Dr. Thomas Kirsch **

Dr. B: Can you comment on the relationship between Freud and Jung as depicted in this movie?

Dr. Kirsch : I thought that David Cronenberg’s portrayal of the relationship between Freud and Jung was fair, showing the strengths and weaknesses of both characters. Jung’s initial enthusiasm for Freud and his theories, as well as his reservations about ubiquity of the sexual origin of neurosis, are well portrayed.  Freud is seen as sympathetic to Jung’s countertransference to Sabina Spielrein — a highly probable response, given what we know of their early relationship.  The movie shows the historical beginning of the study of the countertransference dimension of psychoanalysis as seen through the relationships between Freud, Jung and Sabina Spielrein.The scene on the boat going from Bremen to New York was an especially good rendition of the spirit of Jung’s account of the incident, if not the details. In the movie Jung tells his dreams to Freud, but Freud does not reciprocate.  Actually, according to Jung in Memories, Dreams, Reflections, Freud did tell a dream, but refused to offer his associations . Jung asked why. ‘He said, “But I cannot risk my authority!” At that moment he lost it altogether.’

Dr. B: Jung is shown to believe in premonitions, telepathy and perhaps other non scientific unprovable ideas. In what way is this a fair or unfair representation of his theories?

Dr. Kirsch: I find this question biased towards a  misinterpretation of Jung’s openness to investigating phenomena as his belief in them, rather than seeing it as a representation of his forward-thinking attitude toward of the scientific method; the latter is the way it was accurately set forth in the movie. Famous physicists like Nobel prize-winning physicist Wolfgang Pauli and other equally prestigious scientists have shown a great interest in these parapsychological phenomena. The areas of parapsychology, synchronicity, chaos theory, and subjects related to these fields have received an increasing amount of attention by scientists from a number of fields, including psychoanalysis in recent years. A recent issue of Psychiatric Annals (Vol 41, #12, December, 2011) is entirely devoted to the subject of meaningful coincidences and Jung’s concept of synchronicity, a central part of his study of the archetypal layer of the psyche. In a late scene in the movie, the meeting in Freud’s study when the loud crack resounded, was an apt portrayal of Jung’s interest in what he saw as the exteriorization of psychic tension. Freud refused to find any psychological meaning in the phenomenon. My understanding is that, historically,  Freud was not interested in such phenomena. Furthermore, Jung’s interest in parapsychology has been used by psychoanalysis to cast suspicion upon Jung’s credibility, thus demonstrating that Jung was “unscientific” and truly a “mystic”.  I think the movie portrayed the differences between Freud and Jung on that subject accurately and sympathetically.

Dr.B: Do you believe that Jung had a sexual affair with his patient Sabina Spielrein and if so, should this influence the judgment of Jung’s contributions to psychoanalysis?

Dr. Kirsch: I have no idea whether Jung had a sexual affair with Sabina Spielrein. This is a subject which has been written about extensively .   Zvi Lothane, a psychoanalyst and historian, wrote of his conviction that they had a sexual affair in his earlier papers.  In a later paper he reversed his opinion. Let me give a personal vignette from my experiences around this subject. In 1983 I attended a public lecture by Bruno Bettelheim at the Stanford University Medical School. His subject was the Mistranslation Of Freud, but instead he spoke, to an audience who had no access to documented facts, about the still unpublished correspondence between Sabina Spielrein, Freud and Jung, A Secret Symmetry by Aldo Carotenuto (published the following year.) Bettelheim was emphatic that Jung and Sabina Spielrein had had a sexual affair . In the discussion. I asked him how he could be so sure, and he became characteristically offensive toward my challenge of his view of the truth.  In fact, I was familiar with the researches of Carotenuto and knew about the correspondence he had been offered from the basement of the Psychological Institute where Sabina Spielrein had been working prior to returning to Russia..  It is interesting that Spielrein had left all of her papers behind when she returned to Russia in 1919.

Whatever the truth, it is unfair that we should judge Jung’s contributions on the basis of his relationship to Sabina Spielrein.  Jung was only 29 year old in 1904, just at the start of a long career in a still unformed field of study, depth psychology.  To the movie’s credit, it treats Jung sympathetically in this respect. If the full truth is admitted, in the early days of psychoanalysis there were many such sexual liaisons.  Ernst Falzaeder, a psychoanalytic historian, has mapped out the various sexual liaisons between early psychoanalysts and their patients.  It is a remarkably long list. Many of those patients themselves became psychoanalysts. If Jung did have a sexual relationship with Spielrein, his was one among many.

Furthermore, Jung knew about the close relationship between Freud and his sister-in –law, Minna Bernays.  I myself have seen the signature of Freud where he signed himself and Minna into the guestbook of the Hotel Schweizerhof in Majola, Switzerland as husband and wife.  This is highly suggestive, yet Freud loyalists have long protested that this proves nothing about the nature of their relationship.  Jung in an interview with Kurt Eissler for the Library of Congress to be released in 2013, does not expressly say that they had an affair, but he does report that both he and his wife Emma had observed, when they visited Freud for the first time in Vienna in 1907, that Minna  was au courant with Freud’s ideas (in contrast to her sister Martha) and that she looked at Freud adoringly.

There is no question that Jung and Sabina Spielrein had a mutually erotic transference/countertransference relationship. From this distance in time it is going to be very difficult if not impossible to ascertain to what extent it was acted upon.  But is that the most important question to ask?  This was the beginning of psychoanalysis, and we know that Breuer had left the field because of this issue.  The fact is that Sabina Spielrein was helped by Jung’s psychoanalytic treatment of her and that Jung encouraged her aspirations, demonstrating his respect for her.  That she became a physician, a psychiatrist, and an early member of Freud’s psychoanalytic group in Vienna surely demonstrates that his good influence was not misplaced.  The movie also highlights her role in broadening Freud’s libido theory. Her influence on Freud’s theory of the death instinct is documented in a seldom cited footnote in Freud’s Beyond the Pleasure Principle.

Dr. B: How will a movie such as this one or the play by Christopher Hampton, upon which it is based, influence the legacy of Jung?

Dr. Kirsch:I have heard from some of my colleagues that they are disappointed by the portrayal of Jung in the movie. On the basis of this, as well as its sensational trailers, I was prepared to not like the portrayal of Jung.  Certainly the spanking episode is over the top.  The role of Otto Gross, and the fact that Jung and Gross were engaged in a mutual analysis, was one of the strongest historical, as well as dramatically pivotal, aspects of the film.  Gottfried Heuer, a Jungian analyst in London and the president of the Otto Gross society, believes that Otto Gross influenced Jung deeply in 1908 toward greater sexual freedom.

Unfortunately, there is a glaring error at the end of the movie.  When Sabina asks if Jung is involved with another patient, Jung says yes, and furthermore tells her that Toni Wolff is half-Jewish.  That is a complete fabrication!  Toni Wolff comes from one of the oldest Christian families in Switzerland.  Her family tree can be traced back to the beginnings of the Swiss Confederation in the twelfth and thirteenth century.  Christopher Hampton was told of his error before his play The Talking Cure opened in London, but he chose to leave Toni Wolff as half Jewish, and to perpetuate the error in his film version.  Furthermore, many prominent psychoanalytic historians have taken Hampton’s  drama as a statement of fact!  Diedre Bair has documented Toni Wolff’s genealogy on page 713, note 27, in her biographical work, Jung.

I was especially taken by their rendition of Jung’s plea to Spielrein for a reciprocation of the caring patience he had shown toward her in her own state of terrible inner conflict.  This is a faithful rendering of his state of confusion, as documented in their published correspondence, as well as alluded to by Jung in MDR and demonstrated in his Red Book, although this is generally regarded in part as his emotional reaction to the ending of his relationship with Freud.

Dr. B: Did you enjoy this movie and would you recommend it to others?

Dr. Kirsch: I did enjoy the movie.    I thought that both Jung and Freud were well represented and I especially found myself liking the Jung of Michael Fassbender.  The role of Sabina Spielrien was superbly played in all its dramatic potential by Keira Knightly.  The one person who was not well represented was Emma Jung.  She was a much more earthy and powerful person than the haughty, frail creature see in the movie.  That was a real disappointment, because nothing I have heard about Emma Jung was represented, either by the role or by  the actor Sarah Gadon.

I certainly would recommend others to see this movie with the caveats I have raised.  Overall, I found myself admiring and empathizing with David Cronenberg’s portrayal of Sabina Spielrein and both Freud and Jung.  I hope that mine is a more widespread reaction.  If so, it may mark a shift in public awareness of Jung’s value as a pioneer and major contributor to our knowledge of the psyche.

The misrepresentation of Toni Wolff, though, poses a major problem, especially because of the later accusations against Jung for his alleged anti-Semitism. When portrayed as having begun yet one more intimate relationship with a (half) Jewish woman, when he is already widely seen as anti-Semitic, Jung the man comes across as a character lacking integrity.  As the repetition of Hampton’s error by prominent psychoanalytic historians proves, drama can wield a powerful influence over even the most scholarly of minds.

** Thomas Kirsch M.D. is a graduate of Yale Medical School, the residency program in psychiatry at Stanford and the CG Jung Insitute of San Francisco. He is Past President of  the Jung Institute of San Francisco, past vice-president and president of the International Association for Analytical Psychology. He has written numerous chapters in books on Analytical Psychology and is  Co-editor of the Jungian Section in the  International  Encyclopedia of Psychoanalysis, Psychology,and Neurology. He also is author of The Jungians, a social history of the Jungian movement and is co-editor of book: Initiation: The Reality of an Archetype. Dr. Kirsch has written  numerous book reviews and is a well known  lecturer on Jungian subjects. Most recently he has written the preface of a publication of the  correspondence between his father , Dr. James Kirsch who was a psychoanalyst  and Jung titled C.G. Jung/James Kirsch Correspondence, published by Routledge, London 2011. ( There are 150 letters between the two men.) Dr. Thomas Kirsch is in private practice in Palo Alto, California.

I would  would like to thank Dr. Kirsch for answering these questions for PsychiatryTalk-MB

I have read many books about the holocaust, have seen many movies about this subject and have visited various holocaust museums throughout the world.  As a psychiatrist, I have treated a few holocaust survivors and many more children of holocaust survivors. I was therefore surprised how impacted I was by reading this book which consisted  first person stories of 52 holocaust survivors most of whom were born between 1926 and 1938.

I became aware of this book  when a good friend of mine John Glass who is one of the 52 authors, showed me a copy of the book and told me about the project behind it. Each author is a member of the Child Survivors of the Holocaust, Los Angeles Organization that was founded in 1983.  Dr. Sarah Moskovitz and Dr. Florabel Kinsler organized the largest international group of child survivors with a membership of more than five hundred people. In the introduction to this book, Marie Kaufman President of the Los Angeles child survivors group and Chair of the Editorial Committee that put together the book noted that many of the authors have given oral testimony  to museums  and to the Shoah Visual History Foundation. But in the fifteen to twenty years since they have done so, they have become aware that for many reasons they have left part of their story untold. This book gave them opportunity to disclose secrets never divulged before.

As one reads this book and digest the  narrative which is recounting horrific early childhood memories, you cannot help but consider whether these are true memories. Could they be screen memories, retrospective memories based on things they were told and learned at a later age? In the course of psychotherapy and psychoanalysis we  often help patients reconstruct early childhood memories and feelings. The accuracy of the actual memory may not be as important as the meaning. I do believe that the memories reported in this book do ring to be quite true. I also would suggest a simple exercise before you read this book. Reflect back on your three or four earliest memories. Sometimes it will be helpful to choose a key event which you can easily date such as the birth of a  sibling, a  death or tragedy or famous event such as the assassination of JFK or Martin Luther King or the  landing on the moon, a particular grade school teacher etc. Often the event that you recall will have some negative or conflictual quality. My own earliest memory is when my mother left me alone  in our apartment for a few minutes to do an errand and brought me back a chocolate bar. When I discussed this memory with her many years later, she was astounded that I exactly recalled the events and she was able to date it when I was less that three years old. I recalled being under the care of an aunt during the time that my sister was born and my disappointment that a cousin has seen her first. I was less than 5 years old .   I also recalled my first day of kindergarden , when I was a  few months older than 5. While each of these memories had some anxiety and conflict, they were minuscule compared to the intensity of experiences of being taken away from one’s parents, hiding for prolonged periods of time, starving and witnessing and being threatened with death and destruction, all of which were common place in the 53 stories of this book.

There is another important dynamic which inhibited many of the child survivors from publicly telling their story . Many were hidden children who often had to assume non Jewish identities, sometimes having  several different gentile names and personas over time,  as young children during the war . Each time it was impressed upon them that under no circumstances were they to reveal their Jewish identity as this could mean death to them and their adopted families. So even after they were liberated, reunited with any surviving families and were beginning new lives in the United States, many still would not readily talk about their Jewish identity especially with strangers

It is very difficult to understand the experience that these children had where a  normal childhood was transformed almost overnight when Kristalnacht occurred in Germany, or when the Germans took over in Poland and issued the new regulations for Jews or similar events that happened in France, Hungry, Italy, Holland  and any other places conquered by the Nazi’s. They moved from their comfortable apartments or homes to the Ghetto where they were jammed into one room with extended families and strangers. In anticipation of this situation or in response to it many of their parents who suspected even worst was to come  made a decision  to send their children into hiding with non-Jewish families. In most of the cases the parents could not be hidden with their children. Childhood separation from parents is a very meaningful experience, usually traumatic with the possibility of lasting yearning, resentment, with a wide range of fantasies. This becomes colored by the subsequent events which might include loving or rejecting the adoptive parental figures  as well as being torn away from one such family as you are moved to another one.  The fate of their own Jewish  parents was often death as was that of most of the their original  families and friends. While many of the  child survivors intellectually came to understand that the decision to try to hide them allowed them to live, the full emotional understanding of this generous act on the part of their parents did  not come to them until many years later. It was often when their own children born in a safe environment were now the age at which they had been  put into hiding by their own parents, did they appreciate the sacrifice that was made for them. For some this realization did not occur until they had grandchildren who are at the age that they were hidden .

It is important to note that the trials and tribulations for many of these child survivors did not cease with their liberation from concentration camps or from their places of hiding.In some situations there was persecution by the Russians who liberated them or continued anti-Semitism when they tried to return to their home town. There were hard times often relieved by the many  organizations and people who tried to help them reunite with any exisiting  families. There were painful discoveries of what happened to missing family members. There was also  long waits for visas to new countries , travels across the ocean, learning new languages and adapting to a new culture

As was the case of many survivors who were adults during the holocaust, these child survivors  spent many years trying to forget and not to look back.  Their parents who survived or adoptive parents and relatives often did not believe that the experiences which they had as children made a lasting impression on them. They were building a new a life and did not want their own children haunted by such terrible events. As they moved on to a “normal life” in the United States the child survivors themselves thought that their memories and experiences were quite unique and as mentioned above were not inclined to talk about them. Many report an amazingly dramatic unburdening feeling when they attended their first meeting of child survivors. The intensity of that feeling and the realization that so many other children had gone through similar events was life affirming and literally changed the course of the lives.

It is noteworthy that so many of the child survivors have gone on to have very productive lives. Perhaps because they themselves have been helped by strangers (many of whom have been recognized in Yad Vashem  as the ‘righteous gentiles”  or “righteous among nations”) they have chosen a helping profession themselves. It seems to me that a high percentage have gone on to be social workers, therapists  and teachers. Some report moving into these fields after a successful career in business. Others have become artists and poets expressing their feelings and experiences in their work. There were numerous poems  as part of the narratives.

Many of the child survivors did not talk about the past for most of their lives   and for many it has only been in their twilight years that most have  felt an obligation to tell their stories or record  a first hand account that will exist for future generations. A good number of the authors of this book   have devoted many hours to teaching about the holocaust in schools and museum  and giving lectures in various settings. These activities and the writing of the chapter for this book as well as other publications that some of them have done appears to have been therapeutic for them.

The authors  tried their best to be sincere and honest in sharing all these events and their past and present feelings about what they have been through. For  most there is a triumph for having survived and for being responsible for the presence of so many wonderful people that they have nurtured and supported in their subsequent  lives  For some of people there is still an ever present wound or bewilderment and pain which stretches from their childhood to their later years. They are still trying to figure out why and how the events of their childhood  could have happened. For all there is the satisfaction of having told the story of what really happened  so those who were deprived of their lives will not be forgotten 

This was not an easy book to read. While I read it in linear fashion over a two week period and did not intersperse with other books perhaps that might not be the best way to read it. For some it might be best to consume it in small doses .  I suspect that some readers will appreciate the value of the book but will put it aside and may not complete it.

I realize also that I may not have captured the essence of the experience of the authors in this review. I would like to give you a few random excerpts although I hope over time you will read the complete version of each of these  52 stories as they all deserve to be remembered:

Lea- Born 1938 I was placed through the Dutch underground with a Christian family. There were many other children. Suddenly the family was betrayed. The underground took all the children away to new hiding places. On of my first memories was of being on a train with other boys and girls…. I  was taken to family of farmers in the small town of Horst by two men dressed in police uniforms. My clothes were torn and I had sores all over my body.  The men said that they ha d smuggled me out of some detention center but I have never been able to find out what happened to me.

Jack- Born 1926- The ghetto was organized  into factories of every possible trade and all the  the production was for the German military…My father could not get employment…When I saw my dad for the last time he was forty one years old…In July 1944 we were transported in cattle cars to Auschwitz-Birkenau. I was with my mother…(We) went through a selection conducted by Dr. Mengele. My mother was sent to the other side. Now sixty four years later, I can still see her walking hunched over, as if she know where she was going. I’m still haunted by this picute and I know that I will for the rest of my life. How do I reconcile the fact that my children are now older than my parents were when they were murdered.?

Lya- Born 1936- When I was seven and she (sister) was four we both went into hiding with different families. The thought never occurred to me that this would be the last time I’d ever see my parents. They never knew where we ended up…In 1946 my sister and I were sent live with  Parents Number 5 in Denmark…I was a very difficult teenager. Obstinate, opinionated, aggressive. I was sent out of class many times. It was sheer anger- a way of expressing myself to the world…My husband ( also a survivor) wasn’t interested in talking about his experiences and for the longest time I didn’t think that mine really countered. …I started dealing with my past in 1993, I was fifty six…. That’s when I first shared my story ( in a group ) about  losing my parents, grandparents, being separated from my sister and being in hiding with strangers. After that night, I became more aware of my own feelings. I could justify them. They were real and they weren’t something nonexistent.

Peter- Born 1936- In 1940 when I was four years old I was no longer permitted to attend my pre-school nor to attend any other school. From my earliest memories, I had to wear a yellow star with the word “Jude” on my jackets and shirts…People looked at us in disgust and were often rude to my mother when she shopped for food…Only 32 out of the 100 Jews transported in the cattle car I was in survived the Holocaust. I lived in the children’s barracks (in Terezin)…We slept in bunk beds on straw and had only a thin blanket. There was only cold water to wash ourselves in the summer and harsh winters…There was small piece of bread in the morning with some brown water they called “coffee” and for supper a watery soup with  an occasional small potato. We were half starved yet we were expected to work…(After the war)I lived my teenage years as a laborer, farm hand truck driver across the US. …By the age of 33 I had completed high school, graduated from San Diego State University and received a graduate degree in  Global Management.   … I have seven grandchildren.

Robert- Born 1935- When I was four years old our lives changed forever, The Gestapo came to our apartment and told us to take just a little luggage and follow them. They sent us by train to the Polish border. The poles would not let us in and Germans would not take us back…We traveled around Poland living as gentiles with an assumed name….The family that hid me decided to put me in the attic in the house. Many times they forgot to take care of me and did not feed me. …After the uprising failed the Germans planned eliminate the city’s population.. Everyone was loaded upon trains, which were headed to Auschwitz. …We knew we were going to be killed…My mother noticed that one of the cars had an opening on top. The train stopped about 100 yards from the Auschwitz concentration camp. My step father Emil lifted me up over the open car and I was able to open the train car door…In February 1947 we took a boat to America and settled with our extended family in Pittsburgh. I quickly learned English and graduated from Carnegie Mellon University in 1957 with degree in electrical engineering. …Over the years I have spoken about the holocaust to thousands of middle and high school children.

Erika- Born 1928- At the time of my birth my parents (in Hungary) owned two kosher restaurants.  I went to school unitl the age of fourteen when the anti Jewish Hungarian government closed the Jewish schools. Anti-Semetism forced many Jewish owned businesses to close or be taken over by non-Jews. Most of my uncles had been taken to forced labor camps in early 1940-42…I was deported to Auschwitz with my mother. We were lucky and escaped the selection. …On the day the Soviet liberators entered our camp they raped many women and wanted us to work for them. …I was helped tremendously by breaking the silence and talking about my experiences. Confronting my losses and acknowledging the effects of the traumatic times in my life have helped me to recover psychologically. However I still have problems such as fear of authority, anxiety about the health of my family, about separation  and the fear of loss.

For more information or to order this book go to www.childsurvivorsla.org

An  American  training program for mental health professionals in China provides classes via telepsychiatry (via video conferencing ) but many of the trainees wish to have their own therapy by experienced therapists who are in quite short supply in China at this time.

There are highly functioning productive people in the United states who are in occupations and jobs which often take them out of town or have long commutes to work with irregular work hours. This situation makes it quite difficult for them to arrange  psychotherapy with experienced psychiatrists  which would require them to come for sessions at least once per week.

During the past year I have become involved with devoting part of my practice to telepsychiatry and am now offering therapy in each of these three situations.

When I agreed to provide treatment one morning per week to the above mentioned clinic I already had experience in teaching courses online with video conferencing but I had not treated patients with this modality. I knew that some of these patients might have complicated mental illnesses which would require complex medications and that some might have to be hospitalized. I was aware that certain paranoid patients could be suspicious of electronic communications and some patients might require a translator if they did not speak English. I was pleasantly surprised to find how smoothly everything was able to run. A mental health nurse is in the room with the patient and a translator was available when needed.  The patients understood the concept that they were being seen by a psychiatrist in another city via video communications. We had a clear face to face discussion and the patients seemed as comfortable as in any other setting in bringing me up to date on their symptoms. I had access to a very sophisticated confidential electronic medical  record where I could record my findings and check the observations of any other visits that the patient had at this clinic. I could refer the patient for lab tests as well as to a primary care physician. I also could make referrals to other mental health professionals connected to this clinic who could do individual, family  or group meetings  with the patient. I prescribed medication directly through a very efficient electronic prescribing system, which electronically connects to every pharmacy in the state. If needed I could alternately fax a prescription or make a telephone call directly to the pharmacy. On the few occasions where a patient needed an immediate hospitalization I could arrange that and provide the referral information needed by the admitting doctors. It has been a very gratifying experience to spend this time providing this needed service.

First CAPA Graduation in Beijingi

For the past year I had been teaching as part of  the Chinese American Psychoanalytic Alliance (CAPA),a very innovative program  founded by a friend and colleague Dr. Elise Snyder.This program uses video conferencing mostly by Americans who provides high quality training to mental health professionals in China who previously had very limited access to this type of training. The program has grown and become quite in demand by young Chinese professionals embarking  upon a career in providing mental health treatment in China. One year ago I participated in study tour to China with CAPA where I had an opportunity to give a few lectures and also witness the first graduation from this program which was held in Beijing. In conjunction with such training, it has been common for the trainees to arrange their own personal therapy. Unfortunately for a variety of reasons, there has been a lack of therapists  who could offer such treatment to the trainees in China. Many of the Americans who have been teaching in this program have offered to treat such a Chinese trainee via telepsychiatry ( video conferencing) as did I. Due to the wide disparity in income between Americans and most Chinese, such treatment has to be offered at fraction of the usual fee received by American therapists in the United States. The trainees usually speak English quite well but there are at times interesting challenges related to the nuances of the meaning of words as well as in understanding various cultural differences. The fact of there being a “ one child policy”  in China means most of the trainees have grown up as an only child which has important psychological significance. Most Americans are not familiar with the Chinese concept of “shame” which reassembles but is quite different than “depression” which can be an important part of the childhood experience of growing up in China. Participating in this program as a therapist has also been a gratifying and interesting experience which I am pleased to continue.

The third situation which I described above, reflects an anticipated  shift in the  attitudes of many Americans towards  technology and psychotherapy. This change, I believe, is taking place in both patients and therapists. I practiced psychiatry in Manhattan as well as in a suburb of New York City  and more recently now in Los Angeles. I have seen  many sophisticated patients who chose their psychiatrists by referrals from trusted physicians or friends and would rework their schedules to make regular sessions, often in the early morning or evenings. People tended not to change jobs very often and it was common to have an entire course of  therapy with one therapist. Now days people commonly choose their psychiatrists after a careful investigation of their credentials and background online. Since the Internet is used for obtaining other important information it seems natural for  so many people to rely on the Internet and feel comfortable in evaluating information available on it. It is a known fact that people are changing jobs much more frequently, even in  higher paying positions. Therefore, one can’t be confident that a therapist in one location will be convenient to see at a later date. It seems that time is even at a greater premium than it was in the past. Commuting time is longer especially in a city such as Los Angeles and work environments frequently require people to be quite flexible. This means working at home at times, traveling when needed and irregular hours. Certain occupations such as the entertainment industry in Los Angeles requires long periods of time out of town as does pilots and airline personnel to name just a few. There is  increasing comfort with modern technology illustrated by  the growth of the use of video conferencing in business and education and the personal use of texting, Skyping , Facetime etc. Therefore it is inevitable that there will be a shift in the practice of medicine to use more telemedicine and for psychiatrists to use increasing amounts of telepsychiatry.  Therefore, I was very interested when the California Telepsychiatry Group (also now American Telepsychiatry) ,who were running the services for the mental health clinic described above, asked me if I would be interested in devoting some time to seeing private patients with their group.

I spent some time talking with their Director Dr. John Schaffer and I was impressed how they have arrange their video conferencing, electronic records and electronic prescribing to be HIPPA compliant (meaning state of the art confidentiality techniques) . They had addressed the various legal, ethical and questions of malpractice insurance and were carefully vetting the psychiatrists who would work with them. In addition they set up a very novel and interesting “meet and greet system” where potential patients, at no cost, could have a preliminary 10-15 minute   telepsychiatry meeting with any of the psychiatrists available for treatment . They could therefore review the credentials and experience of potential therapists, as well as meeting them, before they decided to enter into treatment. I am very pleased to now to be connected to an entity which I believe is on the cutting edge of a system for providing quality psychotherapy with this modality.

I suspect in 10 years from now or less,  people will look back on the three examples which I described above and see them all as every day occurrences in the delivery of mental health services in this country and throughout the world.

I lived in the northern suburbs of New York City at the time and the local newspapers had photographs of cars in train station parking lots that were not picked up by commuters who had perished in the World Center attack. I did not think that I knew anyone personally who died or had a close family who was killed  in the tragedy. Several months later I found out that  a chaplain with whom I worked with from time to time at the medical center had lost his son who worked at the World Trade Center. Over the ensuing years I saw many patients whose lives were impacted significantly by this event and worked in intensive therapy with several of them.

On the morning of 9/11/01 I was at Westchester Medical Center when I heard of the unfolding events. The nearest television set was on a psychiatric inpatient service near my office. I sat with staff and patients and watched the second plane hit the tower. Although many of the patients had severe acute mental illness-schizophrenia, other psychosis, suicidal behavior etc., we all responded in the same manner. There were groans and tears and statements of  “those poor people.” There was no panic and no apparent incorporation of this reality into the patient’s delusions. It has been shown that people with decompensated mental illness often show improvement at least in their short term symptoms when they are faced with emergency or tragic events.

I was reminded of an experience I had while I was in training in New York City many years previously when there was a sudden unexpected blackout with loss of power citywide for at least several hours. I also was visiting on a psychiatric inpatient service when it occurred and most people handled it quite well. I eventually published a paper how this event did interact with the psychopathology of a two patients.

By coincidence I was scheduled to give a Grand Rounds presentation on September 21 , 10 days after 9/11 at a hospital in downtown Manhattan from which you would have been able to see the World Trade Center. Ironically the topic of my talk had been about disaster psychiatry but I changed it to specifically allow a discussion on how my colleagues had responded and what they had done to address the mental health issues related to this tragedy in their backyard. A center had been set up on Pier 92 for the survivors, families and friends  of the victims. Mental health professionals from all over the Metropolitan area donated their services to work with the Red Cross in helping these people with their physical and emotional needs.

At the time of this presentation, I walked around downtown Manhattan and the area surrounding ground zero. I noted the presence of something very interesting there and also scattered throughout Manhattan.. There were posters with pictures made by family and friends of people who had been in the World Trade Center at the time of the tragic events and did not come home. The posters, as you can see, were made from the point of view that these people were “missing.” They provided a description of the person with the request that if anybody were to see them they should call a specific telephone number. There were numerous such posters. The fact is that people were not found wondering throughout the city. The relatively few injured people who were brought to the hospital were identified and families were notified. Of course, the New York City morgue had a very sophisticated system of trying to contact any family members if they had made identification of the remains of victims. So what were these posters about?

They obviously were part of the denial phase of  the acute complicated grief that the survivors were beginning to feel as on some level they realized their  loved ones were killed. Within the next two weeks people began to make alterations in these posters which showed that they recognized that these people had died.  They crossed out the words “lost” or  “missing” and would write things like “in memory of”. The posters now would be adorned with flowers. I don’t recall this phenomena ever being reported in the psychiatric literature.

While I did not participate in the work on Pier 92, I was asked to do some “debriefing” activities for some organizations. One such group was the personnel of a major TV network. (I had done some previous work identifying the psychological trauma that members of the working press often experience in the course of their work). I was the co-leader of this group with a Professor from the Columbia School of Journalism.  Prior to this time debriefing activities would have meant trying to get the participants to express their emotional reactions to their recent experience in the disaster. More recent research had suggested that this wasn’t the best approach. In fact,  it might even make things worst. So our approach was a much more general approach in which we acknowledged the type of emotional symptoms that they might experience and made suggestions how to minimize them.

The evening before I worked with this group I had spoken with a family member of mine who told me that she had a dream that the well known television anchor from this network was having a personal conversation with her about the disaster. This dream appeared to reflect the importance that such TV personalities have in reassuring people at the time of frightening events. I was able to tell my relative that I spoke with the TV producer who worked with this anchor and she was going to tell him about her dream .

There has been a great deal written about this disaster in professional journals as well as in other media.We also will dearly hold on to our personal memories of that fateful day. Feel free to relate any of your experiences or thoughts about this day in the comment section below.

Don’t Change the Subject

This is a documentary about suicide, by a film maker who lost his mother to suicide when he was twelve years old. It seems to be his attempt to understand that tragic event in his life at the same time he is making film that he hopes will save some lives. Usually we don’t review films before they are ready to be released. In fact, the final edit on this movie has just been tweaked. It hasn’t hit the film festivals yet and a distribution deal has yet to be made. We hope in a small way, the availability of this review will help the process along as well as encouraging folks in the mental health community to consider using this film as a discussion tool at professional meetings and most of all to be used for educating the public.  According to the National Institute of Mental Health suicide is 10^th leading cause of death in the U.S. and the 3^rd leading cause in the age group 15-24. There are 11.3 suicides deaths per 100,000 people in this country. An estimated 11attempted suicides occur per every suicide.

While these and other statistics are important, this film is not about numbers and risk factors. It is about real people who tell little pieces of their stories. It is about people who came very close to killing themselves but for some circumstance or reason didn’t do so. It is about the filmmaker who comes across as a very likeable guy who is trying to figure out why is mother, who he believed loved him, would leave him by her own hand. He reads her letters, listens to tapes of her talking, looks at old film clips and ponders this issue with his older brother, aunt and step mother who married his father after his mom died. His brother never understood how she could have done this when she was in the music business and knew how important was his debut as an opera director that was happening the following week. His aunt, who was a psychiatrist, knew her sister had problems but didn’t see this coming. His stepmother only recently reveals her own special connection with suicide.

Sally Stutz

While the filmmaker may not have ever completely understood why his mother ended her life, he did realize that more then how she ended her life, she should be remembered for how she lived her life which included much love and support to her children. This message alone gives the film great value.

The filmmaker, Michael Stutz is also the director, writer and producer. He does go beyond just his own story and some close up vignettes of people who struggle with depression and have come close to doing this fatal deed. He follows a talented choreographer who is preparing a group of young dancers to perform a piece about autopsies. The result is as dramatic as is the meaning to young performers who had to come to grips with what their dance was about. We are introduced to a fairly successful comedian who has a team of writers help him prepare his material that daringly enough is going to be about suicide. It is always tricky business when humor is touching a potentially raw nerve. You have to understand, as a psychiatrist I usually don’t even like it when people use the word “crazy” in stories or in every day life but I appreciated the use of humor in this film. In fact the highlight was a piece by a comedian who did a monologue as a character who was leaving a video to his family prior to his suicide. He said just about everything a loved one would dread that their family member who was ending their life might say about them and how the suicidal person felt about them. It brought me to out loud laughter and will be for me one of the most unforgettable parts of this film about a very serious subject.

I said earlier that I hope professionals will view and use this film in their efforts to prevent suicide. It is not because this film will necessarily educate my profession about suicide. It didn’t really examine the difference between suicide attempts and suicide gestures nor did it attempt to show the different psychiatric diagnosis that people who attempt suicide might have. In fact there wasn’t much of a psychiatric presence in the film. However it has the potential to be very meaningful to anyone who has struggled with suicidal thoughts, had fleeting suicidal thoughts or has been close to anyone who has had these issues. Unfortunately there are a great number of people in at least one of these categories. This film can save lives so it deserves to be seen and will be a worthwhile experience for many people. I don’t know yet when and how it will be distributed but more information about it can be obtained on the following website: http://www.dontchangethesubject.org/ (2011)

Q & A with Michael Stutz

Shortly after I viewed the movie, I spoke with Michael Stutz, the filmmaker and he agreed to answer some questions for this blog.

MB: What made you decide to make this film?

MS: I wanted to make a film that I would have wanted to see when I was a kid dealing with my own mother’s death.  At that time I was struck by the typical adult reactions when talking to a twelve year old and how incredibly awkward they were.  Everyone seemed to be walking on eggshells.  If they talked about it at all it was in vague clichés or condescending attempts at “she’s in a better place.”  My mother was in and out of mental institutions for more than two years before she died.  I watched her sob and collapse and sleep for eighteen hours a day.  I also was the one who found her after her overdose.  I didn’t need clichés.  I needed honesty and a path to help me process my feelings and move on.  For me that path turned out to be theater and comedy and dance.  You can’t really capture all of the raw emotions going on in your head after something like this.  It’s surreal.  The arts helped me to work through images, fragmented thoughts and deeply conflicted feelings better than a straight on discussion could.  With this movie I wanted to suggest different ways of communicating beyond conversation.  It’s incredibly important to talk about it but not everyone is able to talk about it in the same way.  As I sit down to write this I am remembering the one adult who really helped me the day I found my mom.  It was a friend of my grandmother’s who came over to watch me while everyone else was at the hospital.  I was crying and she sat down and instead of clucking out soft meaningless words she showed me a book of watercolors she had painted over the years.  She said she normally didn’t show it to anyone but thought I might like it.  We just looked at the trees and lakes and various images that she had created and it calmed me.  I see now that’s a part of what I wanted to do with the film.  Share something private in the hopes that it might help somebody out in their own time of need.

MB:Is there a special audience that you had in mind when you made it?

MS: I made this movie for members of the suicide community who would cringe at being identified as part of the suicide community.  Over the years I’ve taught a lot of classes to various groups, teens in particular.  I’ve taught theater, comedy, dance etc. and I always find the kids I like the best and the ones who ultimately seem to get the most out of class are the ones who were the most resistant and cynical in the beginning.  The smartasses, the awkward shy kids, the kids who think they would rather be anywhere but in that class.  I made this movie for them.  Our movie is a punky, awkward, smartass, oddball little film for everyone who feels like they’d rather be anywhere but in a theater watching a suicide movie.

MB: Was it therapeutic for you to go through the process of making this film?

MS: Absolutely.  Though I have to admit when we started out my concept of the film was very different than the film that ended up on the screen.  I thought I’d interview several well-known people in the arts who had experienced suicide in some way and then see them creating their own artistic pieces.  After being turned down by everyone that I asked, I realized first how incredibly taboo this subject still is, and second that I’d have to be willing to step up to the plate and share my own story if I was going to ask others to do the same.  So then my family got dragged into it.  At the same time we were making the film my stepmother Judith was in the end stages of cancer.  Because of this she and I had been having a lot of conversations about family, including something that I didn’t know when I was a kid; her father had killed himself too.  She had held his head after he’d shot himself just like I had cradled my mother’s head after she overdosed.  Her father killed himself just before her birthday, just like my mother had done before mine.  It was amazing that we had lived under the same roof and never talked about this.  So, as Judith was entering hospice and going through her last year of life we were also filming this movie with family as they visited.  It was an incredibly bonding experience.  Judith was very involved with the whole process and always asked about its progress and was even able to see the first full rough cut three days before she died.  The conversations we had both on camera and off were some of the most rewarding and meaningful conversations I have ever been a part of and I think she felt the same way.  I will say it’s amazing that it took a camera to help all of us in the family to talk to each other in ways we never had before.

MB: How did the comedy piece of the character making the video for his  family before he killed himself, come about?

MS: There’s a comedic monologue called “Daddy’s Last Video” in the movie that I wrote several years ago for a brilliant actor named Ron Riegler.  He’s quite simply the funniest and most subtle actor I’ve ever worked with and I knew he could pull this off.  It came from my experience as a child where people would come up and say various versions of “this wasn’t your fault.” This is of course a very kind and reasonable and I’m sure in many cases very helpful thing to say.  But then again what is the alternative?  What if someone, in this case the daddy who killed himself, said in those same low and comforting tones, ‘well actually this is your fault.  You really were a lousy little kid.  Thanks for killing me.  Love Daddy.’ Now, out of context I’m sure this reads as horrifying but you have to see it to understand that I’m simply pointing out the ridiculousness of almost anything you say to a kid after a parent has killed him or herself. The situation is so bad it becomes absurd.  I guess I just hate low, hushed-toned speaking.  As a kid I thought, “Really, this isn’t my fault?  No kidding?  I just found my mom on the bed and that’s the best you can do?  Thanks.”  But, I was a weird kid.

MB: Were you concerned that this piece or any of the other humor would be found offensive by some people?

MS: I’m sure right now someone reading the previous answer is thinking ‘seriously you want me to see a movie where children are blamed for their parent’s suicide?’  I promise, it’s funny in context.  So yes, I’m sure it’s possible that some reasonable people could be offended by this or other parts of the movie.  But what I’ve found so far is that most of the people who have seen it who have experienced suicide up close and personal have laughed right along with it.  I’ve met with more resistance from those outside that world who worry that we may offend.  Gallows humor is what I do.  I’ve done plays and sketches about all sorts of issues related to mental illness.  I promise you they aren’t done to mock these very serious issues.  I was raised on Monty Python and Woody Allen.  I blame them.

MB: What kind of responses have you had from people who have seen the film ?

MS: We’ve gotten very positive responses so far, especially from folks in the psychiatric community.  I was somewhat worried that because the film is a little more “colorful” with its language in some places and does use humor to deal with very heavy issues that some folks might not be willing to take the trip with us.  But so far I’ve been very pleasantly surprised.  It’s also been great to see a broad range of people get something out of this.  A friend of mine pointed out that even though he hadn’t experienced suicide in his immediate family the way he felt after his parents’ divorce was very similar to how I felt after my mom’s death.  In some ways you could say that the movie isn’t primarily about suicide.  It’s about communication.  Everyone has had a time in their life when they felt misunderstood or unable to communicate their feelings.  That’s what we’re talking about.

MB: Do people “change the subject” when you discuss the content of the film?

MS: When I say I did a movie about suicide people usually drop their eyes and mutter something under their breath while trying desperately to inch their way away from me.  But when I say I did a weird dance comedy performance art movie with kids performing to autopsy reports and comics flipping out on rooftops and dark little animation sequences then the eyes sort of come back.  In the end many of the loveliest parts of the movie are actually the quiet, sometimes sad, sometimes funny little moments where survivors are relating their stories in this heartbreaking but incredibly inspiring way.  But since a lot of folks can’t quite wrap their brains around that we give them some other fun things to look at in between the stories.

I had always wanted to learn more about the interesting work of psychiatrist Robert J. Lipton that I had heard about, but I never got around to reading his various books and other writings. This is the reason that I was pleased to embark upon reading this recent memoir. The author not only reviews his four main projects but he shares his recollections and feelings about the many people he has met along the way of his fascinating life’s work.

Lifton’s  psychiatric training was interrupted by having to join the military as a physician during the Korean War. Although he was able to resume and even ultimately have some training at the Boston Psychoanalytic Institute, he never became a conventional psychiatrist or analyst. After spending sometime in Hong Kong Lifton became intensely interested what had become known as Chinese thought control. The Chinese communists had embarked upon what they had called a “reeducation” program  aimed at indoctrinating everyone in the country but especially the educated and the young people to completely and without any question accept the sanctity of their leader and the validity of their doctrine.. Lifton’s technique of gathering data was to make contact with appropriate subjects and then hold open ended exploratory interviews. He used a trusted translator most of the time. He had made friends and contacts in Hong Kong who led him to meet various people from China who had been subjected to this mind control. A variation of this technique was applied to the Americans airmen taken prisoner of war by the Chinese in the Korean War. At that time the term “ brain washing” became popularly applied to what was being done .The techniques involved isolation, repetition of ideas, raising self doubts about old ideas. It was a relentless style of re-education which also included the encouragement of reporting to the authorities anyone known to rebel and not accept this new way of thinking. As Lifton saw the overall impact on Chinese society, he applied the term “totalism” to the complete penetration of this doctrinal thinking in all phases of living in China. Lifton was to also use this term when he studied other groups particularly the German people falling under the influence of Hitler. His suggestion that any group whether it be religious, political or even social which makes an all out effort to control the thinking of it’s potential followers should be identified as applying “totalism” to its efforts. He is very clear about the destructive nature of such thinking and the reader cannot but think how various modern day movements may be leaning in this direction.

While it is difficult to say which of his experiences had the greatest impact on him as they all obviously did and each embellished on the other. However, it seemed to me that his study of the survivors of the Hiroshima atomic bombing  which he did when he was in his early 30s, emotionally penetrated deeper than anything he subsequently experienced and irreversibly changed him. Through his personal interviews with the subjects of his research, as a relatively young man he repeatedly encountered the meaning of death, destruction and mutilation. He appeared to feel their despair. While he intellectually understood and scientifically described the complicated grief and walking death that so many of the Japanese were to live throughout the rest of their lives, Lifton was transformed into a lifelong and very effective pacifist. Those of us who never had the emotional confrontation with the results of the A Bomb, might be able to  accept President Truman’s decision to bomb Hiroshima and Nagasaki based on the calculation to save the lives of many thousands of Americans who would have invaded Japan. Lifton I believe, never raised this issue and appeared to believe in retrospect it had to be the wrong decision. He continues to bring a pacifist point of view to every relevant  modern political and social issue of his time.

While I never met with anyone who went through  anything approaching the magnitude of Hiroshima, my experience as a consultant to a major burn unit and having had some professional work in the aftermath of 9/11 gave me some perspective to to relate to  his writing on this subject. However his decision to attempt to interview the Nazi doctors was “ mind boggling” to me, meaning that I had no frame of reference to this subject. Since this was his memoir, it probably was relatively short on the details of this work and conclusions which was covered in his earlier published work.  But this book was  relatively long on his personal reactions to the people with whom he met. His own perspective in approaching the Nazi doctors was as physician, psychiatrist, pacifist and a Jew. He seemed to have no trouble making the contacts and finding the surviving doctors who were willing to speak with him. In this memoir Lifton shares his struggle to understand whether these doctors were inherently evil people or whether circumstances might induce people to do terrible things to other people.

Lifton’s analysis and discussion of his experience in looking at the Viet Nam War and anti-war movement carried through to his comments on the U.S. war in Iraq. His reasoning and anti-war point of view is not simply founded upon his pacifist point of view but brings in a political and historical analysis. He also describes his interest in understanding post traumatic stress. He may have originated the term psychic numbing based on his earlier observations as well as those on the returning Viet Nam veterans. It is not surprising that he had great interest in understanding the My Lai massacre and raised once again how could descent people (in ths case the American soldiers)  do horrifying deeds.

It was a special treat to learn about the many writers, historians and other intellectuals  with whom Lifton interacted over the years. His personal discussions with people as diverse as Erik Erikson and Norman Mailer were recounted. Many of them took place at seminars he and his wife held at their summer home in Wellfleet. Betty Jean Lifton died shortly after her husband finished most of his memoir  She was a writer mostly of children’s books but she shared his passion for psychohistory  and their relationship is warmly reflected at many places in this book.

Fast forward to the present. A few years ago I set up a new private practice in California where I have relocated. Patients are still referred by the usual sources but in addition the Internet has made it a whole new ballgame. Finding doctors on the Internet has become a common practice. I have a professional website and it is not unusual for people to find me through several Internet sources. They have reviewed my web site and also googled me. They are aware of books and papers that I have written. They have seen my Facebook page. They may have even read my movie review blog. Having an unlisted personal phone number is not necessary since I have had a home office for more than 20 years, originally in Scarsdale New York and now in Woodland Hills, California. It doesn’t take much skill to locate my home address or even my email. People can check my credentials online and find out if complaints have been made against me and even make comments about me online. They probably can find out more about my family members than I know. Why would they want to do that and in fact why was I trying to be anonymous in the first place?

There are a couple of reasons why a psychiatrist might want conceal his or her private life , particularly one that does psychoanalytic or psychodynamic therapy. It is well known that a patient’s thoughts and emotional reactions to his or her therapist reflects important psychological insight into themselves. Therefore it is often the goal of a therapist to try to provide a gray or blank screen of themselves in order to make it easier for the patient to project or imagine things about the therapist. This would facilitate the formation of “transference” which is an extremely important part of psychoanalytic and psychodynamic treatment. The more the patient knows about the therapist, the less the transference originates with themselves and the more it is based on reality. While there is no doubt in the validity of this type of thinking, it is also true that just knowing some factual information about the therapist does not eliminate the development of transference. Experienced therapists can help the patient understand the meaning of their curiosity and whatever they have learned from the Internet about the therapist. Just knowing about the therapist’s life doesn’t mean that you have lost the opportunity to have transference be a vital part of the treatment. The patient’s interpretation and emotional reaction of the information that they have learned becomes useful data for treatment.

There has always been a concern that a patient might stalk a therapist after finding out where he or she lives or perhaps call or email the therapist  (other than for administrative reasons). This might be precipitated by a strong emotional attachment or perhaps because of delusional ideas. While this may not be prevented in rare situations, it is the task of the therapist to help the patient to understand the boundaries between them and the value of discussing any such tendency in the treatment sessions.

Modern day technology offers much more potential benefits than obstacles to good mental health treatment. Information about the credentials and experience of therapists, education about mental conditions and various forms of therapy as well as information about psychopharmacology are available online. The state of the art now even makes it possible to provide therapy in locations where it hasn’t been available via Internet video technology. People who travel a great deal and where it is difficult to commute for regular therapy sessions  may be able to use this modality. There are also many locations where trained therapists are in short supply. I have had some experience with telepsychiatry and I shall blog about it more in the future.

UNHINGED Daniel J. Carlat, M.D. Free Press 255 pages 2010

Dan Carlat, in addition to practicing psychiatry, writing his popular newsletter and blog, editing a series of psychiatry books for Lippincott/Klowers (one of which I co-authored) and writing monthly blogs for Psychiatric Times periodically (as do I)   has written expose pieces about psychiatry for the N.Y Times and other widely circulated publications. He has spoken out about the influence of the pharmaceutical industry on the practice of psychiatry and particularly the large amount of money earned by psychiatrists from the drug companies  often without disclosures. This latter point has been considered to have  ethical and legal ramifications. Knowing this background, I eagerly approached the opportunity to review his new book Unhinged published by Free Press    (2010) and given a subtitle of  “The Trouble with Psychiatry-A Doctor’s Revelations about a Profession in Crisis.”

Early in the book, Dr. Carlat shared his own experience as a practicing psychiatrist where he specialized in prescribing medications and referred patients in need of talk therapy to a “psychotherapist.” He expressed his view “that most people are under the misconception that an appointment with a psychiatrist will involve counseling, probing questions and digging into the psychological meaning of one’s distress.” He goes on to site data which shows that 1 out of 10 psychiatrists offer therapy to all their patients. (I am not sure if this is a valid point since some patients clearly don’t need or want psychotherapy.) He then talks about the well known income differential which favors providing psychopharmacology treatment over psychotherapy. He provides a case history where he did not tell a patient that psychotherapy might work just as well as medication. He said that he decided upon medication because he received little training in  psychotherapy during his three years of psychiatry residency (Mass General) and that he “ doesn’t do psychotherapy  because “I can’t do psychotherapy.” One of the themes of this book is Carlat’s odyssey to ultimately deciding to learn more about psychotherapy and follow a mode of his father who is a psychiatrist and develop a practice which combines psychopharmacology and psychotherapy even if he doesn’t make quite as much income as he did in the past. He shares the interactions with colleagues, teachers and mentors as well as patient vignettes, which lead him to this decision.

This book also examines other controversial issues. For example, Dr. Carlat discusses DSM which he calls “ The Bible of Psychiatry.” He believes that the tradition of psychological curiosity has been dying a gradual death and that DSM is in part the cause and the consequence of this transformation of our profession. He argues that as a result psychiatrists are less interested in “why” and more interested in “what”. (I thought that psychiatrists could chew gum and do other things at the same time. If we continue to use and refine it, DSM allows us to communicate better, do research and get paid.) Carlat interviewed both Bob Spitzer and Alan Francis, the leaders of DSM III and IV respectively who are  both quite critical of the emerging DSMV.

Not surprising, knowing of the previous writings of the author, a good part of the book dealt with the relationship between psychiatry and the pharmaceutical industry starting off with a chapter on “How Medication Became the New Therapy.” There is a  description of the evolution of various drugs used  in psychiatric  practice including the story of Prozac as well as examples of how and why new drugs are introduced as patents on old ones expire. While most of these stories are fairly well known to psychiatrists, it may be surprising to see the behind the scenes descriptions of how side effects such as sexual dysfunction and suicidality were initially minimized and ultimately handled.

The chapter on “How Companies Sell Psychiatrists on their Drugs” reflects some of the writing that Carlat has made in the popular media. He personalizes this important topic by describing his own  previous  relationship with various pharmaceutical representatives. He also reveals the fact that drug representatives have access to each doctors’ prescribing pattern before they visit him or her. He discusses how friendliness and  bringing little gifts such as books or one’s favorite Starbucks coffee have played a subtle but distinct influence on doctors and their prescribing habits. (There have been recent restrictions on these practices.)

Dr. Carlat also outlines his own experience of being a “hired gun” where he gave paid talks to primary care doctors and psychiatrists earning as much as $30,000 in one year. He told how he and his wife were flown to NY and stayed at luxurious hotels and ate in fine restaurants paid for by the pharmaceutical firm for which he was a speaker. He eventually decided that this was morally wrong and stopped this practice. He did go on to write about other psychiatrists whom he reports have made millions of dollars and in some cases were also receiving research grants.  He told  how they were not reporting to their universities, the income that they were receiving which was required. He details Iowa Senator Grassley’s investigations into very well known psychiatrists. He raises ethical questions about doctors taking pharmaceutical money while promoting off label use of various medications for treatment of ADHD and bipolar disorders in children.

There is a discussion of what Carlat calls “the seduction of technology”, specifically referring to the promotion of Vagal Nerve Stimulation and Trans Magnetic Stimulation.    (I observed how the latter technique was actively being promoted at the recent APA Meeting in New Orleans).  Interestingly, Carlat concludes this chapter with a statement that “psychiatrists  need to reacquaint themselves with the missing skill of psychotherapy.”

Perhaps one of the most interesting and controversial thesis of this book is the author’s conclusion that “medical school is the wrong place to train psychiatrists.” He believes that there should be programs that integrate psychopharmacology and psychological technique from the beginning of the training of psychologists . He goes on to say that  psychologists should ultimately prescribe medication as well as do psychotherapy. He describes one experimental model that was briefly used in the 1970s  at  a teaching institution in California but failed to be accepted as a model for licensed care. .

Whether or not you  agree with the arguments, analysis or conclusions of Dr. Carlat, there is no doubt that he has written a very thought provoking book that is based on his own experience with a reasonable attempt at documenting many of his statements .(There are 16 pages of notes and references).  His discovery of psychotherapy as a valid form of treatment will not surprise many of the readers of the journal where this review is appearing. His idea that that psychiatry at this time is troubled and in crisis is probably best judged by a longer historical view. However I suspect that this book will be used by historians to reflect some of thinking of the time as will be  another book written by the psychiatrist Peter Kramer  which came out  17 years ago titled Listening to Prozac . In the meantime Dr. Carlat’s views are out there for discussion and debate.

Take Five With the Author

Following are the answers to five questions I recently asked Dr. Carlat for this blog:

Dr B:  Can you describe the reaction of your colleagues to this book?

Dr. C: The reaction from colleagues has been mixed. Most have agreed with the central idea, which is that psychiatry has moved too far into psychopharmacology and has largely abandoned therapy. Many have disagreed with my fairly radical proposals, such as creating an entirely new training system that would be an alternative to medical school and residency. And of course, some have become positively apoplectic at the idea that psychologists can prescribe from a limited formulary safely. So I’ve had my share of fan mail and hate mail.

Dr. B: Do you believe that at present there  is enough transparency about possible conflicts of interest in national presentations at meetings and in journal articles ?

Dr. C: No, all we get is the name of the company. We don’t get the amount of money, nor the name of the product that the presenter has promoted. These pieces of information are critical for the audience to judge the likelihood that money is affecting the accuracy of a presentation.

Dr. B: Do you have any ideas how the new healthcare legislation  (Obamacare) will impact on the practice of psychiatry ?

Dr. C:It will increase the demand for psychiatrists, simply because we will be adding about 30 million people to the health insurance rolls. Some have argued that the emphasis on gate-keepers and accountable care organizations will take business away from psychiatrists, but I can’t imagine PCPs have either the time, interest, or expertise to deal with our patients.

Dr.B:  Do you see psychotherapy by psychiatrists being viable in over the next 5- 10 years.?

Dr.C: Not unless psychiatrists are willing to take a drastic pay cut. There’s way of prettying this one up. Insurance companies are never going to pay nearly as much for an hour of therapy as for 3 or 4 psychopharm visits. So the more therapy you choose to do, the less money you will make in direct proportion. That’s assuming, of course, that you are taking insurance. As many as a third of psychiatrists have opted out of insurance and charge their regular fees for therapy, much higher than what they get reimbursed by insurance. Personally, I don’t think that’s a viable option from the standpoint of ethics and health care policy. And it’s demeaning to us. We’re saying, essentially, “our skills are not valuable enough for your health insurance to pay what we think we’re worth, so we don’t take insurance.” I’m not one of those who villainizes insurance companies, partly because many of my trusted psychiatrist colleagues work for insurance companies, and I know what they are up against. They make a serious attempt to come up with a fair market price for therapy, and they have found no compelling empirical evidence to suggest that a psychiatrists’ therapy session is worth double a social workers’

Dr. B:  Can you tell us about any new books or projects with which you are involved?

Dr. C: I am just extremely busy managing my publishing business right now. I wish I had time to write another book, but I have nothing in the wings.

Edward Bibring Photographs the Psychoanalysts of His Time

Edited by Sanford Gifford, Daniel Jacobs & Vivian Goldman

Pub. by The Analytic Press, Psychosozial-Verlag ( 2005), 206 pp.

People who are interested in psychoanalytic theory are usually quite fascinated with the period of time in which these ideas emerged and the people who developed them. Therefore a book of photographs of these people taken by one of them should be a valued treasure. This must have been part of the impetus that led the editors to put together this book which is suppose to be the first of a series of publications by the Boston Psychoanalytic Society and Institute based on material from their archives.

The photographs span the time period between 1932 and 1938. These are photographs taken by Edward Birbring at the 12^th IPA Congress in Wiesbaden in 1932, the 13^th IPA Congress in Lucerne in 1934, the 14^th IPA Congress in Mariendbad in 1936, the Vierlandertagung (which was a meeting of analysts from the four Central European countries) in Budapest in 1937 and the 15^th IPA Congress in Paris in 1938 as well as some miscellaneous photographs. Biebring used a Rolleiflex, which is a small camera that allowed candid pictures. It produced a nearly square format and the pictures in the book are all 4 x 4 ½ inches, in black and white of course.

Individual portraits were not the main theme of the book but there were some excellent head shots of Ernest Jones, Max Eitingon, Abraham A. Brill, Sandor Ferenczi and Sandor Rado at the beginning of the book. There also is a self portrait of Edward Bibring which appears on the cover of the book. It would be quite easy to obtain very good individual pictures of other subjects by editing the pictures where there was more than one person in the photograph.

Most of the photographs are groupings of people. While there are some in which all are smiling at the camera or eating food together, most show the subjects engaged in conversation with each other. Perhaps it is my imagination but it appears that they are intensely involved with their discussions. I wish I could know what Anna Freud and Melanie Klein were talking about. Perhaps they were discussing their well known  disagreements about psychoanalytic theory.

There were many excellent photographs of various people with Anna Freud and one of her brother Martin Freud, the eldest son, standing by himself. There were no pictures of Sigmund Freud and I can only assume that he did not attend these meetings although I do not know for sure.

Although I did not do a count, some people were in many more pictures than others. Max Eitingon, President of the 12^th IPA Congress, and Ernest Jones, President of the 13^th and 14^th IPA, were in various photographs with many different people. Marie Bonaparte seemed to get around and was in many pictures. Understandably, Grete Bibring, wife of the photographer and also an analyst was amply represented. There were many other well known names and some of their spouses. They were all dressed in the fashion of the times with many of the men wearing vests and hats and the women in long dresses. There was a particularly endearing picture of Helene Deutsch sipping a tall drink with a straw while Heinz Hartmann sits next to her with his arm draped around her chair, smiling at her with a cigar in his hand.

The last 30 pages of the book were short biographical sketches of many of the subjects in the book. This gave the reader not only a thumbnail view of the individuals but reflected the professional interactions of the times. It was very interesting to also see how the spread of the Nazi regime impacted on the people involved in the psychoanalytic movement.

There were many photographs of a woman named Vilma Kovacs about whom I knew nothing and was not included in the biographical sketches. A good book will often stimulate further thinking and I became curious about the role she may have played. I could not find any reference to her in the Ernest Jones or the Peter Gray biography of Freud where just about everyone else in the analytic movement seems to be listed in the index. I did track down information about her with an Internet search that I will summarize below to give an example of the lives and contributions of the extraordinary people who were photographed in this book.

Vilma Kovács-Prosznitz, the Hungarian psychoanalyst, was born at Szeged in Hungary on October 13, 1883 and died in Budapest in May 1940. She was the third daughter of a provincial bourgeois family and her father died while she was still very young, less than six years old. The family found itself destitute, and Vilma was married at the age of fifteen and against her will to a cousin, Zsigmond Székely, who was 20 years older than she. By the age of 19 she was the mother of three children. Alice, the eldest, later married Michael Balint. Vilma contracted tuberculosis and had to spend prolonged periods in a sanatorium. It was there that she met Frédéric Kovács, an architect, whom she married after a difficult divorce that separated her from her children for several years. A serious case of agoraphobia led Vilma into analysis with Sándor Ferenczi. He was quick to spot his patient’s talents and during the 1920s he trained her as a psychoanalyst, making her one of his closest collaborators.

In 1925, Vilma Kovács became head of the training committee. A highly reputed training analyst, she organized the Hungarian Psychoanalytic Association’s clinical seminars and along with Sándor Ferenczi she elaborated the Hungarian training method: the candidate’s analyst supervises the candidate’s first case on the couch. Vilma Kovács’s work related almost totally to training. Practically every Hungarian analyst of her time frequented her clinical seminars at one time or another. More specifically, she analyzed Imre Hermann and Géza Róheim. She published only five articles, but one of them, Training Analysis and Control Analysis (1935), is a classic of psychoanalytic literature and has been translated into several languages. In another article, Examples of the Active Technique, dating from 1928, she provides a remarkably clear presentation of this technique that her mentor, Sándor Ferenczi, had just introduced, illustrating it with several examples. Through her clear-mindedness, her remarkable clinical sense, and her organizational skills, Vilma Kovács left a profound mark on the Hungarian school of psychoanalysis. – Summarized from the Psychoanalysis Dictionary

I have two suggestions for any future editions of this book or similar types of publications of historical photographs. It would be useful to have an index so that particular people of interest could be easily located. Also it would be helpful to have an accompanying DVD of digitalized photographs so that when we write about these people in the future we can to pull up these wonderful photographs and continue to share these images with future generations.

Long Campaign to Change

There has been a long standing campaign to get the President to change the previous policy, led by families who had soldiers die by suicide. Various veteran groups, members of Congress and  mental health professions, including myself have been publicly advocating that the President change the policy.

The Keesling  Family

I first wrote about this issue in my blog (Psychiatry Talk.com in December 2009) after reading a NY Times piece the previous month about the tragic loss which the Keesling family suffered when their 25 year old son Chance killed himself in Iraq in June of that year. He was in his second tour of duty when the stresses of combat combined with an argument with his girl friend over the phone led to hopelessness and suicide. Hours before his self-inflicted fatal gunshot wound the Keesling family received a rambling despondent email message from their son.

Chance Keesling (Photo from the Keesling family)

His father Gregg commented on my blog and we began a correspondence about this issue. He and his wife had decided to share some of their grief with the public in order to try to bring about a change in the Presidential policy, which was so hurtful to his, and other families who suffered similar losses.  They would receive a folded flag, a letter from the Army praising their son, a rifle salute at his burial and financial death benefits. But the letter of condolence from the President of the United States, which is the symbol of the voice of the people of our country, which is sent to every other fallen soldier in war since the presidency of Abraham Lincoln, was conspicuously absent. There was an increasing frequency of articles touching on this subject in the media. I wrote about it again in my blog and in the Huffington Post and received more comments than any other pieces that I have written. The House of Representatives voted in May 2010 to add an amendment sponsored by Representatives Burton and Napolitano to the Defense Authorization (HR 5136) that urged that the policy be overturned. The only response from the President was that this policy was being evaluated.

Why There Was Resistance to Change ?

It was difficult to say exactly why there was resistance to changing this policy. It appeared to come from certain factions within the military who had the misguided idea that such recognition would encourage suicide or would be rewarding those who were “weak” and couldn’t deal with stresses compared to those who did. These ideas were antithetical to the fact that there were so many accounts of the comrades of these soldiers who did die from suicide who were quite devastated by these losses and very supportive to the families of their fallen comrades and to their memories. There also was no psychological basis for such theories. I could not help but feel this was another example of the stigmatization of mental illness.

American Psychiatric Association Weighs In

As a Past Speaker of the Assembly of the American Psychiatric Association (APA) I believed that it was important that American Psychiatry speak out on this issue. I wrote an Action Paper (a resolution) with Dr. Roger Peele of Washington D.C. which was also co-authored by Drs. Catherine May, Eliot Sorel, Hind Benjelloun and Joseph Napoli which was voted upon and approved by the APA Assembly in May of 2010. The Board of Trustees of the American Psychiatric Association then approved it. In July 2010 James H. Scully Jr. M.D., CEO and Medical Director of the American Psychiatric Association wrote to President Obama representing the 37,000 psychiatric physicians. He called upon the President to eliminate the stigma and shame associated with suicide for families and survivors by reversing current policy and forwarding Presidential condolence messages to families of individuals who complete suicide while in military service. In October of 2010  the APA issued a public statement urging President Obama to reverse the policy of barring such letters. A number of other mental health groups including the American Foundation for Suicide Prevention and the Mental Health America had officially come out in favor of this policy change. APA President Carol Bernstein, M.D. issued a statement in which she noted, “ The contributions of these men and women to their country are not less for having suffered a mental illness. A reversal of this policy to allow condolence letters to family members will not only help to honor the contributions and lives of the service men of women, but will also send a message that discriminating against those with mental illness is not acceptable.”

The Long Awaited Change

The number of suicides in the military continued to go up either approaching or in some analyses exceeding the number of combat deaths. The problem of PTSD and the mental health of our combat troops became a high priority of the military but there was still no change in the Presidential policy.

Last month (June 2010) I met with Gregg Keesling for breakfast as he was in Los Angeles for a business meeting. He had received some indication that the President was reconsidering his policy but nothing had come down yet. Senator Barbara Boxer had just sent a letter to the President, which was made public.  We reflected in our discussion whether this issue might come to a head sooner if fate had led to a high profile family to lose a military family member to suicide rather than unknown but valiant people such as Gregg and his wife. It was clear that he and others like them in memory of their lost loved ones were not giving up the fight and were continuing to push for a change in the Presidential policy.

The Keeslings were notified in advance of the official announcement that henceforth the families of soldiers who die in a combat zone by suicide will receive a Presidential letter of Condolence. They understood that this would not be retroactive but were nevertheless overjoyed that the battle that they had fought in memory of their son was won. While there is nothing that relieves the pain of the loss of a child, hopefully the significance of this accomplishment will help in a small way.

I certainly am very pleased that the President has seen fit to make this change in his policy. I imagine that it was not an easy thing to do since there apparently was strong resistance in the military.

Still Unfair Discrimination

Coming Home (Photo from the Keesling family)

However, it should also be pointed out that there is still something inherently unfair and discriminatory about the new policy. As I understand it, letters of condolence will only be sent to families of troops who have killed themselves in a war zone. I am certain that if a soldier is critically injured by an explosive device but does not die until he or she is back in the United States receiving treatment, his family would not be denied a letter of condolence from the President. Similarly what if a soldier develops a mental disorder related to the stresses which he or she is experiencing in a combat zone and is transferred to the US to be treated but unfortunately succumbs to this condition and commits suicide? Shouldn’t this soldier also be considered to be a combat victim and shouldn’t his or her family also receive a letter of condolence.  Sometimes changes come in small increments and perhaps this important step and the attention to this issue will help the destigmatization of all mental disorders.