What She Left Behind by Ellen Marie Wiseman (Book Review)

Screen Shot 2016-01-12 at 10.53.06 PMWhat She Left Behind

By Ellen Marie Wiseman

This book is composed of two interweaving stories. Clara, a woman who lived in the 1930s was committed to a mental institution against her will based on her wealthy father’s unhappiness about her Italian immigrant boyfriend and her refusal to marry the rich guy that her father picked out for her. The other story is about a current day teenager named Izzy who is a foster child of Peg and Harry after having lived with several previous foster parents since her mother unexplainably murdered her father. Peg is working on a museum project examining newly discovered suitcases of belongings of former patients (including those of Clara) of a now closed psychiatric facility, in order to gain some understanding of their lives. Izzy helps out with this project and finds the diary of Clara and becomes interested in her life.

Being a psychiatrist, I was initially drawn to this book with the idea that I would gain some insight into the lives and treatments of psychiatric patients living in the first half of the twentieth century. This was the case and it included vivid description of the treatment that was done at that time such as ice baths, insulin shock therapy and electroconvulsive therapy (ECT).

Although I never worked in a state hospital, when I toured them in the late 1960s, such treatments except occasional ECT under humane conditions were things of the past. As far as the possibility of someone spending most of their life committed to a mental institution based on the word of her father when she clearly did not have a mental illness, I would like to think that this would not have been possible. Certainly, in modern times from my experience someone being hospitalized against their will would have to go through a legal hearing with the patient being assigned an attorney if they don’t have one. Once in a hospital with treatment with modern-day medicines (which were not really available until the 1950s) most mental illness can be put at least in temporary remission with such treatment. Today, there would be reviews by multiple doctors with no mandate to keep the person in the hospital against their will unless they were a danger to themselves or others due to a mental illness. I would hope that nothing like Clara’s situation could occur today. Obviously, I can’t speak for every state hospital in the United States and certainly things were different in the 1930s.

There was another aspect of Clara’s case was particularly disturbing to me in that the psychiatrist in charge of her care was depicted as a mean, cruel, selfish man who was mainly responsible for Clara’s lost life. I felt it was an unfair indictment, which suggested all psychiatrists of that time might have been of the same cloth. I understand that the author has the creative choice to develop characters in whatever fashion she chooses. I probably would not be complaining if the character were a dishonest lawyer who did unsavory things in the interest of an interesting storyline but nevertheless, I felt that this book was stigmatizing my profession.

There was particular theme of this book, which also had a special interest to me. Three characters in the book were driven to try to understand their early origins. Izzy, understandably could not fathom why her beloved mother murdered her father. This ultimately led her to empathize with a schoolmate who had some parental trauma. It contributed to her mission to find Clara’s daughter who was essentially separated from her at birth, and hand over her mother’s diaries so she could know about her mother’s story. Clara’s daughter led a life of yearning to know what happened to her mother and Clara similarly went through life wanting to know what happened to her daughter. This is a variation of a theme, which I have seen played out in many people’s lives as well as in some interesting movies. Persons, sometimes separated at birth or when they are quite young often yearn to know their biological parent or parents with whom they may have had no relationship for decades. I have reflected on the psychodynamics of these issues in an earlier posting in this blog. Therefore, I was particularly interested to see how they played out as major motivating factors in the characters in this book.

I believe the author Ellen Wiseman has created an intriguing story that will hold the interest of the reader whether or not you come from a psychiatric background.

 

Suicide: Main Theme of Meeting in San Francisco May16-18 2013

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Suicide is the 11th leading cause of all death in the United States. It is one of most important issues which mental health professionals are concerned about in their clinical work. The American Academy of Psychoanalysis and Dynamic Psychiatry of which I have the honor of currently being President, has designated the title of its 57th annual meeting as: Psychodynamics: Essential to the Issue of Suicide and Other Challenges to Modern Day Psychodynamic Psychiatry.  It is fitting that the meeting is being held in San Francisco which although not on the top 15 cities with the highest suicide rate does have the Golden Gate Bridge as its symbol which is the second most common suicide site in the world.(see previous posts on this subject)  Any mental health professional is cordially invited to register and attend this meeting (see AAPDP.org) which will take place May 16-18 2013.

images-1Mental health professional must always consider the suicidal potential of any patient especially when that patient is depressed or experiences significant distress. I recall as a junior psychiatry resident when I first was given the responsibility of making a decision to hospitalize  patients (even against their will) because I felt he or she was a danger to themselves (or others). As much as this is a heavy burden, it is likewise a major responsibility not to hospitalize a suicidal patientand face a situation where this person has ended their own life.  In the latter case there also is the possibility of legal consequences.

If a person is determined to end his or her own life, they will ultimately succeed. However when the desire to do it is due to a mental condition that we can treat, there is a good chance that we can prevent the suicide if we can intervene and facilitate proper treatment. Unfortunately this is not always the case since patients who are in treatment or who have had treatment do kill themselves.

Depression is the most common condition which has the potential to lead to suicide. This may be part of biological condition with genetic components which brings about severe bouts of depression. Depression may be part of the grieving process or it may be due to complicated psychological reasons which lead  some people  to be so depressed that they want to end their lifeimages-2.

Sometimes there is anger at a lost object (person) that gets turned inward leading to self destructive acts. When the ability to test reality is lost, the  reasoning for suicidal actions can be quite bizarre and may include internal voices commanding the persons to hurt or kill themselves. There are still other situations where a person does a self destructive act, not with intent to commit suicide but rather with an intent to suffer or manipulate others but inadvertently does die as a result of this gesture. There are certain personality patterns where there may be repeated suicidal gestures which have the potential to be fatal or very harmful. Drugs and alcohol and complicate the problems and may actually be the cause of suicide.

There are some special circumstances where a patient with a serious, very painful  or perhaps  fatal illness may want to end his or her life or may ask the doctor  to facilitate their demise. There are ethical discussions how should this be handled. In some of these situations, if pain and discomfort is better controlled this may not be an issue.

The treatment for a patient with suicidal potential is a delicate situation. First the decision needs to be made if the treatment is to be inpatient or outpatient (sometimes a combination of both). There needs to be a treatment plan that will almost always require psychotherapy frequently with a combination of psychopharmacology. In rare situations ECT (Electric Convulsive Treatment) will be utilized. Family and close friends often play an important role in the support of the person with suicidal thoughts. While psychotherapy needs to be confidential, the patient needs to understand that under certain circumstances where the therapist believes that the patient is an immediate danger to self or others, the therapist may have to break the confidentiality for the benefit of the patient. It goes without saying that there needs to be a trusting relationship with the therapist so the patient understands that there are two people working together in the best interest of the patient.

Many of these  topics and others  are going to be addressed at the San Francisco meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry  May 16-18 at the Westin St Francis Hotel which was mentioned at the beginning of this blog.  All mental health professionals are welcome to register  either in advance or onsite and attend the meeting . Go to AAPDP.org for more information or you can contact me if there are any questions. There will three plenary sessions by Drs Mardi Horowitz, Jeste Dillip and Herbert Pardes as well as  many panels and workshops. There will also be a very interesting documentary about suicide titled, Don’t Change The Subject  with a discussion with Mike Stutz,  the filmmaker after it is shown. A few of these presentations will be made available to Auto-Digest subscribers but if you are able to attend in person, I suggest that you  do so. I look forward to meeting any attendees at the meeting.