The Moral Responsibilities of Pastors and Psychiatrists

A recent New York Times article reports accusations of "inappropriate" sexual behavior on the part of Reverend Bill Hybels. The article describes Hybels as a "superstar pastor" who initiated the megachurch era by founding the Willow Creek Community Church.

In 1985, feeling lost after her divorce, Pat Baranowski felt that God had spoken to her when Reverend Hybels reached out to her, drew her into the church, gave her a job, and ultimately invited her to live with him and his wife and children. She alleges that Reverend Hybels drew her into a relationship that included oral sex. She ultimately ended the relationship, but was plagued with guilt, shame and a feeling that God's servant had betrayed her.

Ms. Baranowski kept her story to herself until other women brought forward allegations of their own. Reverend Hybels vigorously denies all of the allegations, calling them a mix of "misinterpretations" and "outright lies." The church elders investigated the allegations against Reverend Hybels and concluded that they were not believable. But a day after the New York Times article, Reverend Hybels resigned from his leadership role in the church.

The Hybels/Baranowski story illustrates in dramatic fashion the tinder-box nature of pastoral and psychiatric relationships. A vulnerable person feels uniquely understood by a trusted caretaker who is invested with the charisma that comes from being seen as a pastor serving God or a physician serving the healing profession. The pastor or physician receives love, gratitude and idealization. Used skillfully and responsibly, this "transference" can promote healthy development. But as Ms. Baranowski and other members of the Willow Creek congregation allege, the relationship of trust can be exploited, with potentially devastating consequences for the congregant or patient.

As is so often the case, this is a "he said/she said" situation. Reverend Hybels presents himself as a victim, not an exploiter/sinner. There is a continuum of possibilities. At one extreme, he could be the victim of a combination of misunderstandings, fantasies, and malicious accusations. At the other he could be an exploiter who is fully aware of his duplicity and issues denials he knows to be false. In between is a range of misunderstandings and human frailties on the part of all parties to the relationships.

Pastors and psychiatrists have distinctive ethical obligations associated with their roles in society. These obligations go beyond ordinary morality. Whatever religion they follow, pastors present themselves as servants of gods, devoted to the salvation of their congregants. Psychiatrists and other physicians present themselves as servants of medicine, devoted to serving their patients' health and well-being. In return for these commitments, society grants pastors and physicians distinctive forms of respect and privilege.

Whatever the truth is about the Willow Creek Church situation, it's a tragedy. #metoo will see one more example of male exploitation. Some of the faithful Willow Creek congregants will see misunderstanding, maliciousness, or even the devil instigating false accusations. An anthropologist from Mars will not claim certainty about the truth of the situation, but will see it as an inevitable hazard created by our human needs, vulnerabilities and limitations.

(For posts that discuss the power of transference in the pastoral and psychiatric relationships, see here and here.)

Civil Society and Doctor-Patient Sex

On June 4 the Boston Globe reported that for two years the Massachusetts Board of Registration of Psychologists had taken no action on Ms. Lisa Grover's complaint of abuse by her therapist, Dr. Mel Rabin. In a subsequent article the Boston Globe told readers that the next day Dr. Rabin surrendered his license, "acknowledging that he put the patient 'at risk of harm' and failed to maintain professional boundaries." In response to Dr. Rabin's letter the Board revoked his license, information that can be found on its website.

In cases with allegations as serious and believable as those brought forward by Ms. Grover, a professional board must act, as by suspending the practitioner's license while the case is investigated, by requiring monitoring of the practice, or some other way of protecting the public. Failing to act invites public distrust of the regulatory process and of the profession itself, and exposes the public to avoidable risks. In Dr. Rabin's case the media report accomplished what the Board of Registration should have done two years earlier.
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 After I published my initial post on the situation I spoke with Ms. Grover. Our conversation highlighted two additional issues - the mysterious sources of resilience and the power of peer support.

When Ms. Grover came to see her relationship with Dr. Rabin as exploitative, she determined to land on her feet and to do all she could to protect others from comparable abuse. She's not clear where her strength came from. Her family was supportive, but there was also an internal resolve to speak out. It's not uncommon for legal settlements to include a gag order, under which the complainant agrees not to speak in public about the situation in return for the financial agreement. Ms. Grover refused to accept any such requirement.

She made her way to the TELL (Therapy Exploitation Link Line) website where she "met" others struggling with their own experiences of abuse. Meeting peers strengthened her resolve and sharpened her sense of how to take effective action on behalf of others and for her own healing. She is working with other volunteers to respond to the 40,000 hits TELL receives each year.

 In Ms. Grover's situation, government regulation (the psychology licensing board) failed, but civil society - in the form of the press (the two  Boston Globe articles) and peer support (TELL) - came though. Dr. Rabin did not govern himself by the ethics of his profession, and the licensing board was dilatory in its response, but resilience, the press and peer support helped Ms. Grover move from victimization to effective advocacy.

Doctor-patient sex and professional self-regulation

The topic that has attracted the largest readership on this blog is doctor-patient sex. In the past 10 years the 30 posts I've written on the topic have received 75,000 hits. An article in today's Boston Globe focuses on an aspect I've discussed only briefly thus far - professional self regulation.

The story concerns a complaint from Ms. Lisa Grover that Dr. Melvin Rabin, the psychologist she sought out when her marriage broke up, drew her into a sexual relationship. Grover's allegations dramatize the way "boundary crossings" like calling the patient at home "just to talk," calling the patient a "special person," and hugging at the end of the appointment, can lead, over time, to "boundary violations" like sex. Apparently Grover brought a malpractice action against Rabin which, the article reports, was "settled for an undisclosed sum."

In February 2016 Grover complained to the Massachusetts Board of Registration of Psychologists, but the case is still "open" and Dr. Rabin's license is still unrestricted.

A core component of the implicit contract between the health professions and society is that in exchange for the autonomy and trust society gives to the professions, the professions will regulate themselves with regard to quality and integrity. Two years is much too long for a professional board to leave a serious complaint like Ms. Grover's unsettled.

In dealing with complaints of the kind Ms. Grover brought, a board must consider three values:

First and foremost, safety for patients. If the board believes Ms. Grover's accusations, it should have suspended Dr. Rabin's license. A therapist who acted as Ms. Grover describes should not have an unrestricted license, which allows unrestricted, unmonitored access to patients. What Ms. Grover describes, if true, is very serious misconduct.

But second, a board must also recognize that complaints are not necessarily true. The board must consider fairness to the accused.

I know this first hand.When I joined the Harvard Community Health Plan practice in 1975, one of my first patients was a sensitive and vulnerable young woman with a mild autism spectrum disorder. The treatment was proceeding well until I cancelled an appointment because I was going away. My patient contacted the psychiatry board to complain that I had molested her. Psychologically my cancellation felt to her like a "molestation." By the time I heard from the board my patient and I had resumed meeting and the treatment was again on track. She explained that she had been upset by the cancellation and apologized for what she said to the board. I didn't appreciate at the time just how serious a threat a false accusation could be.

To the credit of the Boston Globe, the headline to the article refers to an "alleged betrayal." But if the Board does not believe Ms. Grover, it should have closed the case by now. Two years is too long for the case to be in limbo. A false accusation is a serious injury to the clinician.

Finally, a professional board should conduct itself in a way that fosters trust in the profession. The story reported in the Boston Globe does the opposite.

(In addition to the Boston Globe article describing Ms. Grover's allegation, readers may be interested in an interview with Dr. Rabin in which he describes himself and his approach to therapy.)

Retirement from Clinical Practice

Next week I have the privilege of facilitating a meeting on retirement sponsored by the Massachusetts Psychiatric Society. On two counts I was happy to be invited to do this.

First, from the perspective of this blog, medical societies are significant organizational players in the world of health care ethics. A well-functioning medical society helps newly minted physicians find their way into practice, provides guidance throughout the active phases of clinical careers, and supports colleagues in concluding their practices in ways that work as well as possible for our patients and for our own well-being. If a medical society isn't strengthening the ethics of its members it's not doing its job!

Second, the invitation prodded me to review my own experience of retirement from clinical practice, with the aim of distilling some comments to launch a group discussion. These are my major thoughts so far:

DREAD: Even though I was only practicing 1/3 time, I was frightened at the prospect of clinical retirement. My fear showed up in two visual images. I identified with King Antaeus, the figure in Greek mythology who derived his strength from the earth. He challenged Hercules to a wrestling match. Each time Hercules threw Antaeus to the ground, Antaeus's strength was renewed. Hercules caught on, held Antaeus in the air and crushed him to death. In one version of the story he hurled Antaeus into space, where he became a constellation. In the other image I saw myself as a sailboat utterly becalmed and helpless. Both images conveyed a feeling that my vitality and worth as a human being came from my role as a practicing physician.

MENTORING: I asked to meet with a colleague who was 10-15 years older, who to my eye was negotiating his life in an admirable manner. I told him about my fear of ending clinical practice. He told me he'd had similar concerns, but was surprised to find an element of relief when he stopped practicing, even though he'd never thought of practice as a strain to be relieved. He gave me some other practical tips, but I still remember with gratitude his reassurance about my fears.

MONEY: The meetings my wife and I had with our financial advisor were crucial. Confidence that we wouldn't go down the tubes financially was necessary for proceeding with the retirement plan, but not sufficient in itself to assuage my fears.

ENERGY: When on Friday August 31, 2007, I acknowledged to myself that I was really going to end my practice at the turn of the year, a surprising thing happened. In a desultory way I'd imagined starting a blog about ethics at an undetermined time in the future. But when I pinned down the date by which I would end my practice, without any forethought I went to Google and put in "start a blog." The inner experience was as if a stream that had been flowing in one direction (clinical practice/identity as a clinician) shifted into a new direction (the blog and the beginning of a new identity). I started this blog that day.

DISORIENTATION: When I was working full time my days were organized - especially on days when I saw patients. For clinicians, our schedule of patients tells us why we should get up in the morning. Trying to help people who are suffering assuages doubts about our purpose in life. 

LONELINESS: Retiring from clinical practice didn't mean retiring from professional activities. I continued my cherished academic position and leadership of the Harvard Pilgrim Health Care ethics program. These activities provided important and valued human connections. But I missed the richness of clinical life - connections with my long term patients and colleagues.

I'm proud of the Massachusetts Psychiatric Society for its attention to the penultimate phase of clinical career and grateful for the opportunity to participate. The health professions are devoted to the well-being of patients and the public health. If clinical retirement is handled well, these values can be pursued in new ways after physicians hand up their clinical hats.

When is Rationing Ethically Accptable?

If I prefer a medicine that produces fewer side effects or marginally better outcomes, how much should you be expected to pay for my preference?

That's a question we in the US run away from. We'd rather say - "rationing is unethical! Period."

In truth, rationing happens all the time. The trend towards requiring us to pay a larger portion of our health care expenses out of pocket aims at making us responsible for our own rationing choices. If my physician recommends a CT scan "so we can be sure..." and I decide it's not worth the cost to me - that's self-imposed rationing. In our personal lives we make rationing decisions based on informal cost-effectiveness decisions every day.

But at the level of policy, acknowledging the need for ethically-grounded rationing is a third rail.

That's why the publication of Cost-Effectiveness of Long-Acting Injectable Paliperidone Palmitate Versus Haloperidol Decanoate in Maintenance Treatment of Schizophrenia is so important. for my field - psychiatry. In addition to providing valuable clinical information, the authors are admirably honest in presenting the rationale for potential rationing decisions.

Here's what the article is about:

Some patients with schizophrenia who benefit from antipsychotic medications follow their regimen reliably. But some don't, and for them a long-acting injectable antipsychotic medication can literally be a life-saver. I remember well a patient of mine who wouldn't take pills and wasn't keen on seeing a "shrink," but who accepted a monthly injection of haldol from his primary care physician. I made a serious joke with my colleague - "I may accomplish some useful things, but you are 'curing' schizophrenia in five minute appointments!" My patient and his family were enormously grateful that he functioned better and was happier than he'd been for a decade.

Paliperidone palmitate is still on patent and theoretically had some advantages over haldol decanoate, a much less costly generic medication. In a well-controlled randomized comparative effectiveness study, the authors compared the two medications, quantifying the differences between them in terms of quality adjusted life years (QALYs). Paliperidone had a slight advantage in terms of side effects, but at a cost of $500,000 per QALY, well-above what virtually every explicit discussion of QALYs has seen as an acceptable cost. Here's part of the author's conclusions:

The results of this study should encourage consideration of older, less expensive drugs, such as HD. Used at moderate dosages in this study, HD’s overall effectiveness and tolerability were only slightly worse...than those of PP, and it had clear advantages in cost-effectiveness...A rational policy for treatment of chronic schizophrenia might limit use of the more expensive [PP] to patients who do not benefit from or cannot tolerate HD. 

My colleague and friend Norman Daniels and I have written extensively about the overall ethics of rationing. I'm proud of the work we've done and believe it's useful. But progress in coming to grips with the need to ration care in a clinically grounded, ethically admirable manner will have to be done specialty by specialty in medicine, in concert with concerned members of the public.

The comparative effectiveness study of paliperidone and haldol illustrates four crucial steps that need to be taken for us as a nation to learn to set limits fairly:

1. Develop clinically and humanly meaningful evidence about key treatment choices.
2. Acknowledge the findings in an explicit, east to understand manner.
3. Do economic analysis to define the costs involved with the choice.
4. Decide whether the differences between the choices are worth the costs entailed.

The fifth and most difficult step is making use of these findings in the real world. In a health system based on competing health plans, health plan A would be reluctant to apply findings like these in its policies before health plan B does the same. If they did, word on the street would be "health plan A RATIONS CARE! How can we tolerate money grubbers like that in our health system?"

Learning to set limits fairly is more of a challenge to the heart than the head. At an intellectual level it's easy to see that limits are necessary. But thus far in the US, health system leaders, health care organizations, and the public have preferred to act as if rationing is evil and can be avoided.

That may have been true in the Garden of Eden. But, alas, that paradise vanished long ago.

Borderline Personality Disorder and Public Health Ethics

An article in the May issue of the American Journal of Psychiatry - "The Emergence of a Generalist Model to Meet Public Health Needs for Patients with Borderline Personality Disorder" - shows how experts can move from a specialty niche to public health relevance. This isn't just a clinical act. It's also ethics in action!

Borderline Personality Disorder is a relatively common condition, said to affect 1%-2% of the population and to represent 15%-20% of psychiatric hospital admissions and 6% of primary care visits. People with the condition evince symptoms like: vulnerability to feeling abandoned; unstable relationships that oscillate between idealization and disenchantment; destructive impulsiveness; self-harm; difficulties controlling anger; transient psychotic episodes; and more. The condition takes a high toll on individuals, those involved with them, and the health professionals who try to help them.

In the past 25-30 years, three evidence-based forms of treatment have emerged:

• Dialectical behavior therapy. DBT involves a combination of weekly individual and group therapy that emphasizes understanding one's vulnerabilities and reaction patterns, combined with learning new self-management skills. 
• Mentalization-based treatment. This treatment is a variant of psychodynamic psychotherapy that focuses on better understanding of mental states in oneself and others, based on the hypothesis that patients with borderline personality disorder interpret and react to others in terms of their own fantasies, and that more realistic understanding will decrease their desperate emotional over-reactivity. Like DBT, mentalization-based therapy typically involves weekly individual and group sessions.
• Transference-focused psychotherapy. For this approach, twice weekly individual sessions are recommended. The treatment makes maximum use of the patient's reactions to the therapist as an avenue into modifying the internal structures that lead to the chaotic life pattern.

All three approaches can legitimately claim to have been validated. But all three require training and skill beyond the level of most mental health clinicians. Nine years ago Glen Gabbard, perhaps the leading educator in psychiatry, asked "Do all roads lead to Rome?" and suggested that the three techniques may reflect different ways of delivering common healing processes. In the just-published article that I cited above, John Gunderson, a leading researcher on BPD, builds on Gabbard's suggestion and offers a common-sense generalist model that emphasizes educating the patient about the condition, focusing on life outside of the office more than on the interaction between patient and therapist, integrating medication management, and selectively involving family and significant others.

I'm writing about this clinical issue in a venue devoted to health system ethics because the move from a specialist orientation to generalism embodies admirable public health ethics. Our U.S. health system tilts towards a specialist for every organ and condition. At its best, this approach cultivates deep clinical skills. But it also disarticulates the care of individuals into unrelated segments and mirrors the inequity of our wider society by providing a lot for the few and much less for the many.

When I did my residency in the 1960s, psychoanalytic training was regarded as the pinnacle of professional development. I valued the deep intellectual rigor of psychoanalysis, but couldn't see limiting my practice to a relatively small number of patients who would be seen 3-5 times per week, and who, by practical necessity, would have to be relatively affluent. 

Gunderson's article points in the direction I'd mapped out for myself at the start of my career. U.S. health care needs to strengthen its generalist orientation at the level of primary care and within specialties. Moving towards health insurance for all is the first step in correcting the moral failings of our health system. But the ultimate challenge is improving our commitment and capacity to provide excellent cost-effective care for the entire population. Gunderson's work illustrates what every segment of medicine needs to do.

Euthanasia and the Slippery Slope

Some of the arguments for and against what is now being called "Physician Assisted Death" (PAD)  rest on core ethical beliefs and are intractable. But the "slippery slope" argument that legalizing PAD in limited and arguably ethically acceptable circumstances, as with the Oregon "Death with Dignity Act," will inevitably lead to ethically unacceptable actions, is testable.

PAD became legal in Oregon in 1997. In the intervening 19 years there has been no significant public pressure to legalize PAD for persons who are not terminally ill, and no evidence suggesting that PAD is victimizing vulnerable populations such as the poor, ethnic minorities, or frail elderly. PAD is a relatively infrequent event, accounting for 0.4% of deaths in 2015. Further, PAD has not undermined good end-of-life-care, another slippery slope fear. In actual fact, Oregon is among the national leaders in providing good palliative and hospice care.

But although Oregon proves that the slippery slope argument against laws modeled on the Death with Dignity Act is invalid, reports from Belgium and the Netherlands are worrisome. In those countries PAD and active euthanasia occur at 10 times the rate in Oregon. What I find most disturbing is the way Belgium and the Netherlands have extended the practice beyond the terminally ill to include people described as "tired of living" and to others suffering from otherwise non-terminal psychiatric ailments.

If you're interested in PAD and the potential validity of the slippery slope concern, please read Rachel Aviv's brilliant New Yorker article from last year - "The Death Treatment," in which she tells the story of Godelieva De Troyer:

Godelieva De Troyer

At 64, De Troyer had recently been abandoned by a boyfriend and was feeling distant from her son. She sought out Dr. Wim Distelmans, an oncologist and professor of palliative medicine (!). Distelmans, who is apparently revered in Belgium for his support for euthanasia, cuts a handsome and charismatic figure:

Wim Distelmans

De Troyer had lived a roller coaster life. Her emotional states ranged from ebullience when her relationships were fulfilling to painful despair when her important attachments were disrupted. But given the clear history of relatedness during her adult life, I would wager that virtually all experienced psychiatrists in the U.S. would have seen De Troyer's wish for death when she met with Distelmans as a transient symptom, not an autonomous choice.

Rachel Aviv was able to interview Distelmans. Here's a crucial paragraph from her article:

Distelmans told me that he had no doubts about the way he handled Godelieva’s case. He explained that she was “a very nice person, a very warm person,” and that she had “wanted to do one decent thing in her life, and that is to die in a decent way, because the rest of her life was such a horrible mess.” When I asked if he worried about transference—perhaps she had idolized him or depended too much on his opinion—he laughed and said, “I’ve never met a patient who is willing to die to please someone else.”

I'd make the further wager that most experienced therapists in the U.S. would share Aviv's speculation that a "transference" was at work. And Distelmans's statement that no one is willing to die to please someone else is sheer nonsense. If we needed more proof than "psychological autopsies" conducted after suicides provide, just think of the suicide bombers who blow themselves up with heroic martyrdom as one of their motives.

Washington (2009), Vermont (2009) and California (2016), the three additional states that have passed "Death with Dignity" laws, all follow Oregon by limiting the procedure to patients with terminal conditions from which they are expected to die within 6 months. The slippery slope argument holds no water against that approach. But advocates for similar laws in other states should recognize that there appear to be real slippery slopes across the Atlantic, and must explain clearly the difference between Belgium and the Netherlands and what Oregon, Washington, Vermont and California have done.

(I've never met Rachel Aviv, but I've written about her superb work here and here.) 

Curing Depression with Light: Let the Sun Shine in

In an elegant Canadian study, light outdid Prozac in a head-to-head comparison as treatment for nonseasonal major depression.

The study design is fascinating. Patients were randomly assigned to one of four groups: (1) light and a placebo pill; (2) Prozac and placebo light (an ion emitter modified to hum softly but emit no ions); (3) light and Prozac; and, (4) placebo light and a placebo pill.

The informed consent process involved deception. Subjects were told that the researchers were comparing light to ion treatment, and that half of the devices would be inactive. They were not told that all of the supposed ion emitters were inactive and all of the light units were active. The ethical rationale for allowing deception was that (a) the study goals could not otherwise be pursued, (b) the study had significant scientific and clinical merit, and (c) the deception posed no significant risks to the subjects.

The most effective monotherapy was light. Prozac alone was barely better than placebo. Light combined with Prozac was the most effective arm of the study, but not by much.

Light has been recognized as an effective treatment for seasonal affective disorder (SAD), but has not been rigorously evaluated for non-seasonal depression. If I were still in practice and saw a non-suicidal depressed patient who preferred not to use medication, I would recommend light treatment as part of our initial approach, combined with whatever form of psychotherapy fit the patient best.

We're a pill-happy society, and psychiatry, alas, has tilted away from non-pharmacological approaches to care. If Cazorp (Prozac spelled backwards) were a new pill that beat Prozac as decisively as light did in the Canadian study, the Cazorp company's stock would go through the roof. If further research confirms the Canadian findings, light should become a standard part of the initial response to depression. But although there's some financial opportunity for device manufacturers, inexpensive do-it-yourself light boxes are relatively easy to construct, so we're not likely to see a light boom analogous to the dominant pill boom.

Money talks, so pills thrive. Light cures, but produces little financial (as opposed to clinical) profit. Ergo, pill-popping wins hands down.

Talking about Suicide

Earlier this week my friend Steve Moffic wrote a powerful post about his experience as a psychiatrist dealing with suicide. He presents a moving discussion of how difficult it was to think and talk about the suicide of a patient he treated in residency. Here's the concluding paragraph of Steve's post:

Legal fears, confidentiality concerns, shame, and stigma are formidable obstacles. But talk we must, for talking—and listening—is a key to prevention and treatment. Any clinician knows that most who survive serious suicide attempts end up being glad they did, if they receive the help they need. They wanted to relieve the terrible psychological pain, not to die. Although the suicide will relieve the pain (as in the song from Mash, “Suicide is Painless”), it can cause intense pain in loved ones. Those left behind need the same forgiveness, relief of guilt, and community support that I received from my supervisors and fellow residents. Like a rock thrown into the river, the ripples of suicide can be mighty and wide. 

In my experience, learning to talk with patients about their suicidal ruminations posed more of an emotional than intellectual challenge. When I first encountered seriously suicidal patients I was tempted to try to "talk them out of it." There were three main ways I considered doing this: persuading them that their problems were solvable; emphasizing the reasons they had for wanting to be alive; and, imagining the impact of suicide on family and friends.

Luckily, wise supervisors pointed me in another direction. The task, they told me, was to find out what made suicide seem like such an appealing alternative. Over the years I learned to probe what I called the "logic" of suicide. What made suicide seem like the right thing to do? What was the source of its magnetism?

I found this approach easy to describe but hard to do. My own temperament is somewhat rigidly optimistic. Some aspects of my growing up were difficult, and in retrospect I believe I learned to see life's glass as half full rather than half empty as a way of warding off depression. My father's brother killed himself when I was 13. I didn't know him well, but I believe that even as a youngster I sensed the pain he experienced. When my two sons were teenagers they teased me about my determined attention to the bright side of life with the term "poptimism."

When I first read The Myth of Sisyphus in high school, I was transfixed by Albert Camus' opening sentence: "There is only one really serious philosophical question, and that is suicide." I thought - "this man gets it" - and underlined page after page. But it took me years of clinical practice to truly "get it." When is a patient's wish to turn off the ventilator a "competent refusal of treatment" and when does it represent a "irrational" suicidal impulse that should be impeded? These are great questions for an ethics seminar, but when I was called upon to make real decisions in real time I learned at a vastly different level.

Thanks to Steve Moffic for so vigorously bringing the importance of talking about suicide into open discussion!

Learning about Aging from Patients and their Children

Last month I wrote about how 13 years after the death of Emily Lublin, a patient with whom I'd had a very warm and constructive relationship, I had contact with her daughter, Langley Danowitz. (I'm using names with Langley's permission.) Emily was more than two decades older than I. I believe she benefited from my attention as a psychiatrist, but I know that I benefited from the insights she offered about aging with spirit and energy.

When Langley and I spoke on the phone she spoke so interestingly about her experience in her 60s (and now, at 70), that I invited her to share her thoughts with others in the blogosphere. A few days ago she sent me this further posting. It's been well documented that physical activity has multiple benefits for the over 65 crowd. Langley brings the research findings down to earth with this personal story:

Fitness and How It Helped Me


To be honest, I am actually 70, as of January. This seems odd, as I feel pretty much the same as when I was 50 and 60, give or take a little stiffness when I get up. I am reminded of the Tin Woodsman’s plea for an oilcan. I hope one day to be able to just spray myself in bed and voila - all the kinks are gone. Is anyone working on this?

Aside from my oilcan hope, I know there is no miraculous fitness method. I started going to the gym late in life – I was 59 and had seen a picture of myself. (My exercise routine for years had been to read the NY Times while doing 15 minutes of leg lifts.) Once I stopped crying, I signed up with a personal trainer for a trial session. I wore my favorite exercise outfit – black ballet tights and a large tie-dyed tee-shirt. My husband photographed me as I descended to the gym in the basement of our building. The trainer was encouraging – she called me “Honey” as in “Honey, just 50 more”, “Honey, what did you eat yesterday?” and “Honey, keep going”. I hated and loved her. She got me started on the Fitness Path and I have never looked back (except when someone’s trying to pass me).

In the 10 years since I discovered fitness, I have tried a variety of exercise, from boxing to Zumba. I started with a personal trainer once a week – now I exercise EVERY DAY. Being a Party Animal, I have found happiness in the socialness of groups. Picture a class – 40 women of varying shapes and 2 guys who either are lost or got dragged in by their girlfriends. It’s like a weight loss meeting – the men are rare and ignored. Before you think I’m a martyr - I should admit that I LIKE exercise. I do it because it’s fun for me and I get to wear cute outfits. Moving my body to commands from an amazing physical specimen just warms my heart – call me strange big time. Many of my newest friends are trainers – I keep showing up for their classes and I guess they appreciate it.

I hope I am inspiring you to give exercise a chance. After all, that is why I’m writing this. If you are just starting, here are Langley’s Five Most Important Tips:

1. Be not afraid to try it.

2. Ask your doctor if you need any restrictions.

3. Join a local gym for a month.

4. Make an appointment with a personal trainer.

5. Try several different classes at your gym to see what you like.

Exercise has totally changed my life – I think clearer, I feel better and I am easier to get along with. Give it a shot and let me know how YOU like it.  All best, Langley

Here's a photo of Langley with her trainer:

In my psychiatry residency, when we overly intellectual twenty somethings asked our training director what we should read to become wise psychiatrists, he said "Listen to your patients...they will be your best teachers!" And when I was dealing with a not very communicative "elderly" man (probably 10-15 years younger than I am now) who became depressed after losing his job at a beer factory, my supervisor advised me to "have him tell you all about what it's like to work in a beer factory all your adult life..." Throughout my entire clinical career I tried to follow their precepts. In retrospect it seems clear that the domains in which I learned most about  life, human nature, and myself, have been family and clinical practice.

But there's always something new to learn. Emily "taught me" about aging before she died 13 years ago. Now her daughter Langley is continuing "conversation" I had with her mother.

What a privilege it is to be allowed to enter human lives as a health professional!

Contact with Families after a Patient's Death

On April 28 I wrote a post to report that the New York Times Ethicist column had taken a quote about doctor-patient sex from this site. The next day I received a phone message from Langley Danowitz, daughter of Emily Lublin, a long time patient of mine, who had died in 2000 at age 84. Emily had a great sense of humor. We had a warm, friendly relationship and very much enjoyed working together on various vicissitudes of her 70s and 80s. At one point Emily said - "you have to promise not to retire before I die." I was sad when she died, but happy to have been able to keep my promise.

Emily and her daughter Langley were close. Over the years I heard a lot about Emily's visits with Langley, who lives in New York. Langley and her husband Jeff conducted a memorial for Emily in Boston, which I attended, and met them there. When Langley saw my name in the New York Times column she called me, to thank me for caring for her mother and to give some news about herself.

When I returned Langley's call we reminisced about her mother, and I heard about how Langley has reinvented herself as an actor when a job she'd been in for 30 years ended. Langley told me she is a "young looking 70 year old," and explained how the advertising industry has used her when they want an athletic, youthful-looking, older person. Since aging is one of the topics I write about on this blog (as well as on Over65, which I co-edit) I invited Langley to write about how she adapted to the end of her long time job. She wrote the delightful piece that follows. I'm publishing it and have spoken in this post about her mother Emily with her permission:

           Part I - Adjusting

Five years ago, when I was (requested to) retire from being the corporate controller (MBA) for a manufacturing company, I was relieved but mostly terrified. After 30 years of non-stop work, I had no idea what I would do to keep myself sane, out of trouble and out of the refrigerator. And although I had always enjoyed the domestic scene, was an avid gym-goer, and had loving family, my life had revolved around the office for as long as I could remember. My 2 thoughts when I got the word were: “you mean I don’t have to come here anymore?” and “omg, now what do I do?” My wonderful husband, Jeff, who had served as Homefront Captain for years, graciously re-introduced me to Laundry and I stampeded into the fray. For weeks, I used my considerable energy cooking and cleaning, organizing and discarding, baking and searing, writing and phoning. Mind you, I was still getting up at 5:30 AM to get to the gym by 6:30 – sleeping in had not occurred to me. Change my Type A style? Never in my mind! Occasionally, I must admit when I raced around my Upper East Side NYC hood, I noticed other gals of an age lunching together and shopping or just strolling…where did they find each other and why did they look so…was it “relaxed”? I wished I had some friends too but – it seemed everyone I knew was still working. Where would I find people to like who would like me too?

Part II – I find a friend

I decided to take up the piano – I’m musical and love a challenge. I hung a sign in our Laundry Room – “Adult student, plays by ear, needs patient piano teacher” and someone penciled on it: “Apt 1222 teaches”. I adopted Friend #1 – my 1982 Kawai console piano, which, as the movers remarked, matches our living room furniture. I found not one, but two teachers, who proceeded to complement and battle each other for my soul. I played in my first recital after 4 lessons – a day which shall live in my annals of terror forever. I basked in the applause and drank lots of wine afterwards.

Part III – I hit the boards

As you can tell, I was learning how resilient I am. So – I finally tackled something I had always wanted to do – become an actor! You should know, I probably came out of the womb taking a bow. After all, I studied Speech at Northwestern and played Little Buttercup in junior high. Now, I had the time to do it professionally – could I? Only one way to find out - headshots, acting resume (somewhat bogus at first), agents – ta dah! As you can tell – modesty is not moi. And, with my physical fitness + energy, I figured that if I said I could do it, I would do it. And now I have the hula hooping (Wellcare Insurance), push upping (Advil) and headstanding (Geisinger) TV credits to prove it.

More to come????

Having the opportunity to know people in depth and work with them on their health and well-being over time is one of the core privileges in being a physician, nurse or other health professional. Thirteen years after Emily Lublin's death I had fond memories of her, and I was moved that her daughter Langley, who I'd only met once, had memories of me from what she'd heard from her mother. Having an opportunity to be once again in the role of Emily Lublin's clinician talking about her with her daughter 13 years after her death is an experience I cherish and feel lucky to have had.

(I couldn't find YouTube videos showing Langley standing on her head in a Geisinger commericial, doing push ups for Advil, or hula hooping for Wellcare, but I did find this tamer video of her in an advertisement for iYogi.

Keep Sound Minds

In 2008 I blogged about how after Marci Thibault, in a state of psychosis, walked into New Hampshire traffic with her twin sister Danielle's two young children, killing them all, Danielle and her husband Ken formed a not-for-profit devoted to "prevent[ing] similar incidents from occurring by improving society's understanding and management of mental health issues."

Keep Sound Minds, the organization Danielle and Ken founded, is hosting an event in Woburn, Massachusetts, on Saturday evening May 18. I have the privilege of being one of the speakers, along with Ken and Danielle. The event is co-sponsored by the Wellstone-Barlow Mental Health Initiative. David Wellstone is son of the late Senator Paul Wellstone, who crusaded for mental health causes. Ken Barlow is a popular TV meteorologist in Minnesota who recently "came out" about having bipolar illness. (See here for a great interview with him.) Their organization is devoted to de-stigmatizing mental illness. David Wellstone and Ken Barlow will also speak.

I encourage readers to go to the Keep Sound Minds website and to watch the interview with Ken Barlow. And, if you're in the area, come to the event on May 18th and tell folks you know who have a special interest in mental health matters about it.

The Bias Towards Drugs in Psychiatry

Two days ago I posted about the bias towards drugs in treating depressed older patients. The next day the New York Times published a heartbreaking op ed on the same theme by Ted Gup, whose son died of a drug overdose 18 months ago.

Gup reflects with pain on his decision to allow his son to be put on stimulants for what was diagnosed as ADHD. In retrospect, he feels he contributed to his son's ultimate death:

In another age, David might have been called "rambunctious." His battery was a little too large for his body. And so he would leap over the couch, spring to reach the ceiling and show an exuberance for life that came in brilliant microbursts...

No one made him take the heroin and alcohol, and yet I cannot help but hold myself and others to account. I had unknowingly colluded with a system that devalues talking therapy and rushes to medicate, inadvertently sending a message that self-medication, too, is perfectly acceptable.

I had the good luck to have been allowed to outgrow my rambunctiousness. I remember my elementary school report card identifying "self control" as a "special need." I remember as well not understanding why it bothered my parents that when I spoke with them I went through the motions of a baseball pitcher. "Ants in your pants" was the "diagnosis" they gave me. After some years, the ants disappeared. The key interventions came from wise parents, teachers, and sports coaches.

Gup sees how the culture that contributed to the death of his son affects us at every stage of life:

I fear that being human is itself fast becoming a condition. It’s as if we are trying to contain grief, and the absolute pain of a loss like mine. We have become increasingly disassociated and estranged from the patterns of life and death, uncomfortable with the messiness of our own humanity, aging and, ultimately, mortality...Instead of enhancing our coping skills, we undermine them and seek shortcuts where there are none, eroding the resilience upon which each of us, at some point in our lives, must rely.

The young move too fast for our comfort and we give them drugs to slow them down. The elderly move too slowly for our comfort and we give them drugs to speed them up.

The Bias Towards Drugs in Treating Depressed Older Patients

I recently read an article on "How to adapt cognitive-behavioral therapy for older adults" that came to me in Current Psychiatry, a "throw-away" journal (one that comes to professionals free of charge and without subscription, typically containing non-peer-reviewed articles and often replete with advertising). The article itself was excellent, but the opening paragraph was revealing in terms of the problematic way psychiatric treatment is typically framed nowadays:

Some older patients with depression, anxiety, or insomnia may be reluctant to turn to pharmacotherapy and may prefer psychotherapeutic techniques. Evidence has established cognitive-behavioral therapy (CBT) as an effective intervention for several psychiatric disorders and CBT should be considered when treating geriatric patients. (emphasis added by me)

Perhaps as the spouse of a college English teacher I'm overly fussy about language, but to my eye this paragraph gives drugs the position of privilege in treating elderly patients with the common symptoms of depression, anxiety, or insomnia, and relegates psychological interventions like CBT to "be considered" if drugs are rejected. Readers wouldn't guess that the National Institute for Health and Clinical Excellence (NICE) guideline on treating depression in adults recommends various applications of CBT as the first intervention for subthreshold depressive symptoms or mild to moderate depression. Drugs only come in later (except for more severe depression)!

Outcome studies suggest that CBT is at least as effective as medication for mild to moderate depression. Given that medication side effects can be especially problematic in an elderly population, why the bias against psychosocial interventions? I see four main reasons:

1. From non-stop pharmaceutical marketing to physicians and the public, we associate drugs with images of butterflies, sunshine, smiling faces, and other seductive visions. The multi-billion dollar marketing campaign synergizes with our wish for quick and easy fixes to our problems.
2. Ageism, as reflected in aphorisms like "you can't teach an old dog new tricks," promotes the belief that elderly folks are too set in their ways to change by psychological means. Empirical studies show this isn't true.
3. Non-mental health clinicians may worry that they aren't adequately skilled at providing CBT or other psychosocial interventions like my primary care colleague years ago who said, in unintended verse: "I know what to do when they're dying/But not what to do when they're crying."
4. For harried primary care physicians (the likeliest group to see elderly patients with mild depression) writing a prescription takes much less time than initiating a psychosocial intervention.

Lack of skill and the crunch of time are serious impediments. But they're not insoluble. CBT has been adapted to self-guided formats. Non-mental health clinicians and aides have been trained in basic CBT approaches. And CBT has been delivered by telephonic means.

The degree to which we favor drugs over psychosocial treatments ultimately reflects a form of bias. That's why I discuss it in a blog about ethics!

(For an example of how our national tilt towards mechanistic thinking about human process affects another age group, see yesterday's New York Times article reporting that 11% of school aged children have been given a diagnosis of ADHD. Stimulants represent a nine billion dollar blockbuster business.)

Using the Web to Improve Care for Depression

I've imagined that if I were starting my career in psychiatry now I'd work at the intersection of clinical care and the web. A recent article on "Web-Delivered Care Management and Patient Self-Management Program for Recurrent Depression: A Randomized Trial" convinces me to stick with my fantasy about what I'd do if reincarnated.

The project was conducted at The Permanente Medical Group in Northern California. Patients with chronic or recurrent depression were invited to participate in a randomized trial of usual care compared to usual care plus a web-based care management and patient self-management program that was available for 12 months. The web program included self-monitoring tools, secure messaging with a nurse care manager, depression education stressing cognitive behavioral methods, a monitored discussion group, a personal database, task lists, and an appointment calendar. Interviewers blind to the treatment condition interviewed the patients at 6,12, 18 and 24 months. Participants could enlist a "care partner" for whom web-based materials were also available.

The outcomes were impressive. The "experimental" group had significantly greater reduction in depression that lasted through the year after the web-based intervention ended. They had more confidence in their ability to cope with the mood disorder and more satisfaction with their care. The intervention itself cost $345 per participant. The nurse care manager logs indicated that a nurse could manage 200 patients in ten hours a week. There was no difference in total medical costs between the two groups.

So why do I write about this on an ethics blog?

In 1994 I was asked to edit a quarterly column about managed care for the American Psychiatric Association journal Psychiatric Services. (I edited and wrote the column for ten years.) Readers probably wanted to read about the evils of managed care, but I felt there was more than enough managed care bashing available, and chose to develop columns on how to manage care in ways that were clinically informed and ethically admirable. My underlying belief was, and is, that managed care, "appropriately" conducted, is the most ethical way to structure a health care system.

The e-care program at Kaiser Permanente took evidence-based components of effective treatment for depression and "re-engineered" them into an efficient web-based format. The medical group carried out the intervention and studied it in a rigorous manner. Their work combined clinical innovation with development of valuable new knowledge. The intervention appears to deliver more benefit at no increase in cost. "Benefit" is a bland word, but anyone who has experienced depression or is close to someone who has knows how much suffering the condition can entail.

There's an ethical imperative for us clinicians to evaluate what we do in order to make treatment more effective and efficient over time. That's what the team at Kaiser Permanente and their colleagues did. It would have been clinically and ethically acceptable for them to have implemented the program without studying its results, but they conducted research along with implementing the program. As a result, we're smarter and have new tools for making treatment better. That's why I write about their work in an ethics blog!

Ignoring Families Can be Fatal

Yesterday in Heathrow Airport on my way home from Singapore I wrote a post about how US medical ethics ignores families and overemphasizes individual "autonomy." When I got home I read a painful story in the New York Times that confirmed the potential harm from the way ethics and law lead clinicians to treat individuals as isolated units: "Drowned in a Stream of Prescriptions: Addict's Parents Couldn't Halt Flow of Attention Deficit Drug.

Richard Fee, an intelligent, popular student who hoped to go to medical school, became addicted to stimulants in college. He faked symptoms of ADHD and received increasing doses of stimulants over a two year period. He ultimately became psychotic, and when the stimulants were stopped, became depressed (not unusual during stimulant withdrawal) and hung himself. The central points of the story are (1) how psychiatry has degenerated into brief "med checks" in which prescriptions are written without adequate thought about what's really going on and (2) how the pharmaceutical industry has succeeded in pushing medication use way beyond what good health and good practice call for.

But having just come from a conference on  "The Ethics of Family Involvement in Healthcare," I was transfixed by what happened when Richard's father, who was terrified about his son's deterioration, and who understood the addiction problem, tried to talk with Richard's psychiatrist: 

In late December, Mr. Fee drove to Dominion Psychiatric and asked to see Dr. Ellison, who explained that federal privacy laws forbade any discussion of an adult patient, even with the patient’s father. Mr. Fee said he had tried unsuccessfully to detail Richard’s bizarre behavior, assuming that Richard had not shared such details with his doctor.


“I can’t talk to you,” Mr. Fee recalled Dr. Ellison telling him. “I did this one time with another family, sat down and talked with them, and I ended up getting sued. I can’t talk with you unless your son comes with you.”

Mr. Fee said he had turned to leave but distinctly recalls warning Dr. Ellison, “You keep giving Adderall to my son, you’re going to kill him.”

I heard about situations like this again and again during my years of psychiatric practice. Whereas in Singapore respect for the family can lead to ignoring the patient, in the US respect for the individual can lead to grotesque stonewalling of the family. Dr. Ellison was not wrong that privacy laws emphasize the individual's right to privacy and to control access to information about him, but skillful clinicians learn how to (a) recognize the law but (b) do what's right for the patient. Law precluded Dr. Ellison from giving information to Richard's father, but it did not preclude listening to his father, explaining why he would not give out information without Richard's permission, thanking the father for his concern, and creating an opportunity for further connection.

Years ago I had a patient who (a) was in a suicidal crisis, (b) hated the hospital and had not benefitted from previous admissions, and (c) had responsible, caring friends who (d) were able to provide support and (e) would want to do so. My patient and I had a version of the following dialogue:

Patient: I won't go to the hospital!
Me: I don't want you in the hospital, but we have to keep you safe, and we'll need help from XYZ.
Patient: You can't talk with them.
Me: Since I know how much you hate the hospital and believe we can get you better without it, I'm going to talk with XYZ, but I want to do it with your permission.
Patient: You can't talk with XYZ - what about privacy and my rights?
Me: Your most important right is to be alive until  your time comes. I'd like to have your permission to talk with XYZ, but I'm going to do it one way or the other...

My  patient ultimately grudging agreed, XYZ came to the office, and we got through the crisis. But I'd meant what I'd said - if my patient had not given me permission I would have contacted XYZ. It made no sense for law to give me the power to impose involuntary hospital commitment but to forbid me from getting help from caring and competent friends without permission.

As Dr. Johnson taught us, the law can be an ass. US laws surrounding informational privacy are well-intended, but they're too simple-minded to apply to all human situations. Richard Fee might be alive if the medical establishment had not treated him as an isolated atom suffering from a deficiency of stimulant medication.

No Treatment as the Treatment of Choice

In the October 3 issue of JAMA, Allen Detsky and Amol Verma offered "A New Model for Medical Education: Celebrating Restraint." Restraint in medical practice is decidedly un-American. Not surprisingly, the authors are Canadian!

Detsky and Verma are concerned with both quality and cost. Here's the essence of their argument:

...we suggest complementing health care cost control initiatives by transforming the current approach used in medical education that primarily rewards meticulousness of clinical investigation to one that also celebrates appropriate restraint...Clinical teachers who are role models could embrace a new approach. They could emphasize teaching restraint, both to improve health care quality and to acknowledge the professional duty of resource stewardship.

The worship of obscure diagnoses is a longstanding part of US medical culture. It's exemplified by the "zebra joke," which I first heard as a medical student in the early 1960s:

Two senior physicians are walking alongside a wall. On the other side they hear galloping foot beats. One says to the other - "what's that?" His colleague replies "it must be a zebra."

Sometimes the search for zebras turns up a real striped quadruped. When that happens it makes a heroic story. More typically the search involves "zebra tests" which turn up "incidentalomas," abnormal findings that have no clinical significance, but which elicit further tests. Apart from the wasteful expenditures the search for zebras can produce, the process can create harmful complications - the side effects of unneeded biopsies or even surgeries, excessive radiation exposure, and more.

I'm a skeptic about medical maximalism and the search for zebras. In the early 1970s, supervising psychiatry residents who had been inculcated in concept of the 50 minute hour, I sometimes had dialogues like the following with my supervisees:

Me: What kind of treatment do you want to prescribe for the patient we've been discussing?
Resident: Twice a week intensive psychotherapy.
Me: How long would each session be, and how long would you want the treatment to last?
Resident: This seems kind of silly, but let's say 50 minutes per session for three years.
Me: That would be approximately 270 50 minute sessions. Do you think we could attain the same outcome if each session was 48 minutes and we had 85 sessions per year instead of 90.
Resident: This really does seem silly. But if you insist on the question, I suppose we could attain the same outcome or close to it.
Me: So even before we look at the techniques psychoanalysts like Peter Sifneos have developed for briefer treatment, we've reduced the cost by 10% without meaningful loss of quality. Not bad!

In 1981 I felt I'd encountered kindred spirits, when Allen Frances, who I've posted about before, and John Clarkin wrote "No Treatment as the Prescription of Choice." They weren't nihilists about treatment, but they correctly noted that psychiatric consultants almost always recommended treatment for the folks they evaluated. Frances and Clarkin suggested a typology of patients who would do better without treatment - patients who were not likely to benefit and for whom treatment might inadvertently be harmful.

As a student, some of the old timers I learned from taught me about the curative impact of "tincture of time." Some conditions will get better on their own if the patient is approached in an optimistic spirit and is willing to allow some time to pass. In non-acute situations where it's not clear what is going on, applying "tincture of time" can be a good diagnostic and therapeutic approach.

Sometimes patients push for this kind of low-interventionist approach. Many years ago I saw a young man who had briefly been hospitalized for what looked like an episode of schizophrenia. I suggested that we start an antipsychotic medication. He objected. He was convinced that the episode came from a recreational drug he'd used. We agreed to follow him - initially weekly, but ultimately every month or two. As best we could tell over the course of two years, he was right. We were both happy. With another patient whose history convinced me that she had bipolar illness, she made a similar argument and refused medication. I told her that I wasn't a worrier, but I was worried about her. I hoped I was wrong and she was right. We followed her status and got to know each other. Unfortunately, as I'd feared, she was wrong - a recurrent episode convinced her of that. But it worked better that she was convinced by her own experience, not simply by yielding to medical authority.

Detsky and Verma come across as wise clinicians. I'm on board with their counsel. I hope others join in. The model they propose would promote a salutary change in US medical culture.

Is it OK for GP's to have sex with their patients?

For anyone interested in the ethics of doctor-patient sex and the relationship between ethics and law, the recent 5-1 decision of the Supreme Court of Pennsylvania in Thierfelder v Wolfert makes fascinating reading. (If the details interest you, make sure to read Justice Todd's dissent - in my view she got the issue right!)

In 1996 David and Joanne Thierfelder became patients of Dr. Irwin Wolfert, a family physician. He treated them both for conditions that included low libido. In 2002 Ms. Thierfelder told Dr. Wolfert that he had "cured" her problems and was her "hero." They began a sexual relationship that lasted for a year. She became more anxious and depressed and finally ended the relationship in January 2003. She told her husband about the affair two months later, and together they brought malpractice action against Dr. Wolfert.

Dr. Wolfert argued that as a general practitioner he should not be held to the same standard as psychiatrists, for whom a clear duty not to have sexual involvement with patients had been recognized. The court accepted this view on the basis that psychiatrists are trained to recognize and deal with "transference" (reacting to current relationships, like Ms. Thierfelder's with Dr. Wolfert, in terms of past relationships). GPs, the court concluded, should not be held to the same duty of care, since they are not trained to do treatment based on dealing with transference. If they were held to this standard it would discourage them from providing mental health counseling to their patients, which would be a bad societal outcome.

The majority made clear that the fact that Dr. Wolfert's actions were seen as unethical within the medical profession did not mean that he had violated legally enforceable duty. The Pennsylvania Board of Medicine had in fact sanctioned Dr. Wolfert before the Supreme Court heard the case. (It ordered a three year suspension of his license, but stayed the suspension under terms that included professional development activities, 550 hours of community service, and a fine.)

The majority cited Korper v Weinstein, a case in my home state of Massachusetts. Dr. Weinstein had done a breast biopsy on Ms. Korper at the Harvard University Health Service. (It was benign.) After completing her followup care, the two had lunch together, and a consensual sexual relationship ensued. Dr. Weinstein was not involved in a further treatment relationship. When he ended the relationship two years later she brought action against him. The court opined:

Any trust and confidence she placed in the defendant as a person...even augmented by circumstances that made her emotionally dependent on him, did not create a fiduciary duty in the defendant to prevent the personal relationship that developed consensually between them, especially where he terminated the physician-patient relationship as soon as the personal relationship began.

In her dissent, Dr. Todd concluded that (a) general practitioners frequently provide mental health services and are allowed to do so by their licenses and (b) sexual relations with patients is explicitly prohibited by the medical community, with (c) the result that she had "no hesitation in concluding that general practice physicians who provide mental health disorders to patients have a duty to abstain from sexual relations with their patients...and that these physicians may be potentially liable in professional negligence actions for any harm to their patients - patients they pledged to take no action to harm - as a result of engaging in such conduct" (page 18 in the dissent).

I believe Dr. Todd, though outnumbered 5 to 1, was correct. It's widely known that sexual relationships with patients being treated for mental health conditions have high potential for causing harm. Treating mental health conditions is within the purview of general practitioners. The ethical standards of the profession are well-known to prohibit sexual relationships with current patients. It's hard to see why the allegation of malpractice should not have been judged on the basis of its facts, rather than being prevented from coming to trial. The facts would have shown that Dr. Wolfert breached a duty. But it would have to be further shown that this had directly led to damage to Ms. Thierfelder.

The majority did not argue that it's ethically acceptable for general practitioners to have a sexual relationship with patients they are treating for mental health conditions. But in my view their conclusion that seeing a duty not to do so sets too high a standard is insulting to GPs. Being sued for malpractice is every physician's nightmare, but implying that GPs don't have enough understanding of human psychology and the treatment process to know that sexual relations and mental health treatment don't go together is demeaning to their competence and maturity.

Bereavement, Depression and DSM-V

In January I criticized the American Psychiatric Association (APA) for planning to drop the "bereavement exclusion" from the definition of major depressive disorder in the forthcoming new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Under the exclusion, the diagnosis of depression is not made if:

The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

In a recent issue of the New England Journal of Medicine, Richard Friedman, a distinguished psychiatrist at Cornell who writes excellent New York Times columns for general readers, adds to the voices criticizing the APA for medicalizing normal grief (see here). Here's the essence of Friedman's argument:

In removing the so-called bereavement exclusion, the DSM-5 would encourage clinicians to diagnose major depression in persons with normal bereavement after only 2 weeks of mild depressive symptoms. Unfortunately, the effect of this proposed change would be to medicalize normal grief and erroneously label healthy people with a psychiatric diagnosis. And it will no doubt be a boon to the pharmaceutical industry, because it will encourage unnecessary treatment with antidepressants and antipsychotics, both of which are increasingly used to treat depression and anxiety...The medical profession should normalize, not medicalize, grief.

Despite criticism the DSM-V working group has not changed its plan to eliminate the bereavement exclusion, but it has added a footnote that at least acknowledges the challenge of distinguishing normal grief from the illness of depression:

The normal and expected response to an event involving significant loss (e.g, bereavement, financial ruin, natural disaster), including feelings of intense sadness, rumination about the loss, insomnia, poor appetite and weight loss, may resemble a depressive episode. The presence of symptoms such as feelings of worthlessness, suicidal ideas (as distinct from wanting to join a deceased loved one), psychomotor retardation, and severe impairment of overall function suggest the presence of a Major Depressive Episode in addition to the normal response to a significant loss.

I don't know if Dr. Friedman would be mollified by this footnote, but I'm not. For those who want to delve more deeply into the research, the working group presents its rationale here.

To my eye, clinical and epidemiological research relevant to distinguishing the illness of depression from the painful but not unhealthy state of grieving doesn't settle the controversy. The DSM-V working group has chosen to drop the bereavement exclusion out of fear that it might lead to misdiagnosis of some depressive episodes as normal grief. I, along with Dr. Friedman and other critics, see the potential for medicalizing normal grief as a significantly greater danger.

Years ago, when I was teaching a group of primary care physicians about use of antidepressant medication, one of the PCPs commented in the form of a two-line poem:

I know what to do when they're dying,
But not what to do when they're crying.

Between the degree to which harried physicians have become less skilled at dealing with existential concerns like grief and the seductive pharmaceutical marketing that will emerge with the death of the bereavement exclusion, before too long we'll be seeing patients experiencing normal grief being flogged with unwarranted diagnoses and unneeded medication.

Grief typically lifts on its own without medical intervention. Some of these patients and their physicians will conclude that they have been "cured" by the unneeded medication and will remain on it, exposing them to pharmacological side effects. In addition, some will experience an altered self image - "I'm a 'weak' person who got sick when X died and needed medicine to get over it" - rather than "I miss X terribly and experienced severe grief after the death."

The DSM-V working group is factually correct in its belief that loss can trigger the illness of depression and that it's important for clinicians not to miss the diagnosis when this happens. But dropping the bereavement exclusion won't eliminate this risk, and eliminating the exclusion will add to a destructive cultural trend of over-medicalization and excessive use of pharmaceuticals.

Gay Liberation and Psychiatric Arrogance

Last month at the Lyric Stage in Boston I saw The Temperamentals, a docudrama about the founding of the Mattachine Society, the first sustained LGBT advocacy organization in the US. The program pointed me to a biography of Harry Hay (1912 - 2002), founder of the Society.

I was especially interested in Harry Hay's single encounter with psychiatry. Harry had been sexually (very) active since his teen years. He experienced no doubt about his sexual identity and wasn't conflicted about it, despite strong social stigma at the time. After his lone experience of heterosexual intercourse he blurted out - "I certainly hope I never go through that again!"

Harry was a passionate, romantic soul, given to infatuation and heartbreak. He was also a devoted member of the Communist Party. In his mid 20s he told his doctor about a recent breakup. The doctor referred him to a therapist. Harry told the therapist about his despair "in not being able to find a flower-faced boy who was a Marxist like me, and who would stand with me in the class struggle against oppression." The therapist suggested that Harry think about women: "Maybe instead of a girlish boy, you're looking for a boyish girl. Do you know one?" Harry did - Anita Platky, also a member of the Party.

But Harry worried as to whether he could sustain a physical relationship with a woman. The therapist assured him that he could. Harry reported to his biographer - "He told me that all I needed to do to change my orientation was to deliberately close one book and open another."

The official line of the Communist Party was that homosexuals (the word "gay" wasn't in use then) were excluded. It's unclear how much this policy represented homophobia and how much it reflected fear that gays and lesbians were vulnerable to blackmail at the time. (Most likely it was a combination.) Harry's devotion to the Party made heterosexual marriage desirable to him. He couldn't be an activist and leader in the Party if he remained unmarried.

Harry and Anita stayed married for 13 years, but Harry increasingly returned to covert gay relationships and finally to the founding of the Mattachine Society. When he ultimately left the marriage in 1951, Anita felt deeply betrayed.

The therapist's recommendation to Harry in 1938 was consistent with what I was taught as a psychiatry resident in the mid 1960s - that gay orientation was a "symptom" or a "disorder" that could be changed by therapy or willpower. There was no evidence for this view - it was purely ideological. It was an especially implausible recommendation to have made to Harry, given his unambiguous gay orientation. In retrospect, the mental health professions and the therapist Harry saw just one time were arrogant in regarding ideology as truth.

Harry's experience of marriage to a woman he cared about as a friend but couldn't embrace as a sexual partner convinced him that the LGBT community had to organize and advocate for human rights. It's an irony of history that the arrogance of his one-session therapist contributed to the gay liberation movement in a way that couldn't be appreciated at the time!