UCLA Medical Alumni Highlights Yours Truly

 

 

 

 

https://alumni.ucla.edu/email/maa/2015/bruin-md/summer/default.htm

Oh My! Psychologists As Double Agents

 

http://www.nytimes.com/2015/07/11/us/psychologists-shielded-us-torture-program-report-finds.html?_r=0

 

The Hoffman report exposed that the heads of the American Psychological Association, on the one hand condemned torture, and on the other hand, taught people at the CIA and DOD about “enhanced interrogation”. There was money to be made, for sure. Businesses were started and consulting fees were obtained. Does this explain the breach? And, or, was it the power, the inside track to government officials? Is this about the thrill of living a lie? Is this the same dynamic as the religious figure who is caught messing around? Mental health professionals, as with all professionals, have the ability to help and hinder. Using the understanding of motivation to torture someone is akin to psychiatrists in the USSR who said people were insane because they had different political views? It is horrifying to think that leaders in my profession would use their skill sets to promote cruelty, and then cover it up. How can I be surprised though? I often write about how the human condition involves good and evil. We are all capable of both. There is no immunity based on the image we project of ourselves. I the “charmingly cynical” person, as one reader has characterized me, should take this new revelation in stride; one more example of how trusted officials can go to the dark side. Yet, I am taken aback. I know some of the players accused in this scandal. I have shared meals, hosted their speaking engagements, and generally felt like we were on the same side. That makes this story personal. I am shocked and not shocked at the same time. The American Psychological Association issued an apology. That was good. They took responsibility. That gives the scandal some closure. I am still disappointed. Given my understanding of the underbelly of human behavior, I continue to wish that people behave in the way they say do. That is my fantasy, I know.

Andreas Lubitz

27 years old. Premeditated murder/suicide. 149 innocent victims. h/o depression with suicidal ideation. What of it? How do we make sense of these facts? As a psychiatrist, what are my thoughts on the matter? For a week I have thought about my perspective, wondering how I reconstruct this story which has no answers and only questions. As this is also the eve of holidays in which many family and friends get together, Mr. Lubitz might make it into dinner table conversations. For the families of the victims, there are simply no words. For the world, there is fascination and quick answers, hoping that the next plane we step on, or the plane our loved ones step on, does not suffer this tragic fate. My first point is that I want to rid the world of the shock value of these tragedies. Like school shootings, or suicide bombers in the middle east, there is a  small group of people, who will take harmless victims with them to the next world. This will always happen, and there is no way for psychiatrists, or anyone else to fully prevent these tragedies. For a variety of reasons the perpetrator of these crimes believes that this murder-suicide is justified, and as the human brain can convince oneself of almost anything, once the brain is convinced, the behavior follows and terrible consequences ensue. To be shocked by this behavior is to be naive to human nature. Most humans want to help others, but a minority of humans do terrible destruction. This is our landscape. To pretend that is not true, is denial. The shock of Andreas Lubitz behavior is evidence of this denial. My second point is more difficult to articulate. Mr. Lubitz has a history of depression with suicidal ideation and he sought medical care immediately prior to this event. Does this mean he was mentally ill? Probably, but we will never know, unless the physicians who evaluated him can disclose their findings. Assuming he was depressed and a danger to others, then he should not have been allowed on that plane. However, it is rarely that clear. He may have been vague in his description of his mental state, and he may not have mentioned that in his suicidal ideation he was contemplating taking down innocent people. A psychiatric assessment includes asking about homicidal ideation, but his answer could range from “sometimes I hate people” to “I can understand the man who did Sandy Hook.” The privacy laws in Germany are not clear to me, and so I can only imagine if Mr. Lubitz walked into my office in California. If he specifically stated that he was going to take the plane down, then I would call Lufthansa immediately. However, the likelihood is that he hinted at his plan without being explicit, leaving, I imagine,  the five doctors he saw prior to the plane crash in terrible despair, desperately trying to remember exactly what he said. Unfortunately, the relationship of mental illness to violence is not clear. Our most clear understanding of behavior comes from the past and from family  history. The adage that past behavior predicts future behavior holds true. I do not know what is in Mr. Lubitz’s past, but I suspect he had no violent history, making this event even more difficult to predict. My final point is that as awful as this tragedy is, we need to acknowledge that we are terribly inadequate at predicting these events, and hence having two people in the cockpit at all times is a good intervention. Trusting passengers to one pilot will ensure that this tragedy will repeat.

Hollywood Shows Empathy

Analyzing Bad

 

http://www.latimes.com/nation/la-na-c1-albuquerque-breaking-bad-20140131-dto,0,3467725.htmlstory#axzz2s1Q0nxNK

This series, ‘Breaking Bad,’ has brought television to a psychological depth, never seen before, as far as I can tell. Walter White, played by Bryan Cranston, depicted in the photo above with a gun pointing at the audience, demonstrates a middle-aged man looking for meaning and power. We, as an audience, relate to his struggles, while at the same time, we despise him for making meth, a toxic substance, ruining the lives of so many addicts. As today’s LA Times article describes, although Walter White is a chemistry teacher turned meth cook, the show is about his search for meaning, in a world which feels to him, to be so empty and so unfair. He turns passive into active by taking charge of his “partner” and former student, Jesse, played by Aaron Paul. Together, they form a relationship that is complicated, twisted, manipulative,  and loving. There is no relaxing while watching this series, as each moment is tense with surprises and disappointments, like a life lived with such passion, that there is no room, or desire, to coast. I, for one, could feel my blood pressure rise and fall during each episode, as I cared for these characters, needing to remind myself that they are not part of my caring world, only my imaginary world of wanting to understand motivation and wanting, but failing, to have some sense of predictability of their behavior. The one thing I could count on is that I would feel each character’s need to make a difference; each person’s strong desire to be seen, to be heard, and to matter. How each of the main characters translated this desire into behavior was where the writers took my breath away. The lines between good and evil faded, not just within each person, but in a constant shifting sands where the confusion of sympathies created a blood-boiling tension. I confess that I binged on this series as I was intensely curious to know the next chapter, like a life that is constantly on the edge of change. This is the curiosity that drives my work, but that is so rarely driven by media. ‘Breaking Bad’ broke me into a rapt consumer. I am not alone, and yet, I feel the show touched me as an individual. I am still thinking of the characters, wondering how they are doing, needing to remind myself, they are not real. That is a good show.

Medical Education: What Should We Teach?

http://www.latimes.com/opinion/commentary/la-oe-rekhi-medical-education-policy-20140103,0,2359257.story#axzz2pMQl1ym1

Medical education is an unscientific exposure to medical science which results in physicians with, hopefully, enough common sense, to question what they have been taught. Today’s LA Times, Mr. Rekhi highlights the lack of training in health care policy. How can a doctor work in a system without understanding its outside forces? Yes. This point has been an aggravation of mine for some time now, given that my medical education never made sense to me, but nor does the current educational environment. In the 80’s I was in school for forty  hours a week for two years, with homework and assignments added on top of that. I enjoyed it, but apparently, UCLA has now become the school with the least demand for classroom activities. The reversal is striking, and questionable. That medical education needs an overhaul is clear. There is so much to learn; so little time to learn it. Prioritizing learning is a very complicated, and unclear endeavor. Mr. Rekhi says, and I agree, that with the change in healthcare delivery, physicians should have a sophisticated understanding of the impact of that change on how they practice medicine. UCLA is a gem in that students rotate through a multitude of settings, giving them exposure to a range of patients and health-care delivery systems. This, thankfully, has not changed. Perceptive students learn by experience how different settings result in kinds of care, but it would be better if this understanding was enhanced by providing the research on health care policy and the resulting  impact on patient outcomes. He makes an obvious point, and yet, as with many important decisions, sometimes the obvious needs to be stated.

 

Should A Psychiatrist Testify About A Patient’s Ethics?

http://www.latimes.com/local/la-me-stephen-glass-20131107,0,65391.story#axzz2jzexTSRa

 

Stephen Glass lied, went into psychoanalysis, went to law school, passed the bar, and now is not allowed to practice law because of his history of unethical behavior. According to the above article, his psychiatrist testified on his behalf, causing me to pause. As a psychiatrist/therapist, I could not verify the ethical behavior of my patients, as I only know what is presented to me in my office. I am having trouble imagining how I could weigh in on whether a patient of mine could or could not work in a particular field, as there is too much uncertainty, given the limitations of my contact, and the limitations of my understanding of the criteria for employment. I could weigh in on his state of mind, with his permission, but to say that his ethics have undergone a major transformation, to me, seems like a large leap, and possibly a wish, on the part of the psychoanalyst. The analyst wants to believe that his work is curative, and, as such, previous “bad behavior” transforms to a positive life force, where patients learn to respect the rules, as they develop new-found respect for themselves. This, sometimes happens, but other times, is an analyst’s fantasy. The patient that has affairs, does not necessarily cease this behavior, because he understands what unconscious motivation drove him to betrayal. Understanding and changing behavior are sometimes related, but not consistently or reliably. I think it is dangerous to say that because a patient comes four times a week, “we really understand him,” as if we can not be fooled into seeing what we want to see. Of course, we can, and are, and it is this understanding that makes us do good work, because humility is part of the therapeutic action. Understanding our limitations strengthens our work. Taking assumptions outside our office threatens to weaken our value as psychoanalysts. We help people understand themselves better, and then we hope for the best, like any parent who raises a child. Ultimately, the patient makes decisions for themselves, and we care that they behave in a way which both helps society and themselves. Caring, though, is different than knowing.

Greg Louganis

 

http://www.latimes.com/sports/olympics/la-sp-plaschke-louganis-20130913,0,903841.column#axzz2emmEgRpF

 

The Greg Louganis story has returned to prime time, giving me the opportunity to remind my readers, and my students, that this is an example, of how not only do doctors care about their patients, but patients care about their doctor. In this case, the doctor was my beloved old boss, Dr. James Puffer. As the story goes, and some of you might remember, Greg Louganis hit his head during the Olympics of 1988, at which point, Dr. Puffer ran to stitch him up, enabling him to get back in the game and win a gold medal. Many years later he was quoted as saying that his biggest regret was that he did not tell Dr. Puffer that he was HIV positive. I tear up, as I think about this confession, as it speaks to the intensity of their relationship. Sure, the story has a happy ending. Dr. Puffer is HIV negative, and Greg Louganis is now 53 and seemingly enjoying his life. Yet, this story, even without it’s positive outcome, is a tale of connection, which I fear will be lost as medicine becomes more dependent on electronic devices. If a faceless doctor came to stitch him up, would Mr. Louganis have felt so bad? I do not think so. I think modern medicine has made it such that both physicians and patients believe that “buyer beware,” which in this case the buyer is the physician. This bond, where the patient cares about his physician, leading to the patient taking better care of himself, seems to me, is slipping away, as we, as a society, become more dependent on machines to evaluate our symptoms. The joke, on medical teams, is that the doctor will not believe the patient’s leg is amputated until he sees the X-ray. I am compelled to remind my readers that I love technology and I am excited about how modern science is rapidly changing how we track people and disease states. The complex area of following patients over time is much simpler with machines which contain the notes about  the last visit and the last time the medication was changed. However, if these tracking systems are valued over the personal connection between the doctor and the patient, then I fear that medicine will be less fun for doctors, and patients will lose incentive to take care of themselves. The human touch, remains in my mind, a vital force for promoting wellness. In the case of Greg Louganis, that human touch, could have had fatal consequences for Dr. Puffer, but luckily, instead, it brought to  light, the humanity between patient and doctor.

The Power of Listening

 

 

https://www.google.com/webhp?source=search_app#q=school+shooting+prevented+by+talking

http://www.npr.org/templates/story/story.php?storyId=214000118

“He told me he was sorry for what he was doing. He was willing to die,” Tuff told ABC. Antoinette Tuff demonstrates the power of human connection in preventing antisocial behavior. She approached Michael Hill, an almost school shooter, with dignity and compassion, thereby preventing an enormous tragedy. Ms. Tuff gave Mr. Hill and ear, a compassionate audience, allowing Mr. Hill to reflect on his behavior before he proceeded to hurt innocent children. This story illustrates the value of human kindness in the prevention of serious human destruction. It parallels the work of psychotherapy, where human to human understanding helps people think about their behavior, rather than act impulsively. There is no checklist, or automated treatment, but rather a sense of understanding human suffering, because, as Ms. Tuff, explained to Mr. Hill, she too, has gone through hard times. This remarkable empathy led to heroism that was celebrated by President Obama. I imagine that instinctively, Ms. Tuff knew, that if she could see this 20 year old gentleman, as a man in pain, and not a horrible murderer, then she had a chance to help him. Her instincts proved right, as she was a compassionate person, believing that with a little self-revelation, she could change the course of history. It seems to me that she saw Mr. Hill as a man looking for help, but not knowing how to ask for it, and so she supplied an ear, giving him the intervention he needed, but did not know how to elicit. This story should be our model for how to help the mentally ill. They need understanding and caring, and sometimes, not all the time, this simple modality, will prevent violent behavior.

Steve Lopez….No!!!!!!!!!

http://www.latimes.com/news/local/la-me-0811-lopez-andy-20130811,0,175788.column

 

 

Yes, Steve Lopez is a tremendous advocate for the mentally ill. His journalism has brought awareness to the problems in LA County in ways in which psychiatrists have been anemic. I have applauded him before in my posts. https://shirahvollmermd.wordpress.com/2013/07/17/mentally-ill-are-locked-up-where-are-the-psychiatrists/ . In today’s LA Times, I also agree with his main point that in the proper environment, it is both cost-effective, and helpful to patients to get quality treatment for their mental illness. I also agree that Step-Up-On Second is a model facility for the mentally ill. Yet, it is this paragraph that I am compelled to comment on.

“At Step Up, which serves hundreds of clients, Andy got counseling, he switched to a more effective medication and worked as a chef after culinary training. He also moved in with his girlfriend, social worker and therapist Kathy McTaggart. Without McTaggart and Step Up, Andy told me, he might still be in jail or worse.”

This is unacceptable. A therapist should never develop an intimate relationship with his patient, no matter what. I am confused as to why Mr. Lopez chose Andy for this story, as this last detail contaminates his point. This article could lead people to believe that if the patient can “take their therapist home,” literally speaking, then there is hope. In fact, most of the time, this boundary violation creates more mental suffering, as the playing field never balances. The image this gives to the therapeutic community is potentially very damaging. Many therapists help patients, such as Andy,  develop intimate relationships with others, thereby giving them the confidence to create a life for themselves which has meaning. The therapist is that essential bridge to self-confidence and self-esteem. When the patient never gets off that bridge then perpetual dependency, and not deep self-esteem, ensues. That this worked out for Andy is not the point. The point is that Mr. Lopez should not have exposed this practice as the model treatment.