Golden Gate Bridge more than 60,000 people responded in a supportive manner.

I am sure that we still have a long way to go before stigma about mental problems and receiving therapy is eliminated. However there are lots of indications that we are moving in the right direction. Most psychiatrists and other therapists are probably well adjusted enough that they don’t need to see their patients praising them on national TV as Ron Artest chose to do. However when someone wants to issue a public thank you it is great to realize that there is no reason to feel that they can’t do it.

In a recent blog I wrote about empathy and how we might try to teach medical students to be empathic physicians. Psychiatrists, other physicians and therapists try to put ourselves into our patient’s shoes (or skin) in order to understand how they are feeling in regard to the things which are troubling them. When we do psychotherapy we often approach this with an added dimension. We know that the patient will usually experience the therapist in a similar manner to how they experienced important people in their early life, most probably their parents and/or siblings. Freud has dubbed this situation as transference and for certain types of psychotherapy understanding the transference and using it in the therapy can be very helpful. In fact, for psychoanalytic and much of psychodynamic therapy, it becomes the essence of the treatment.

Social Empathy

I was recently made aware of another aspect of empathy which I never thought about before and which I would now label  “social empathy” . My consciousness to this form of empathy was raised when I read about a blog called Postsecrets which weekly displays anonymously mailed-in secrets on artistic postcards from across the country. It has been around for several years and has long been known for revealing suicidal secrets. It has set up a phone hotline in response since the blog began in 2004. Recently a postcard read, ” I have lived in San Francisco since I was young…I am illegal…I am not wanted here. I don’t belong anywhere. This summer I plan to jump off the Golden Gate Bridge.”  According to a blogger Kristi Oloffson .within 24 hours nealry 20,000 people had signed up for a Facebook group titled “Please Don’t Jump, which was later linked beneath the secret on the Postsecrets blog , linking in thousands of supportive comments. On the group’s page, sympathetic users posted comments ranging from simply “I want you here” to “If I knew when you’d be at the bridge, I’d drive all the way from Ohio to meet you there, and hold you until you changed your mind.”  A video about this phenomena has become the most viewed video on the Time Magazine web site.  ( For information about the issue of suicide from the Golden Gate Bridge please see two previous blogs I have written on this subject , Suicide Jumpers From the Golden Gate Bridge and  More on Jumpers, The Movie ).

I checked it out and sure enough and as of this writing there are more than 60,000 people  who have tuned in to this secret and obviously felt an empathic response which they posted on the Facebook site. It may have been that this group comes from a populations which were drawn to the  Please Don’t Jump Facebook page because  they themselves are in touch their own secrets and feel for someone who has this one.  Others without being aware of their own secret may also just want to reach out to someone else whose pain they can feel. It is also clear that people responding to the would be San Francsico jumper are not mainly other immigrants who are in a similar plight. They seem to come from all age groups, geographic areas and different backgrounds as best as I could tell scrolling through a sample of the now more than 60,000 responses.  I believe that it is the identification with loneliness  and isolation which  is the universal  piece that many people have felt at some time in their life which is connecting people with the San Francisco postcard sender.

Implications For Psychotherapy

I don’t believe that social medial will replace the role of psychotherapy. However, it does appear that there is a natural role that it is playing in the support of people who are feeling psychological pain. This new media is clearly interdigitating with other  forms of psychological support and there is no reason whey they can’t overlap. We should be asking patients if they have had  previous psychotherapy, whether they have been treated by any self help groups as well as including an an inquiry whether they  have been interacting with the social media in regard to their current or other problems.

]]> http://www.psychiatrytalk.com/2010/06/60000-empathic-responses/feed/ 2 http://www.psychiatrytalk.com/2010/06/can-we-teach-empathy/ http://www.psychiatrytalk.com/2010/06/can-we-teach-empathy/#comments Wed, 16 Jun 2010 09:01:07 +0000 Dr. Blumenfield, M.D. http://www.psychiatrytalk.com/?p=1107 This week’s blog is based on a blog I recently wrote for “Couch in Crisis” which is on the website of Psychiatric Times. It was reprinted as an essay in the printed edition of Psychiatric Times.

Please note: During the summer period June 16- September 22 this blog will appear biweekly and then will resume as a weekly blog on September 22nd

Some Have It and Some Don’t

Empathy is the ability to put yourself in someone else’s shoes and understand what they are feeling. This is something that psychiatrists try to do in our everyday work. Those of us who have worked in medical schools have struggled with the question of whether or not we can teach this to young men and women who are learning to be doctors or whether it is something that they either have or do not have. Certainly I have seen medical students who seemed to be decidedly lacking in this quality just as I have seen students to whom it came very naturally and some who were far more empathic than I was as a student or even after years of experience.

Choose Empathic Students in the Admission Process

I have gone through many phases in trying to figure out how medical schools can graduate doctors who have this empathic quality. My first thought was to try and influence the selection process so students who seemed to have this natural quality would be chosen. I had the opportunity to join the admissions committee of the medical school where I taught and participated in the interviewing and selection of prospective students.

Actually there were a few psychiatrists already on the committee along with other medical specialists and basic scientists who would be training the students in their preliminary non-clinical years. It was relatively easy to determine which students had this quality in abundance and which students did not.  I could see the tears in a student’s eyes as they told me about experiences which they had known someone who had been ill or disadvantaged and how this had motivated them to want to be a doctor. I remember the caring response of one student to me as I was suffering with allergies with my eyes running on a particular day that I was interviewing her.  On the other hand I could detect the intellectual response of students who ticked off their many volunteer activities or told of their dedication to finding the cure of cancer because it  would then increase life expectancy. However when it came down to the votes on the committee, despite my efforts,  a student being the most empathic would never trump the one with potential to become a world famous doctor.

Trying To Teach Empathy in the Classroom

I had opportunity to see if it were possible to teach students to be empathic. It was traditional in our medical school for psychiatrists to teach students interviewing technique both in formal lectures and at the bedside. In preparation for a formal lecture I made a video tape (we were not yet using DVDs) in which I had some senior students act as doctor and patient in a hospital room in various scenarios. In one of them the “doctor” asked the “patient” if anyone in their family had a cancer. The patient began to cry and said her daughter died of cancer. I then showed three possible responses. In the first one the doctor just continued with the interview and kept asking questions. In the second scenario, the doctor got up and excused himself and said he would come back later when the patient was feeling better. In the third case the doctor offered the patient a tissue and said that he was sorry. Obviously the third  vignette was meant to be the correct one and most students seemed to get it. However, a group of Asian students approached me after the lecture and told me that they did not agree with the choice of the best vignette. In their particular culture it was a sign of respect to let a patient be alone by themselves in that particular situation. Excusing one self and walking out of the room was the correct response as far as they were concerned.  So I began to realize that this was not an easy task.

Trying To Teach Empathy at The Bedside

Each week I would take a group of three students to an actual patient’s bedside to practice doing an interview. The patients knew they were “students in training” but usually responded to them as if they were doctors taking a history from them. On a particular day, before  we entered the room, I told the student who was to do the interview that sometime during the interview he must use the following words, “ that must have been very difficult.”  The student proceeded with the interview with the other two students and myself standing by the bedside. At one particular point in the interview the patient started to talk angrily about how she hated to go through all these tests when she knew she was going to have an operation anyway. The student was a little flustered by the patient’s emotion but then he remembered and said, “That must be very difficult.” The patient’s demeanor changed and she continued in a very friendly and cooperative manner. At the end the interview the patient remarked to all of us that “this doctor was the most caring physician that I have seen in the hospital.” In our post interview discussion the student was beaming (his overall interview actually was quite poor). I asked why did he think that the patient thought he was so good. He couldn’t answer, apparently feeling he had just done a good job. The other students understood and were able to appreciate the value of the comment that he had made at the right time. However the next week I suggested the same technique to another group of students who objected to this approach. They felt it was artificial, phony and they did not want to be actors when they were trying to be doctors. Other groups had similar responses. This was another indication of how teaching medical students to be empathic was quite complicated.

Life Experience Teaches Empathy

After several years my teaching and clinical work took me away from this particular type of medical student teaching. One day however, I encountered the following situation. I was a psychiatric consultant called to difficult situation in the medical emergency room.  A male patient in his thirties with multiple traumas did not survive a motor vehicle accident and died in the Emergency Room. The mother of the patient became hysterical and out of control. Nobody could calm her down. A first year medical resident (two weeks out of medical school) was the only one to stay in the room with her while she screamed and berated the hospital, the doctors and the medical system. After he patiently stayed with her during the tirade, he gently asked if there was anything he could do for her. She said, “Yes, remove the damn tube from his mouth” (the breathing tube from her son). While he knew this was not usually the procedure because of the preference of the medical examiner, he did so in her presence and then turned to her and asked if she would like to help him clean up the body. She agreed to do so and he asked the nurse for a basin of water allowing her to clean her son’s face. He stayed with her  until she was ready to leave. When I asked him later how he felt and how he was able to do this, he told following story. Recently his best friend had died. In his own grieving, he repeatedly thought of how painful it was for his friend’s mother and how he had imagined such a loss would affect his own mother. He also recalled how his friend’s mother said many times that she was bothered by seeing the IV lines  in her son’s arm after he died.

The  capacity for empathy does vary from person to person . We need to provide teaching and mentoring to our students on this subject  and we need to listen and be empathic to them in regard to their previous experiences. It is no different than our obligation to be empathic to our friends, family and especially our children. This will make future generations, better doctors and better people.

13 Suicides In One Factory in China

According to recent reports from China, since the beginning of the year 13 workers form Foxconn a large factory in Shenzhen have committed suicide. Foxconn manufactures products for Apple, Hewlett Packard and Dell. Some reports in the media tell of difficult working conditions where plant workers could not talk while working and were fined for mistakes. The average salary of workers in the factory was $140/month but since the reports of suicide, it reportedly has been raised 66%. On the other hand, in an effort to discourage suicides, the factory has stopped offering compensation to families of those who have killed themselves since it must have been thought that this compensation might be an incentive for some of the workers to commit suicide. It is also reported that some of the political leaders in China are unhappy with the bad publicity that this rash of suicides has been bringing to China and are taking steps to stop it. Nets are  being built around the dormitories where many of the workers have jumped off in their suicide attempt. More appropriately counselors were being trained and brought in.

Similar Situation in the United States

This situation reminds me of a somewhat similar set of circumstance in which I had been involved. Many years ago I was asked to be part of a small team to study a series of suicides that had occurred at a large entity that was frequently in the public eye. The press was clamoring for answers about this unusual problem and management was concerned about the bad publicity. They assured us that they would do whatever they could to help us get to the bottom of  this problem and expected a full report from our team within 60 days.

Approach to the Consultation

Our first step was to meet with the managers and supervisors, as well as the union leaders. Management agreed to help us in any way but the union people were suspicious that we were going to whitewash the problem.  After much discussion and many meetings, we convinced them that we were independent of management and although we would ultimately be reporting to them, we would pull no punches. They agreed to encourage full access for us. This initial step was very important.

We obtained the all records and documents of the workers who had suicided. We attempted to meet with their co-workers. Although meeting with their families would probably be enlightening, we ultimately decided not to do so. Since  much of the work of this entity involved vehicles driving from place to place we arranged to ride with them and chat informally in addition to the structured interviews that we did as noted above.  As some of the emerging information indicated that working condition, time schedules, salary, benefits and opportunities for advancement might be an important factors in the suicides, our team made an effort to benchmark this entity in regard to these factors  using similar entities in other cities in the US and internationally.

Findings

We found that there was a great deal of demoralization among the highly skilled work force which may have contributed to the suicides. As far as we could determine, most of the employees were very dedicated to their work but felt that management did not care a great deal about them. They were expected to frequently work overtime (with pay) but often did critical work while sleep deprived. A small undetermined percentage took drugs mostly to stay awake and mentally sharp (some to deal with their demoralization and depression). We heard of examples of workers doing work which could endanger other’s lives while under the influence of such drugs. They felt that their work skills were not easily transferred to other jobs and also  believed that there was little chance for advancement within their current job. There were some circumstances where workers became psychologically traumatized related to their work.  However most people whom we interviewed shared the belief that if they complained of being depressed, anxious and not able to work , they would be penalized in the job.. We had the impression that this lack of support contributed to the suicidal behavior which had occurred in at least several instances.

Our study team prepared an extensive report with these findings and with a list of constructive suggestions which was based on our interviews and our benchmarking inquires. We suggested policies concerning time off , breaks and areas where breaks could occurs. We advised  drug and alcohol educational programs with a guaranteed no penalty for those who sought help for these issues or any mental health concern which should not be part of the employment record. We suggested a review of the salary, vacation  pension and promotion policy   based on the preliminary information that we had from our examination of other similar entities. We did not think that meaningful changes would be a financial burden and in the long run would provide more efficient functioning. We also suggested a mentoring program utilizing senior people, many of whom were held in high esteem by the younger workers.

Consultation Report Initially Rejected

We were surprised at the total rejection of our report by the highest level of management. They told us we would have to rewrite the report or we would not be paid for our services. I believe that they had expected us to confirm their belief that the people who suicided were mentally unstable and not typical of the work force. While that was true in some of the cases, we obviously felt that there were factors stressing the workers and that suicidal behavior was one result of these factors which needed to be addressed. It also appeared that the highest level of management was concerned that his report might be leaked to the press which of course we had no intention of doing. Ultimately the report was accepted as a confidential report. Some but not all the recommended changes were made over several years. The unusual number of suicides did not continue and in fact  may have been a coincidence which unearthed some problems which needed to be addressed.

This theme reminds me of many vignettes which I have known from my personal friends, family and from my practice. Each one could be movie in itself as they encompass deep human emotions and relationships with individual complicated stories. (Reality is always more interesting than fiction). The similarity in all of them is a powerful desire for a reunion with the person or persons from whom they were separated  so many years previously. I will briefly review some of these true stories with some disguising of the details.

Identical Twins Separated At Age Five

A retired 70 year old year man had been  separated from his identical twin at the age of five and brought the United States from Poland before World War II. He heard nothing about his brother or his family for fifty years. He  met a distant cousin who had recently been corresponding with some of his relatives in Europe and he found that his brother was alive. He contacted him and made plans to visit. Unfortunately before his scheduled trip, he learned that his brother had died. He decided to visit his brother’s family and went ahead with the trip. When he got off the plane the young grandchildren ran up to him believing he was their grandfather. Both brothers had the same occupation, hair style and both of their children played classical piano.

A Documentary Film Brings Father and Son Together

A successful business man has never seen his father since his mother died at childbirth and his father gave him away to be raised by someone else. Although his father never tried to contact him, he knew his father had been a world famous athlete in another country. One day he went to see a documentary about this particular sport and his father was interviewed in the film. In the interview it came out that he had lived in the United States and in fact had a child which he has never seen since his wife died during the delivery. He further stated that he felt badly about giving away the son and wondered what happened to him. The son now in his 50s contacted the documentary filmmaker who arranged a reunion for the son and his family to meet his father and his large family. The reunion included many people who welcomed the son and his family. There also was a very warm, intense conversation between father and son

Daughter Tracks Down Mother and Establishes New Relationship

A woman in her late 40s had a very happy childhood with her adoptive parents and siblings. She is now married and shortly after the birth of her second child she decides that she was going to find her biological mother. It took a few years with the help of  advertisements, the Internet and a private detective but she found her across the country. She immediately bonded with her mother who as young teenager gave her up for adoption and had remained single. The daughter introduced her to her husband and children and financially helped her out. They corresponded and had regular visits for several years until the mother died.

Unknown Son of Deceased Father Appears on the Scene

About twenty years after the death of a prominent attorney, a man in his 50s contacts the widow of the deceased lawyer and introduces himself as the son of her husband by a relationship previous to that of the widow. He has a very clear family resemblance and provided details indicated that his story was true. He expressed a desire to get to know  his “other family’ and wanted his 28 year old son to also meet them. The widow is agreeable and the children show varying amount of interest in spending time with them. Eventually even those reluctant find him very personable and compatible actually sharing many interests with them. He goes on to have regular contact with his new family.

What Are the Underlying Determinants?

What is it that contributes to this powerful need to make contact and know your biological family even if they had nothing to do with your childhood or upbringing?

Is it simply the belief that they share some genetic connection and therefore this forges a primal attachment that may even be Darwinian?  In other words families that had this need to connect to their biological family survived better in ancient times and therefore this need to find each other survived with these genes.

Perhaps we can find the answer in our psychoanalytic theories. No matter how good the mothering or parenting was by the adoptive parents (and in the cases above they all seemed to be quite good ) there may be a phantasy of an idealized mother ( or father ) with whom one has an unconscious need to connect. In other cases there may be an identification with the mother who cared enough about him or her to give the child to a better off family and the child now wants to repay that love. On the other hand there may be tremendous anger and the burning question of “ how could you do this to me?” or “why did you do it ?”

It is striking to me how the need for reunion in these examples involves other family members in addition to the parent-child dyad.  Overtly some have said they want their children to know their family. Is this a rationalization ? Or is it some obligation that they feel they owe their children perhaps to make up for some deficiency they had in not knowing their own biological family.

Let us not forget the relationship with the adoptive parents. No matter how they handled the adoption, telling the child at whatever age or not, they must have strong feelings, perhaps of rejection, when they see their children seeking out their biological parents. Will the child be torn between knowing they are hurting their adoptive parent but yet needing to find their biological parents? Also what will the reactions of the other children of a parent who now seeks out the child she gave up before they were born?

Of course there can’t be any clear generalizations. Each situation will be different and founded upon the dynamics of their lives .

Still Another Twist

Hidden Jewish Children- Gift of Margit Meier; United States Holocaust Memorial Museum

It was recently reported in Psychiatric News that during World War II when the Nazis invaded Poland many Jews gave their young children  to non Jews to be raised by them . Most of the parents were killed in the Holocaust and many of the children were raised never knowing they were Jewish. Many others learned to keep that knowledge to themselves as they grew up not just during the war but afterward too because of of anti Semitism in Poland. Late in their lives many of these grown children are learning their actual origins and other are acknowledging to their families that they knew they were Jewish. Some psychiatrists are  trying to study the impact of these Holocaust secrets.

There are many international adoptions occurring every day as children are brought to the United States from Eastern Europe, Asia, Haiti and many other places. Most of these are done with the best intentions from all sides but we don’t fully understand how these parents and children will feel in years to come. What kind of arrangements should be made for future reunions if the parties wish to have them in the future? What information should be provided to everyone involved about the disposition of the children?

Your Comments Welcome

Comments are welcome below on this blog whether you have opinions on the questions that have been raised or if you have some illustrative stories of real events.

I would like to examine several possible sources of increased revenue for the APA, which could be used to prevent a cut back of the Assembly and the Components, as well allow for consideration of developing new important programs.

Dues Increase

If the membership wishes increased services, they should be willing to consider paying directly for them. The national dues have not been increased for several years. There are different categories of membership, which have different levels annual dues. If the dues are increased an average of $50 / member over a five year periods, this would gradually increase the income starting with $380,000 the first year. At the end of the five year period the APA  income would be increased $1.9 million /year. Of course, there is the possibility that some small percentage of the 38,000 members would drop out because of the dues increase. On the other hand, if new exciting activities were developed as described below, we could increase membership. A conservative estimate would put this at an average of $500,000/year

How to Use Profits From DSM V

The APA has made an arrangement with APPI so for DSM V the APA will own the rights to DSM V when it comes out in 2011. I understand the previous performance of DSM IV cannot reliably predict the profits from DSM V. However, we still can anticipate this book will be used worldwide as will the accompanying texts which will be published. Most mental health professionals, institutions, government agencies, attorneys, etc  will want to own a hard copy of it, even though there is a trend to looking things up on the Internet. I also assume that there will be DVD versions of it which will be sold. On the basis of some discussions I had  with people who know something about these things,  I would predict that the APA can anticipate a profit of $10 million over the next 8-10 year for this product. This would be a conservative estimate. Therefore if half the proceeds were put into the APA  reserves that would allow another $500,000/year available for the APA budget.

APA Foundation Could Take Over Significant Part of Public Affairs

The APA Foundation is suppose to be 100% in sync with the APA and certainly shares the same goals and aspiration for mental health and education of the public, increasing public awareness and raising money to do good projects for mental health. It is only because of some technical, legal issues related to taxes that there are separate Boards of the APA and the Foundation . There are efforts being made to allow these organizations to function more in unison in the future. As I mentioned in a previous blog, I believe, the forced reduction of the Communications Component has seriously taken away many opportunities for public affairs programs. I therefore suggest that the Foundation should appoint staff consultants who are very familiar with the previous APA public affairs program as well as the current ones . They should use the resources of the Foundation  to run national, state and  local public affairs programs as a major initiative. They can run a Public Affairs Institute, advise and assist mental health advocates from various District Branches write letters to the editor, run educational training for psychiatrists  etc. They can liaison with the APA while still keeping their independence, if that is necessary. They can take over some of the spending in public affairs that have been in the APA budget. I would estimate that this could easily result in a savings for the APA of at least $200,000/year without any loss in the quality of public affairs for mental health and American Psychiatry.

APPI Should Use APA District Branches as a Commissioned Sales Force

APPI was originally developed as an arm of the APA, which was expected to serve a completely dedicated to the APA mission. It has become the most successful publisher of psychiatric books in the world. Even after having sold the rights of DSM back to the APA they still should be able to make considerable profits. Although there is still that problem of having separate Boards although appointed by the Medical Director of the APA, they should be interested in doing everything possible to support the APA. Every publisher makes arrangements with sales teams to take their books into a particular setting, make sales and then pays them a commission. I propose that each District Branch should become a commissioned sales representative for APPI. They should include APPI advertisement for APPI books in all their mailing with special discounts as well as promoting books at all meetings and activities. District Branch members should be aware that buying their books through the District Branch would allow their DBs to receive significant commissions. Once it is determined how much money the DBs are receiving, a certain percentage of APA support or revenue sharing from the Assembly budget being given the DBs should be reduced. The net result should be increased funding for the DBs and decreased support from the APA to the DBs. It might turn out that APPI might make less of a profit but they would be serving their overall mission to support the APA. There would be an incentive for the DBs to promote APPI books and products which could include sales to the local mental health community who they know best as well as the public in their area. These activities might even drive up APPI profits.  I estimate the APA could save at least $100,000/ year by this method.

Use of State of the Art Video Communication

I know that the APA has made great strides in introducing some video communications and have encouraged the use of conference calls, webinar and perhaps Skype meetings. I personally believe that face to face in person meetings should not be completely eliminated and that the combination of at least one face to face meeting combined with state of the art video/personal computer conferencing is now feasible.  I would suggest that the APA become very aggressive in advocating such communications for at least some percentage of most committee meeting including, as an example, of at  least one Board of Trustees meeting. The savings in hotel, travel, food can make a considerable savings for the APA. One would almost think that the members should contribute to buying their equipment own since they would save time away from practice. However, I believe that an investment by the APA in providing equipment in the short and long  run would save the APA money. I would suggest that the APA could save at least $50,000/year.

APA Needs to Go Global

I have saved my most ambitious proposal for last. I am convinced from what I see happening in the economy, business and in the various activities of so many people that I know, that our lives are becoming more global in every way. I believe that the APA has to begin to take significant steps to become a global (still American) organization.  We need to look at every aspect of our organization and see how we can become more global.

Starting with membership, we should offer a membership category to international members at a reduced cost  (to cover journals , mailings etc plus enough to make a profit for the APA). This lower rate should be contingent on the international members being a member of their own national psychiatric organization or the World Psychiatric Association.. This way we won’t compete with international organizations but would allow them to encourage membership as global members of the APA. Obviously we will need to provide international members with special benefits such as discounts of APPI books, facilitated access to disaster materials, perhaps some special online or Skype CME courses. As part of our efforts to go global, the newly invigorated Assembly (with some increased funding) should have a certain number of international delegates to the Assembly perhaps one from each country or from each major area of the world for a start. Oh yes, the APA Assembly should be broadcast live online (as well as being archived) so our members in the US and all over the world can see American psychiatry in action. While we are doing this we should set up electronic voting which I unsuccessfully advocated for when I was Speaker of the APA Assembly – the price has come down and we do need to showcase the fantastic democratic methods we use in the Assembly when we broadcast the proceedings around the world. I estimate over the next five years we should be able to add at least 1000 global members – so lets figure in the long run we add at least another $100,000 /year income after added expenses are taken into account.

How It All Adds Up

I realize that I am letting my imagination get a little carried away. I tried to build these ideas on facts and speculation that has good foundation. I may be wrong in some of my calculations or may be a little ahead of my time (or perhaps behind if some of these things are being contemplated already). However I tried to be conservative in my estimates and I came up with almost  $1.5 million dollars/year available for reinvigorating  the Assembly and reestablishing the Components in a responsible manner.  I am also suggesting that there may be innovative approaches to increasing available funding.  I encourage our members and leadership to continue to look for newer and better ways of doing things for our patients and our profession.