Thank You For Your Service by David Finkel– This is a nonfiction account, which reads more like a novel, of the story what happens to the soldiers who return from Iraq and Afghanistan after being mentally injured in combat. The author David Finkel previously wrote a well-received book, The Good Soldier, about his observations as an embedded war correspondent. Now he closely follows a group of soldiers most of whom know each other as they came home to their families, some with physical injuries but all with post traumatic stress disorder (PTSD). He writes in the third person and there is no trace of the author’s actual presence although it is like he is a fly on the wall, reporting dialogue in their homes, bedrooms, etc. and in the various treatment programs, which attempt to rehabilitate them. The book takes us back to their combat experiences in foreign countries as well as to their battles with their spouses and with their demons. This is a close up view that can get you inside the head of these men and their spouses. It is as if you were the trusted therapist who was being told all. In fact, clinicians in training or those wanting to get experience with this population of people, psychologically impaired by war would certainly benefit by reading this book. There was clear insight into the thinking of all the subjects but there was no simple answer how to treat them or how they can live with the sequelae of this war experience.

The known connection between TBI ((Traumatic Brain Injury) and PTSD is repeatedly demonstrated although it is not invariable. The soldiers bring back tremendous guilt for what they have seen and done which is not easily alleviated by a rational analysis. Seeing buddies maimed and violently killed in a split second, no matter how conscientiously they tried to hold their fellow soldier’s body together while waiting for a medic or intellectually knowing they had no realistic way to avoid these events does very little to mitigate their guilt. One soldier was faced with an enemy firing a deadly weapon at him while holding a 3-year-old child in his arms. It was a self-preservation act to fire his own weapon and kill his enemy and the child but nevertheless the guilt continues to haunt him. It should not be surprising that the families of the wounded warriors also experience emotional damage. This pain is not only psychological but also physical in the form of what at times is severe domestic violence. There is also the suggestion that the participants in today’s volunteer army may be more likely to have had some emotional instability prior to enlisting. There are no statistics given to support this nor does this diminish the responsibility that we have to the all the heroes whom we meet in this book.

The undercurrent of this book is the subject of suicide. Such thoughts lurk in a large number of these injured soldiers and there are numerous examples of serious contemplations to end their own life with some cases where they carried out this deed. I well remember following the rising statistics several years ago as the number of suicides among active duty soldiers and veterans gradually increased until they were more than the civilian population and then ultimately exceeded the number of combat deaths. This book illustrates the stories behind these numbers by not only recounting the suicidal thoughts and near acting out of them by some of the subjects of the book but also by describing a special conference call held on a daily basis. This was the meeting run by a high ranking General linked to military bases around the world during which every suicide committed by a soldier was reviewed. At one point this was more than 22/day. The goal was the valiant but obviously unsuccessful effort to extract suicide prevention measures from this deadly experience to significantly eliminate this deadly situation.. Although not mentioned in this book, this was during a time that many people including this writer were advocating that families of soldiers who suicide should receive an official letter of condolence by the US President which is done for every fallen soldier and which was not happening at that time.

I came away  away from this book hoping that the emotional toll that warriors of war will pay be factored in along with the loss of life and limb, when anyone on this planet contemplates actions that will lead to armed hostilities.

Ido in Autismland by Ido Kedar – Although I am not an expert in this area, I believe that this will be a landmark book for families, educators and any professionals who work with young people with autism. It is a book of short essays written by a 15 year old about his experience with his condition starting with some pieces written when he was 12 years old.

What is unusual, unique and very important about this author is that he cannot speak and only when he was about 11 years old did he begin to communicate by pointing to letters on a letter board. Up to that point no one had any idea that he was an above average intelligent kid who began to read when he was about three years old.He was terribly frustrated by being treated by well meaning experts in autism and education by drilling him on simple exercises meant for a three year old child who was having trouble learning. He was asked to point to his nose which he often could not do and was judged accordingly.  Even when he began to point to letters and make intelligent sentences, just about everyone thought that his mother was guiding his hand since she had to steady it for him to point. It took his father, who is a scientist, two more years before he was convinced that his son was truly communicating fully formed intelligent sentences. The problem would seem to be that he could not control his body. He often would have great difficulty even signaling that he could make even  simple calculations or understood basic concepts.  This was further complicated by his arm flapping which would occur when he was anxious which he referred to as “stims“ . Other times he would do unexplainable pieces of behavior such as pulling his Mom’s hair or that of beloved aide when he was frustrated or embarrassed. This pattern of behavior is common in many children who fall under the rubric of autism except they are usually not recognized to understand things and mainly have trouble in controlling their bodies to communicate. Instead they are often deemed “retarded” and/or  “developmentally handicapped.”

Ido believes that he is not “one in a million” and that he has had indication that many of his friends with non verbal autism are as frustrated as he used to be. Once Ido proved he could communicate with a letter board and then on the keys of a computer, a new world opened up to him. He was put in mainstream classes which he would attend with an aide and has entered high school with the aspiration to go to college. It is a constant uphill battle, as while the administrators of his middle school were very supportive, he found that was not the case of the first high school which he entered. Obviously, it did takes a great deal of resources and some special accommodation to allow him to function in a regular high school environment. After transferring to a second high school he seemed to be quite adjusted as he continues forth.

This book traces his progress as well as clarifying many of his characteristics and experiences. For example he sees people in different colors such as red blue, yellow etc. which are related to their emotional state perhaps in relationship to himself. He is also  is very sensitive to sound and appears to have very keen hearing . He therefore at times gets overwhelmed by loud noises, certain music. being in the presence of multiple people talking . These and other situations can cause him to have what would appear to be overwhelming panic attacks. This is not only experienced as severe anxiety but it intensifies uncontrolled movements of his body. Over the years he has found that various types of physical training and exercise actually improved his self control, something that was not initially recognized as it was neglected in any attempts to assist him.

I found it interesting, as a psychiatrist,  that he did not mention whether or not he was given a trial on any anti-anxiety and anti-panic medications which are believed to directly  effect various pathways in the brain which are involved when people have such overwhelming emotions. I would imagine that the medical experts in this field have evaluated the  effect of such drugs as an adjunct to his treatment program but if they have not, it certainly should be done.

Ido frequently mentions that he knows that he has an illness that places many limitations on him but he prefers to focus on what he can do and what he hopes to be able to do in the future. He also is dedicated to teaching the public as well as families of children with autism and experts about the potential of people like himself.   Ido would probably say “ so called experts” since he has a sense of humor and he is keenly aware of how so many experts have misinterpreted his abilities). Not only is he becoming an advocate but he must be also considered to be a hero for so many people who are locked in the land of autism.

For a view of brief video clip of Ido at a meeting as one of his speeches is read go to:  http://www.youtube.com/watch?v=V4VR1KYRX8s

Hidden Impact: What You Need to Know for the Next Disaster: a Practical Mental Health Guide for Clinicians: A Practical Mental Health Guide for Clinicians, by Frederick J. Stoddard, Jr., Craig L. Katz and Joseph P. Merlino,  Published by Jones and Bartlett Publishers, Boston, 2010, 249 pages

Review originally published in the Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry

Most clinicians who have expertise in mental health aspects of disaster developed their skills in this area after they found themselves seeing patients following some tragic event. It is true that well trained clinicians know about acute stress, loss, grief and PTSD since these conditions come up in many forms with many patients. However, the application of their clinical skills in the midst and in the aftermath of disaster is a whole different ballgame. Having co-taught a course in disaster psychiatry for several years at the annual meeting of the  American Psychiatric Association, I heard this story many times as colleagues joined us for the course after experiencing a disaster in their area.

There are many courses seminars, journal articles and books which will inform you in great depth about the essential topics in disaster mental health, many of them written and edited by the editors and contributors of Hidden Impact. The book is originated from the Group for the Advancement of Psychiatry (GAP) where the authors ore members of the Committee on Disasters and Terrorism . GAP has a tradition of identifying important areas of mental health and supporting publications in these areas. In my opinion this book fits the bill as the first book on this subject you should read or if you were only reading one book this is the one to read. It is the book that you will throw in your suitcase if you find yourself traveling to a site to render care in the aftermath of a disaster

In 250 pages this is  as comprehensive a course of study on this subject as I have ever seen in a book this size. It is well written, interesting and quite practical. Each chapter starts with a vignette, which either centers on victims of a disaster or on the caretakers faced with the dilemma of dealing with the aftermath of such an event.  The book is filled with practical information such as a comprehensive check list (and I do mean comprehensive) of  what to take with you if you go into an area to render care.( ie, pack your own power, take local maps, support socks, brimmed hat, iodine for water decontamination etc. There are clinical tables and charts to be sure you don’t miss the basics such as what to expect during the impact phase (first 48 hours) acute phase (1-8 weeks), post acute phase (2 months and beyond). There are many clinical screening tables such as the one for PTSD in children. There is a discussion and review of pharmacology in disaster situations. There are chapters on the use of telepsychiatry, liability, ethics, staff support as well as some of the latest thinking on resiliency. There is also a list of useful resources including websites

You should not be surprised to  find that if you are working in a  disaster situation, you will be interacting with the media as well with community leaders who have the responsibility to make reports to the media . In this regard the topic of risk communication and “how to do it“ is well covered in a succinct chapter. By the way, your clinical skills can also be useful to members of the working press who are often traumatized by working in a disaster environment. This latter clinical issue is discussed in the chapter about  understanding and helping first  responders. It is clear that the we need to apply our knowledge of the psychological impact of disasters not only to the primary victims  but also to the secondary victims who come to the aid of others. That of course includes ourselves. Perhaps one of the most valuable tables offered in the book is a table from SAMHSA (Substance Abuse and Mental Health Services Administration) about  managing and preventing stress, which includes the signs that you may need stress management assistance and ways to help manage your own stress.

As an added bonus the book is approved for AMA PRA Category 1 CME credits with instructions for getting Continuing Medical Education Credits from the Medical Society of The State of New York.

Addendum:  This review would not be complete without mentioning a recent book which should be a companion piece to this one. It is edited also by two of the same authors Fredderick J Stoddard and Craig Katz along with Anand Pandya and includes chapters by Merlino and many others on similar and related topics. It is titled Disaster Psychiatry: Readiness, Evaluation and Treatment. Published by the American Psychiatric Press, 2011.

Vienna Triangle by Brenda Webster – Published by Wings Press, San Antonio, Texas, 2009

I originally wrote this book review for Academy Forum which is published by the American Academy of Psychoanalysis and Dynamic Psychiatry. I also subsequently published it in my blog PsychiatryTalk.com accompanied by a Q&A with the author which is also included here .

The year is 1968. Helene Deutsch is 84 and, while vacationing in Provincetown, Massachusetts, meets Kate, a young woman who, by coincidence, is writing her PhD thesis at Columbia University about the early women analysts. Dr. Deutsch is one of the most prominent, well-known and respected early women psychoanalysts and who had been in analysis with Sigmund Freud himself. One thing leads to another and in the course of their now mentoring relationship Kate uncovers some previously hidden documents belonging to her mother and which shed light on a family secret that her mother had withheld from her. This secret was that her maternal grandfather was the well-known psychoanalyst Victor Tausk who had been part of Freud’s inner circle and who had committed suicide.

Kate becomes obsessed with trying to unearth the details of her grandfather’s life and to find out why he killed himself. Dr. Deutsch who knew Dr. Tausk and even briefly analyzed him, reflects on distant memories and begins to bring forth pieces of the puzzle. These details involve Tausk, Freud and the beautiful Lou Andreas-Salome. Kate also stumbles upon information that leads her to meet her two previously unknown uncles, sons of the late Dr. Tausk.

Author Brenda Webster uses this plot in her novel to explore and describe life in Vienna and the complicated interactions both inside and outside of Freud’s Inner Circle during the birth of psychoanalysis. The personalities of the cast of characters unfold. Freud the creator, the father figure, is portrayed as extremely protective of his newly developed “baby.” Tausk is described as a brilliant young man who is making important contributions to psychoanalysis but who feels he is not quite appreciated by the Master. He develops a love affair with Salome who at the same time has become one of Freud’s favorite pupils. Young Helene Deutsch is making her own contributions about psychoanalytic theory and women at the same time that she is having her own love affairs. Freud does not grant Tausk’s request to be analyzed by him and instead refers him for analysis to Deutsch. There is a question about whether Freud’s harsh and rejecting treatment of Tausk contributed to his decision to take his life. Documents that purport to show Freud’s reaction to his junior colleague’s suicide do not paint a flattering picture of the leader of the psychoanalytic movement.

The characters in this book are interesting and well developed. There is love, romance, jealousy, rivalry, narcissism, loyalty, rejection, dedication to the cause, and the mysterious suicide of Tausk that contribute to making this a fine novel. It is a page-turner (or in my case a button pusher – I read books on the Kindle). This book should have strong appeal to all students of psychoanalytic and psychodynamic theory. It is well known that to fully grasp all of these ideas you need to go back to the streets of Vienna and the lives of the people who were bringing forth this revolutionary new understanding of human behavior.

However there may be a problem with this book. It is a novel. It is fiction. If you are thinking of reading it to understand the intricacies and nuances of the relationships that existed in Freud’s inner circle, shouldn’t you really be in the non-fiction aisle of your library, bookstore, or frame of mind (if you are buying online).

Brenda Webster states the following in her authors note at the beginning of the book: “This is a work of fiction, not of history; nevertheless it is based on the lives and relationships of real people: Viktor Tausk, Sigmund Freud, Lou Andreas-Salome and Helene Deutsch. I have attempted not to violate the known facts, but have invented diaries, dialogs and secondary characters in order to bring the actors, their ideas and passions to full imaginative life.” This is an ambivalent statement. She says that it does not violate the known facts and yet all sorts of things have been invented.

In the author’s afterword she further elaborates that an important letter mentioned in the book from Freud to Andreas-Salome after Tausk’s suicide is genuine, as are her responses to it. (This is one of the documents to which I referred to above.) Webster also cites Kurt Eissler’s writings that she says defended Freud’s treatment of Tausk. This suggests that she made efforts to found the main premise of the book on as much fact as possible.

My advice to potential readers is as follows: If you have been around the block and studied the history of psychoanalysis to the point where you are satisfied with what you know, or if you don’t really care about who said what or who was jealous of whom etc., then consider reading this enjoyable and interesting novel. It is fun thinking about these people even if many of the facts, attributions and nuances may not be correct. However, if you are a new student of psychoanalytic theory and want to learn more about these historical figures and how they interacted while coming forth with these ideas, hold off reading this novel. I suggest instead, that you read some of the many historical accounts, biographies and diaries, which are available about this period of time and these important people. Ask your teachers and mentors for suggestions, in particular about areas of your interest. By the time the movie comes around of this intriguing plot, if they ever decide to make one, you will be ready for this version of the story.

The following is a Q&A with the author Ms. Brenda Webster

MB: What attracted your interest to these characters and the birth of the psychoanalytic movement?

BW: I had written two previous books of psychoanalytic criticism and a memoir chronicling my history in therapy and had no intention of doing more. Then one day I was reading about how the great Goethe sucked the life out of people close to him and used them for his own purposes. This made me think of Freud and Viktor Tausk. I wondered if genius couldn’t tolerate the existence of great talent in its vicinity and I was off and running.

MB: On one hand you emphasize in the author’s notes at the beginning of the book, that this is a work of fiction, not history, but on the other hand you note that you have attempted not to violate the known facts. Is the story your best guess as to what was the nature of the relationships which you wrote about or is it rather an attempt to write a fanciful interesting novel ?

BW: As I researched my story—and I read everything I could get my hands on from background material to biographies of Deutsch, Lou Salome, Tausk and Freud—I came to feel that Freud played an important role in Tausk’s suicide.and subsequent cover up. I had no impulse to write a polemical book. (My analyst Kurt Eissler had written two books defending Freud) I wanted to explore what happened, to re-create the people and the situations to decide for myself what motivated them. Fiction was from the beginning a way of gaining imaginative insight.

MB: In the story, you show Freud as using Tausk’s ideas without crediting him . As a writer yourself, do you view this as a particularly immoral act or do you believe that things like this can happen without malicious intent?

BW: I think that writers often borrow from each other but in the case of Freud and Tausk there was so much emotional freight behind the borrowing. Each man accusing the other of not giving credit that it took on a more sinister coloring.

MB: Can you picture this book as a movie and would you like to share your ideas as to which actors and actresses might best capture the spirit of your story ?

BW: Yes, I can picture it as a movie. The first thing the Freud scholar Paul Roazen said when he read my early draft was that it would make a terrific movie. I don’t keep up with contemporary actors but I think someone like Helen Bonam Carter would be good for Lou. Both sexy and super intellectual.

MB: Where will you be taking your readers in your next book?

BW: I am working on a play with a New York Producer/director that carries on my interest in Freud and his circle. So far it has been an exciting experience

When Family Are Oceans Apart

Patients in psychotherapy spend a great deal of time talking about family relationships. We examine the nature of the early childhood memories and interactions with parents, siblings and grandparents as well as other close relatives For most people, these relationships are usually the templates for the development of our personality and the strengths and weaknesses of our character formation. Obviously, sometimes there are problems and conflicts, which make us stronger and teach us how to deal with difficult situations. On the other hand, they may  lead to symptoms and serious difficulties which will benefit from some form of therapy, usually later in life. . As we get older we can appreciate how important our presence can be to children to whom we are close.. Many of us  also come to value ongoing relationships with our children, parents, siblings, grandparents and other close relatives.

But what happens when life circumstances separate us from important people in our lives? In today’s world most people can’t expect to spend their lives in close proximity to their immediate family. While something may be gained by being more independent, something is also lost by drifting apart from people whom you value especially when there are children involved.

A New Book for Family  Members When Someone Has Moved Away

This is why I was so interested to see a new book titled Oceans Apart: A Guide to Maintaining Family ties at a Distance by Rochel U. Berman published this year by Ktav Publishing House of Jersey City. Ms. Berman is a  M.S.W. social worker currently living in Florida with her husband. She also is a personal friend of mine. In order to write this book she not only has drawn upon her professional experience which includes conducting an extensive number of interviews with various people in 25 different countries , but has drawn upon her own life experience as her son and his family have lived in Israel for the past 20 years.

In her opening chapter she lists five reasons that people move away.

1- Looking for a better life

2- Forced migration

3- Education and career opportunities

4- Changes in marital status

5- Pursuing and ideology

Even those among us who did not need to pursue a better life or migrate to another country, probably know of how that was a major factor in the lives of a close relative in their family in the last one or two generations. With the ease in which we can travel and meet people, it is no longer invariable that people will  find their spouse within walking distance of their own home. Going to college, graduate training, medical residency, job recruitment almost always include “ going out of town “ which may lead to permanent livng arrangement away from family. While not mentioned it certainly also applies to members of the military may have to relocate, hopefully with their spouse and children but when deployed they may be separated for a year or two under the most trying circumstances.

The author discussed the reason for moving away by giving specific case vignettes, a technique she uses throughout the book which brings it alive as well as making it very practical. She also concludes each chapter with a section called “ Lessons from Life “ applied to the specific chapter where there are usually ten or more specific suggestions or valuable advice. The ideas in the first chapter alone , I thought qualified as valuable pearls of wisdom. For example there was the suggestions to create photo albums of distant grandparents, uncles, aunts and cousins  which should be looked at to reminisce or prior to visits. There also was valuable tried and true techniques for parents to use in dealing with children of divorce.

Living Far Away Doesn’t Mean that You Can’t Be Close

The second chapter was titled Keeping In Touch: Problems and Opportunities, could best be summarized by the opening quote of that chapter “There are many families who live next door to each other who don’t have the relationship we do Mom, we will always be close despite the distance” – A son to his mother following her yearly visit

This was followed by the chapter which probably will be the main reason why people will give this book as a gift to loved ones and that is the chapter titled Grandparenting at a Distance.. The six very practical areas covered are:

1-      Staying connected between visits

2-      Telephone and other means of communication

3-      Preplanning visits with grandchildren

4-      Grandchildren visiting alone

5-      As grandparents age

6-      The effect of distance on relationships.

Each of these topics are elaborated upon through the sue of wonderful vignettes

These are not psychoanalytic case studies although the psychodynamic meaning is usually close to the surface and the practical lesson to be gained is always very clear.

Getting Through The Rough Times

In a subsequent chapter Ms. Berman writes about Getting Through The Rough Times which deals with how to deal with illness and death. This is a subject that she is quite knowledgable and sensitive. She is the author of an earlier very well received book titled, Dignity Beyound Death. Her advice includes suggestions on establishing your own relationship with doctors and caregivers even when you are far away, planning to have final conversations with your terminally ill loved ones and carving out a role with siblings in the care of loved ones.

Sibling Relationships Can Be The Most Difficult

On the bases of my clinical experience, it is frequently the rupture of relationship with siblings which can be the most painful and difficult to heal. I am speaking of situations where the parties are not even separated by a great distance. Therefore it is interesting to see how the author addressed techniques for maintaining ties with distant sisters and brothers as well as distant nieces, nephews and cousins. I believe that many of the lessons from life in these areas could also well be applied to relationships, which are not oceans apart. Interesting also is the discussion about the importance of family traditions and rituals as well as how to share celebrations even when separated and how to deal with missed celebrations. This includes this issue of the cultural divide and discussion of relating to family members who now have different traditions than the ones with which they grew up. Once again, there is great application for  these ideas even to people who live in close proximity.

Creative Use Of Technology

I loved the last chapter which was written by the author’s husband George Berman and that is the one titled , Creative Uses of Technology . He clearly is an expert in communication and is comfortable in many modes  which of course not only includes the telephone but Internet Video, Instant Messaging  and family Websites and blogs. Obviously a chapter such as this one becomes outdated the day that it is written due to constant innovations in social media.

However, the message of this book is definitely current and is becoming more pertinent every year as we become a global society. It should be a great psychological tool for the mental health of those who in one way or the other are oceans apart.

Take Five With the Author

Dr. Blumenfield asks Ms. Berman 5 Questions

TAKE FIVE WITH THE AUTHOR

Why did you decide to write the book?

For the past 20 years I have struggled to maintain family ties with my son, daughter-in-law and four grandchildren who live in Israel.  This led me to research the network of distant family relationships with 70 people from 25 different countries.  Oceans Apart  tells their stories and describes the courageous and creative responses to the challenges they face.

Are you concerned that the application of some of the suggestions made in the book might be considered as being too intrusive to the distant family?

It’s true that some people move far away because they want to get away from family so that they can develop their own lives.  This, however, wears thin after a while, and most of them wish, at some point, to reconnect with their roots.  I believe that in order to develop meaningful and lasting relationships at a distance, one must be proactive, plan ahead and be specific in terms of goals and objectives.

Do you feel that anything has been lost since people rarely sit down to write long letters anymore and instead rely on more instant communication?

Email and text messages tend to convey only information.  What’s missing from them, that is embedded in a long letter, is the contemplative and reflective aspects of what’s going on in one’s life.  While this can be done via email,  unfortunately, we rarely take the time to do it.

If it is only practical to make one visit to a bereaved far away family member, would a more leisurely visit several weeks after the death be better than a short condolence visit immediately after the death or attending the funeral?

There are several issues that need to be considered, namely the needs and expectations of the bereaved, your needs as well as family and/or religious customs.   This is something that should be discussed with the bereaved family at the time of death or in advance if it appears that death is immanent.

You have written very effectively about death and separation.  What is going to be your next project?

I am coordinating a half-day seminar on “Families at a Distance” that my synagogue is sponsoring for the entire community including people of all denominations and faiths.  The centerpiece of the seminar will be five concurrent workshops led by mental health professions.  The purpose of this innovative endeavor is three-fold: To ensure participants that they are not alone in their struggles; to share information; and to seek solutions that they will implement going forward.

Handbook of AIDS Psychiatry by Mary Ann Cohen, Harold W. Goforth, Joseph Z. Lux, Sharon M. Batista, Sami Khalife, Kelly L. Cozza and Jocelyn Soffer, Oxford University Press, New York, 2010, 384pp, $49.95

Book Review originally written for and published in  the Journal of the American Academy of  Psychoanalysis and Dynamic Psychiatry

It is unusual for the Book Review Editor of this journal to request a review about a book that does not have psychoanalytic theory, dynamic psychiatry or the application of these ideas, as it’s main thesis. This book, which is about all aspects of AIDS, is such an exception. It is fitting that it be presented to the readers of this journal since this disease, more than any other modern day medical condition has impacted all aspects of psychiatry and mental health. Those of us who were practicing in the early 1980s, especially if you were doing hospital consultations, first saw this become known as a mysterious disease with dark spots on skin that was universally fatal. It then became associated with homosexuals and drug addicts The disease was believed to be highly contagious and caused by blood and sexual transmission. Medical personal became fearful of contracting the disease from patients. An accidental  needle stick while drawing blood or being nicked with a scalpel during surgery, which once was an inconvenience, now became a potentially fatal event. The disease weakened the immune system  and could lead to  deadly opportunistic infections. It ultimately was identified as being caused by the Human Immunodeficiency Virus (HIV). From it’s discovery in 1981 to 2006 AIDS killed more than 25 million people and is still counting.

Not only did psychiatrists and mental health professional see the impact of this disease in our hospital work but those of us doing outpatient psychotherapy could not help but appreciate the effect of this pandemic on many of our patients. Homophobias, which could be multidetermined at any point in time, became greatly exaggerated because of fears of contamination from AIDS. There was a reexamination of all sexual behavior as people began to realize that heterosexual transmission of this disease was also a reality. Questions were being raised whether couples should exchange HIV testing results before engaging in sexual relations? Then there was the realization that AIDS was devastating the gay and bisexual community. We saw a grieving response that extended beyond immediate close friend and families. People throughout the country visited exhibits of  traveling AIDS quilts with patches made as a memorial to individual patients. There were forensic issues encountered by some of our colleagues where people were acting out their anger about being HIV positive by having unprotected sex . There were discussions among therapists of how to deal with a patient whom they  knew was HIV positive but was not telling his or her partners.

The NIH and the NIMH awarded huge amounts of grant money directed towards AIDS and HIV research in the past 25-30 years. As a result many of the psychiatrists practicing today were supported by these grants at some time in their career or were trained by people who had such support and were well oriented about the psychiatric and psychological aspects of AIDS.

All of this is what makes this 2010 first edition of the Handbook of AIDS Psychiatry such a valuable book. Psychiatrist Mary Ann Cohen, a pioneer in the AIDS field and her six outstanding colleagues have written a book, which includes just about everything we should or might want to know about HIV and AIDS. It is billed as a practical book, which it is, but it is also a definitive work on this subject with over 1500 references. Some of the chapters are adapted from an earlier book titled Comprehensive Textbook of AIDS Psychiatry edited by Drs. Mary Ann Cohen and Jack Gorman, published in 2008 also by Oxford. Seven of the contributors to the earlier work took on the task of developing this current book.

This is not an edited book. All the 14 chapters are written by some combination of the seven authors. Dr. Cohen was involved in all but two of the chapters. Drs. Battista and Soffer were listed as residents at the time the book was published. The first 13 chapters were each followed by multiple pages of references and the final chapter on resources had addresses, phone numbers and web sites.

The widespread imprint of this disease and the comprehensive approach of this book is illustrated in the first chapter where the authors lay out the setting and models of AIDS psychiatric care. They start with effective parenting and prevention of early childhood trauma and conclude with the sections on education, HIV testing, condom distribution, rehabilitation centers, chronic care facilities and nursing homes. They touch upon the prejudice and discrimination labeled as AIDSism which unfortunately is ubiquitous and is also discussed in other chapters in the book.

Chapters titled Biopsychosocial Approach and HIV Through The Life Cycle cover material with which a psychiatrist trained in the past twenty-five years should be quite familiar. However the authors are not content with just reminding the reader to take a comprehensive history in areas relevant to this disease, but they offer over 100 suggested questions in doing a sexual history, suicide evaluation, substance abuse history or a violence evaluation. The following are examples of a few questions, which you may not have thought to use:

1. (Taking a sexual history) How do your cultural beliefs affect your sexuality?

2- Are you aware that petroleum-based lubricants (Vaseline and others) can cause leakage of condoms?

3- (To an LGBT person) What words do you prefer to describe your sexual identity?

4- (Evaluating suicidality) Do you plan to rejoin someone you lost?

5- (Taking a substance abuse history) What led to your first trying (the specific substance or substances)?

6- What effect did it have on the problem, crisis, or trauma in your life?

While it is stated that little is known about the relationship between aging and manifestations of psychiatric disorders in HIV positive persons, the discussion and questions raised about this topic in these chapters seem particularly important as treatment is now allowing people with AIDS to become senior citizens.

In the chapter titled Psychotherapeutic Treatment of Psychiatric Disorders it was noted that the enhanced understanding of the conflicts and struggles of the HIV positive  patient afforded by psychodynamic psychotherapy  has been described by multiple authors. This modality of treatment may be especially suited for patients with a trauma history as physical changes in the body and relationship stresses can awaken conflicts triggered by early trauma and neglect. This history of childhood emotional, physical and sexual trauma as well as neglect is also reported to be associated with risk behaviors and is prevalent in persons with HIV.  Other major themes, which were identified, that could surface in psychodynamic work include fears about mortality with the erosion of defensive denial as the illness progresses and conflicts surrounding sexuality. There also was a review of interpersonal psychotherapy, CBT, spiritual focused care, and various group therapy formats.

The chapters on psychiatric aspects of  stigma of HIV/ AIDS  will also be of  particular interest to the readers of this journal who are usually quite involved in dealing with subtle nuances in psychotherapy. Victim blaming, addict phobia and homophobia also called heterosexism are discussed in this context. While clinicians usually don’t have any trouble identifying stigma when they see it, there are scales which can be administered in both research protocols and clinical settings.

Dr. Cozza is the lead author in the chapter concerned with psychopharmacologic treatment issues. It is the longest chapter in the book and can best be summarized by their conclusion that the prescribing of psychotropic or any other class of medications to HIV positive patients taking ART is a complicated undertaking. The chapter provides an explanation of this statement in a narrative style as well as with some detailed tables showing the propensities of various medications to cause inhibition and induction.

Although psychiatrists are usually not involved with the treatment of physical symptoms or the actual administration of therapeutic drugs for  medical conditions, if they work with patients with AIDS they will be discussing various symptoms and complications. Dr. Goforth and Cohen put together two chapters which clearly explain symptoms of AIDS, as well as the medical illnesses associated with them. They review fatigue, sleep disorders, appetite problems, nausea and vomiting with a complete differential diagnosis and intervention options. The full range of endocrine problems, dermatological disorders , HIV associated opthamalogical diseases, malignancies, liver and kidney disease as well as the potential symptoms of these conditions are covered.

The one chapter, which was written by four authors, was titled Palliative and Spiritual Care of Persons with HIV and AIDS. This not only covered a discussion of the management of pain, other physical symptoms, behavioral symptoms including violent behavior and suicidality but it offered a review of models for spiritual care. The work of Breitbart and colleagues with cancer patients using meaning  centered interventions based on Victor Frankels ideas was introduced as was Kissane and colleagues description of a syndrome of  “demoralization” in the terminally ill which is distinct from depression. It consists of a triad of hopelessness, loss of meaning and existential distress expressed as a desire for death. A treatment approach for this state is outlined. This chapter concludes with a review of the role of psychiatrists and other clinicians at the time of death and afterwards. This includes a discussion of anticipatory, acute and complicated grief.

Although HIV disease and AIDS is no longer the mysterious disease which people are afraid to talk about and healthcare workers dread seeing patients with, nevertheless it is a very serious illness which cuts across all specialties and has great relevance for psychiatrists and other mental health professionals. It is estimated that more than one million people are living with HIV in the USA. Even now with retroviral treatment available, this disease is expected to infect 90 million people in Africa resulting in a minimum of 18 million orphans. Needless to say, this book should be translated into many languages and should be available internationally. This book gives us a full background about AIDS and allows psychiatrists and other mental health professionals to have this fund of knowledge at our fingertips. Also, if and when there is another deadly virus that appears on the scene, our profession will have a model and a valuable compendium of how to approach it, which is something we did not have thirty years ago.

To purchase this book on Amazon, please click here 

The following is a book review that I wrote which was published in the Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry. It is followed by a brief Q & A with the author.

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 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.