John M. Talmadge, M.D.

A Blog Covering Many Topics

Families, Pressure, & Stress

Working families are having difficulty bearing the stress and strain of modern living, despite the many advances that make our lives (so we say) easier and better. The problem, according to a Pew Research study cited in the New York Times, is "the difficulty of balancing it all." The "stress gap" is also notable owing to the correlation with race and education. White college-educated parents are significantly more likely to say that balancing family life and the workplace is difficult. As more mothers have joined the workforce, the share of two-parent households in which both parents work full time now stands at 46%, up from 31% in 1970. At the same time, the share with a father who works full time and a mother who doesn’t work outside the home has declined considerably; 26% of two-parent households today fit this description, compared with 46% in 1970, according to the Pew Research Center analysis of Current Population Survey data.

Working mothers (60%) are somewhat more likely than fathers (52%) to say it’s difficult for them to balance work and family, and this is particularly the case for mothers who work full time. In fact, one-in-five full-time working moms say balancing the two is very difficult for them, compared with 12% of dads who work full time and 11% of moms who work part time.

Overall, relatively few working parents (9%) say parenting is stressful for them all of the time. But a significant share say that parenting is stressful all or most of the time, and that sentiment is much more common among parents who say they have difficulty balancing work and family life (32% compared with 15% of those who say achieving a work-life balance is not difficult for them). In addition, four-in-ten (39%) of those who say it is hard for them to balance their responsibilities at work and at home find being a parent tiring at least most of the time; of those who say it’s not difficult for them to strike a balance, 23% say being a parent is tiring at least most of the time.

Graphic about working parents priorities

Fifty-six percent of all working parents say the balancing act is difficult, and those who do are more likely to say that parenting is tiring and stressful, and less likely to find it always enjoyable and rewarding. For example, half of those who said the work-family balance was not difficult said parenting was enjoyable all the time, compared with 36 percent of those who said balance was difficult.

In her 1989 book The Second Shift, the sociologist Arlie Russell Hochschild described the double burden employed mothers face because they are also responsible for housework and child care. Last year she said that despite some changes in society, the workplace had not changed enough to alleviate the problems. In another widely praised book, All Joy and No Fun, the journalist Jennifer Senior described how little had improved: Working parents face similar stresses, but they are now exacerbated by the expectations of modern parenthood and shared by fathers, too.

Senior draws on the psychologist Daniel Kahneman’s distinction between the “experiencing self” that exists in the present moment and the “remembering self” that constructs a life’s narrative. “Our experiencing selves tell researchers that we prefer doing the dishes — or napping, or shopping, or answering emails — to spending time with our kids. But our remembering selves tell researchers that no one — and nothing — provides us with so much joy as our children. It may not be the happiness we live day to day, but it’s the happiness we think about, the happiness we summon and remember, the stuff that makes up our life-tales.” She talks about parents’ pride in their children, not only in their accomplishments but even in their basic development as human beings, their growth into kindness and generosity. “Kids may complicate our lives,” she writes. “But they also make them simpler. Children’s needs are so overwhelming, and their dependence on us so absolute, that it’s impossible to misread our moral obligation to them. We bind ourselves to those who need us most, and through caring for them, grow to love them, grow to delight in them, grow to marvel at who they are.”

Never Underestimate the Power of a Single Intervention

For many years I have said to my medical students: "Never underestimate the power of a single intervention." Turns out this is true.

A few minutes of counseling in a primary care setting could go a long way toward steering people away from risky drug use -- and possibly full-fledged addiction, a UCLA-led study suggests. (Primary care refers to family physicians and other non-psychiatrists who provide most of our medical care.)

People who participated in the Quit Using Drugs Intervention Trial, or Project QUIT, which was a randomized controlled trial conducted in medical clinics, reduced their risky drug use by one-third when primary care doctors and health coaches provided them with brief interventions during a routine visit and follow-up phone calls.

Risky drug use is defined as the casual, frequent or binge use of illicit drugs such as cocaine, heroin and methamphetamine, or the misuse of prescription medications, without showing physiological or psychological signs of addiction. There are an estimated 68 million such drug users in the United States. These people are at risk not only for becoming addicts, but suffering attendant physical, mental health and social problems.

The study, published today in the peer-reviewed journal Addiction, is the first to demonstrate that a brief intervention led by a primary care physician can significantly reduce risky drug use among patients.

We Don't Plan to Become Addicts or Alcoholics

Most of the patients I (Dr. Talmadge) see in practice did not plan to become addicted to drugs. Casual use introduces powerful chemicals in the brain, and many of us then have our brains hijacked by these chemicals. As described in the HBO special on addictions, the human brain is an extraordinarily complex and fine-tuned communications network containing billions of specialized cells (neurons) that give origin to our thoughts, emotions, perceptions and drives. Often, a drug is taken the first time by choice to feel pleasure or to relieve depression or stress. But this notion of choice is short-lived. Why? Because repeated drug use disrupts well-balanced systems in the human brain in ways that persist, eventually replacing a person's normal needs and desires with a one-track mission to seek and use drugs. At this point, normal desires and motives will have a hard time competing with the desire to take a drug.

How Does the Brain Become Addicted?

As described in the HBO documentary, typically it happens like this:

-A person takes a drug of abuse, be it marijuana or cocaine or even alcohol, activating the same brain circuits as do behaviors linked to survival, such as eating, bonding and sex. The drug causes a surge in levels of a brain chemical called dopamine, which results in feelings of pleasure. The brain remembers this pleasure and wants it repeated.

-Just as food is linked to survival in day-to-day living, drugs begin to take on the same significance for the addict. The need to obtain and take drugs becomes more important than any other need, including truly vital behaviors like eating. The addict no longer seeks the drug for pleasure, but for relieving distress.

-Eventually, the drive to seek and use the drug is all that matters, despite devastating consequences.

-Finally, control and choice and everything that once held value in a person's life, such as family, job and community, are lost to the disease of addiction.

What brain changes are responsible for such a dramatic shift?

Research on addiction is helping us find out just how drugs change the way the brain works. These changes include the following:

Reduced dopamine activity. We depend on our brain's ability to release dopamine in order to experience pleasure and to motivate our responses to the natural rewards of everyday life, such as the sight or smell of food. Drugs produce very large and rapid dopamine surges and the brain responds by reducing normal dopamine activity. Eventually, the disrupted dopamine system renders the addict incapable of feeling any pleasure even from the drugs they seek to feed their addiction.

Altered brain regions that control decisionmaking and judgment. Drugs of abuse affect the regions of the brain that help us control our desires and emotions. The resulting lack of control leads addicted people to compulsively pursue drugs, even when the drugs have lost their power to reward.

Image of brain activity dopamine

The disease of addiction can develop in people despite their best intentions or strength of character. Drug addiction is insidious because it affects the very brain areas that people need to "think straight," apply good judgment and make good decisions for their lives. No one wants to grow up to be a drug addict, after all.

The addiction study cited above has some limitations. The results are based on participants' self-reporting, so the study may suffer from reporting bias. However, researchers found that based on urine testing, under-reporting of drug use was low. Additional limitations: not everyone in the clinic waiting rooms agreed to participate, which could impact the study's generalizability; there was some attrition during the study, though the 75 percent participation rate at follow-up compares to other studies of low income patients and drug use; and the three month follow up was relatively short.

There is a need for larger trials to gauge the QUIT program's effectiveness, but based on these findings the project appears to have the potential to fill an important gap in care for patients who use drugs, particularly in low-income communities, Gelberg said.

Read the entire report and article by clicking here.

Mindfulness and PTSD

Among veterans with PTSD, mindfulness-based stress reduction therapy, compared with present-centered group therapy, resulted in a greater decrease in PTSD symptom severity. The results of the study were modest, but those of us familiar with mindfulness practice are encouraged that we are on the right track. The August 4, 2015 issue of the Journal of the American Medical Association includes an article describing the research. A summary of the article is available here. I discovered the article through a link through Dr. Ian Ellis-Jones and his excellent website devoted to mindfulness practice.

Mindfulness is the intentional, accepting and non-judgemental focus of one's attention on the emotions, thoughts and sensations occurring in the present moment, which can be trained by meditational practices. Although linked to Buddhism and eastern philosophies, many Christians practice mindfulness. It is not a religious practice, nor is it tied to a specific set of religious beliefs. An excellent article on Christianity and mindfulness by Dr. Scott Symington can be found in the Journal of Psychology and Christianity if you click here.

Many psychiatrists and psychologists have moved away from the labels of psychiatry—bearing in mind that diagnosis and traditional treatment are often very helpful—to incorporate mindfulness based practices in our work. Dr. Melissa Polusny from the Minneapolis VA Health Care System, and colleagues randomly assigned 116 veterans with PTSD to nine sessions of either mindfulness-based stress-reduction (MBSR) therapy or present-centered group therapy, which focused on current life problems.

Dr. Ellis-Jones comments on his blog: "The researchers found that during treatment and in the two months following, MBSR therapy improved PTSD symptoms more than did present-centered group therapy. In fact, those who had MBSR experienced a 49 per cent reduction in PTSD symptoms, compared with a 28 per cent reduction in symptoms among those who had present-centered group therapy."

Mindfulness Therapy: Alternative to Antidepressants

Many psychiatrists like me recommend mindfulness and cognitive therapy to our patients. These two approaches work well together because psychotherapy ("talk therapy" is best when individualized rather than using a "cookbook" approach. One size does not fit all. The legendary British medical journal The Lancet (April 2015 includes a recent scientific paper showing that mindfulness-based cognitive therapy (MBCT) could provide an alternative non-drug treatment for people who do not wish to continue long-term antidepressant treatment. This is one example of brain science at its best.


Mindfulness-based cognitive therapy aims to change the way people think and feel about their experiences. How we think affects how we feel. And the use of mindfulness practice is relatively easy for most people. Just 10-15 minutes two or three times daily makes a difference. The current study compares MBCT with maintenance antidepressant medication for reducing the risk of relapse in depression. The results are encouraging.

The study aimed to establish whether MBCT is superior to maintenance antidepressant treatment in terms of preventing relapse of depression. Although the findings show that MBCT isn't always more effective than maintenance antidepressant treatment in preventing relapse of depression, the results, combined with those of previous trials, suggest that MCBT may offer similar protection against relapse or recurrence for people who have experienced multiple episodes of depression, with no significant difference in cost.

"Mindfulness gives me a set of skills which I use to keep well in the long term. Rather than relying on the continuing use of antidepressants mindfulness puts me in charge, allowing me to take control of my own future, to spot when I am at risk and to make the changes I need to stay well." — Study Participant

MBCT builds on the insight that when people with a history of depression experience even a brief period of feeling low they tend to be especially vulnerable to negative thinking. That negative thinking is often accompanied by what’s known as “processing biases”: worrying about past problems, for example, or returning to unpleasant memories. Thinking like this raises the risk of a full-blown depressive episode.

MBCT focuses on helping people to become more aware of these thoughts and feelings, and thus better able to gain distance from them. As its founders put it: “We discover that difficult and unwanted thoughts and feelings can be held in awareness, and seen from an altogether different perspective – a perspective that brings with it a sense of warmth and compassion to the suffering we are experiencing.”

Talk Therapy? Medication?

"We are more than a brain in a jar," Dr. Richard Friedman wrote recently in the New York Times. In his timely article about psychiatry, he goes on to say, "Despite a vast investment in basic neuroscience research and its rich intellectual promise, we have little to show for it on the treatment front." He points out that billions are spent on pharmaceutical research — the quest for the magic pills that will change the way we think and feel — but comparatively little money goes to psychotherapy research.

image of poster about pills

I am an old-timer, and when my generation trained in psychiatry virtually all of us planned on being psychotherapists who were well educated in the use of medication as an adjunct to talk therapy. All psychiatrists I knew back then had been in psychotherapy themselves; personal therapy was considered part of becoming a competent clinician: "Physician, know thyself."

If a psychiatrist has a limited vocabulary, and can't conjugate nouns and verbs, how can they possibly communicate with patients?

Research shows that when psychotherapy and medication are both available, the combination is synergistic. It's like saying 1 + 1 = 3. Today, however, fewer than 10% of psychiatrists are trained and skilled in psychotherapy. My opinion is that this is why a good psychiatrist is very hard to find. I have been teaching young psychiatrists for over thirty years, and I have been a training director in one of our finest medical schools, and I can say with authority that many psychiatrists coming out today get failing grades when it comes to important skills like writing, speaking, and communicating clearly. I'm talking about basic errors in English grammar, syntax, and sentence structure — the stuff most people should learn by the time they enter high school! If a psychiatrist has a limited vocabulary, and can't conjugate nouns and verbs, how can they possibly communicate with patients? This is one reason that psychiatrists today are, in general, poor psychotherapists with little interest in what talk therapy has to offer.

Writing in a medical chart is similar to text messaging. It's easy, and grammar doesn't count. In fact, the modern electronic medical record discourages thoughtful writing, just like text messaging does. A good psychiatrist should not only speak well and write well. A good psychiatrist should be a superior thinker and communicator. Every doctor should have a big sign on the wall behind the chair where the patient is sitting: "DOCTOR, YOUR PATIENT IS TRYING TO TELL YOU SOMETHING!"


Here's Dr. Friedman again: "With few exceptions, every major class of current psychotropic drugs — antidepressants, antipsychotics, anti-anxiety medications — basically targets the same receptors and neurotransmitters in the brain as did their precursors, which were developed in the 1950s and 1960s."

"Sure, the newer drugs are generally safer and more tolerable than the older ones, but they are no more effective."

Prescribing a pill is easier and cheaper than offering the patient psychotherapy. Psychiatrists are paid more to prescribe pills than to counsel with patients. It is understandable, then, that the incentive is to see five patients in a single clinic hour. This saves insurance companies a lot of money. Many insurance companies will not even pay for psychotherapy with a qualified psychiatrist. And think about this: if a patient doesn't like the psychiatrist, there are fewer repeat or return visits. The winners are the insurance companies.

Dr. Friedman is also critical of trends in research, not because they are wrong, but because of simplistic logic. "The doubling down on basic neuroscience research" he says, "seems to reflect the premise that if we can unravel the function of the brain, we will have a definitive understanding of the mind and the causes of major psychiatric disorders." He points to an editorial in May in one of the most respected journals in our field, JAMA Psychiatry, emphasizing the brain but not mentioning the mind, the complexity of mental illness, or anything about how psychotherapy scientifically helps the brain. Friedman believes that "an undertaking as ambitious as unraveling the function of the brain would most likely take many years. Moreover, a complete understanding of neurobiology is unlikely to elucidate the complex interactions between genes and the environment that lie at the heart of many mental disorders."

"Anyone who thinks otherwise should remember the Decade of the Brain, which ended 15 years ago without yielding a significant clue about the underlying causes of psychiatric illnesses."
—Professor and Psychiatrist Richard Friedman

Dr. Friedman's article generated a number of replies, including this one from Christopher Lukas, a noted author:

"Over the years, I have had talking therapy for my depression and post-traumatic stress disorder, and I don’t believe I would be alive were it not for those sessions. I have also taken a whole range of medications for depression and find that psychotherapy outweighs the benefits of any of those drugs.

"Some psychiatrists and some patients think that drugs are better because they work like aspirin: Take two and call me in the morning. But, as Dr. Friedman pointed out, and as I have experienced, other patients find doses of talking therapy can work well if we’re patient and if we understand that many emotional problems may take time to go away.

"Persistence, willingness to give yourself over to the process and willingness to change therapists if the talk isn’t helping you: These are key to talk therapy’s benefits."


The comments by Lukas remind me of something I pointed out to a patient just last weekend. Asking about Alcoholics Anonymous, she wanted to know what it takes to succeed in finding sobriety through AA. "An easy way to think about it," I said, is to remember the three letters H-O-W." The old AA acronym stands for "honesty, open-mindedness, and willingness."

Another writer, who is a physician herself, also agreed with Dr. Friedman:

"For the past 30 years psychotherapy has been given short shrift as drug therapy has become the treatment of choice. There are many reasons for this, but the most powerful are economic.

"Doctors can manage medication for many more patients in a day than they can treat with psychotherapy. More important, pharmaceutical companies, which profit from the drug sales, support research, thus providing funds to psychiatry departments that receive no similar support for psychotherapy research.
Sadly, in the past generation or two there has been a huge loss in professional expertise as fewer psychiatry residency programs provide top-notch psychotherapy education and supervision.

"Twenty-eight years ago I went to medical school planning a career in child psychiatry. My interest had been primed by fascinating conversations I’d heard in high school between my father, a psychoanalyst, and his colleagues.
My medical school psychiatry rotation was a disappointment. There was no attempt to solve the riddles of patients’ emotions and behavior, only the adjustment of medication doses to treat symptoms. Still wanting to solve puzzles, I chose a career in radiology.

"When my father died, I was tremendously moved to hear some of his patients who attended his funeral tell me how the treatment he provided had profoundly changed their lives. Psychotherapy should be an integral part of psychiatric training."

Since I do both — I am a psychotherapist who prescribes medication when appropriate — it's understandable that I agree with Dr. Friedman. It's also true that I practice this way because that approach provides the best care for the brain, the mind, and the whole person.

Female Veteran Suicides

My first experience working with our veterans was during the Vietnam era, when I trained at Duke University Medical Center and The University of Wisconsin Medical Center. Fifteen years ago I was the first director of our UT Southwestern Addiction Psychiatry Fellowship Program, and our primary clinical service was at The North Texas VA Healthcare System ("the VA Hospital") in Dallas. Compared to the 1970's, the military today is increasingly diverse, and for the first time we are treating many women who have served in our armed forces. The latest studies on suicide in the military are alarming. The 2012 VA Report on Suicide can be found here, and the main findings are cited below.

Women are generally a lot less likely to kill themselves than men, but female veterans are an exception with shockingly high suicide rates, according to new Veterans Affairs Department research. Among women of all ages who have served in the military, the suicide rate is 28.7 per 100,000—higher than the rate among male civilians, nearly six times the rate of civilian women, and approaching the 32.1 rate among male veterans. "It's staggering," a Northeastern University epidemiologist said to the Los Angeles Times. "We have to come to grips with why the rates are so obscenely high." Women vets ages 18 to 29 kill themselves at nearly 12 times the rate of civilian women the same age, but the rate was up to eight times higher even among women who served in the 1950s. It is not clear what is driving the rates. VA researchers and experts who reviewed the data for The Times said there were myriad possibilities, including whether the military had disproportionately drawn women at higher suicide risk and whether sexual assault and other traumatic experiences while serving played a role.

The VA suicide study involved data on 173,969 adult suicides in 23 states over 11 years, which included the deaths of 40,571 male vets and 2,637 female vets. The article in Psychiatric Services also says that that people who join the military are more likely to have had troubled childhoods; and it could be the case that women who signed up were at higher risk of suicide in the first place.

• While the percentage of all suicides reported as Veterans has decreased, the number of suicides has increased.
• A majority of Veteran suicides are among those age 50 years and older.
• Male Veterans who die by suicide are older than non-Veteran males who die by suicide.
• The age distribution of Veteran and non-Veteran women who have died from suicide is similar.
• The demographic characteristics of Veterans who have died from suicide are similar among those with and without a history of VHA service use.
• Among those at risk, the first 4 weeks following service require intensive monitoring and case management. • There is preliminary evidence in 2012 indicating a decrease in the rate of non-fatal suicide events for VHA utilizing Veterans.
• Decreasing rates of non-fatal suicide events are associated with increasing age.
• The data show a decrease in the 12 month re-event prevalence in fiscal year (FY) 2012.
• The majority of Veterans who have a suicide event were last seen in an outpatient setting.
• A high prevalence of non-fatal suicide events result from overdose or other intentional poisoning.
• Continued increases in calls to the Veterans Crisis Line may be associated with efforts to enhance awareness of VHA services through public education campaigns.
• The majority of callers to the Veterans Crisis Line are male and between the ages of 50- 59.
• Differences in the age composition of callers to the Veterans Crisis Line are associated with gender.
• A large percentage of callers to the Veterans Crisis Line are identified as Veterans.
• Approximately 19 percent of callers to the Veterans Crisis Line call more than once each month.
• The percentage of callers to the Veterans Crisis Line who are currently thinking of suicide has decreased.
• The percentage of all calls resulting in a rescue has decreased, indicating that the calls are less emergent and callers are using the Crisis Line earlier.
• The percentage of callers receiving a referral for follow-up care is increasing.
• Approximately 93 percent of all Veterans Crisis Line referrals are made to callers with a history of VHA service use in the past 12 months.
• Service use continues to increase following a referral for care.
• Between FY 2009 – FY 2011, use of inpatient and outpatient services increased following a rescue.
• The 12 month re-event prevalence has decreased among those who have been rescued or received a referral for follow-up care.

Aging Brain? Not So Bad...

From Harvard Health Publications at Harvard Medical School comes some exciting news about the aging brain.

At middle age, the brain begins to draw on more of its capacity for improved judgment and decision making.
If you forget a name or two, take longer to finish the crossword, or find it hard to manage two tasks at once, you’re not on the road to dementia.
What you’re experiencing is your brain changing the way it works as you get older. And in many ways it’s actually working better. Studies have shown that older people have better judgment, are better at making rational decisions, and are better able to screen out negativity than their juniors are.
Although it may take you a little longer to get to the solution, you’re probably better at inductive and spatial reasoning at middle age than you were in your youth.


The brain changes as we get older, and in some ways it works better as we get older.



How is it possible for older people to function better even as their brains slow? “The brain begins to compensate by using more of itself,” explains Dr. Bruce Yankner, professor of genetics and co-director of the Paul F. Glenn Laboratories for the Biological Mechanisms of Aging at Harvard Medical School. He notes that MRIs taken of a teenager working through a problem show a lot of activity on one side of the prefrontal cortex, the region we use for conscious reasoning. In middle age, the other side of the brain begins to pitch in a little. In seniors, both sides of the brain share the task equally. The cooperative effort has a payoff. “Several studies suggest that seniors who can activate both sides of the brain actually do better on tasks, while those who can’t do worse,” Dr. Yankner says.

If you’ve found that it’s a little harder to carry on a conversation while searching your bag for your keys, MRI studies offer some clues. They show that in younger people, the area of the brain used to do a task goes dark immediately once the task is completed, while in older people it takes longer to shut down. As a result, it’s harder for the older brain to take on several tasks, because not only do you need to use more of the brain for any single task, but the brain also has a harder time letting go of a task. So even after you fish out your keys, you may have trouble getting back into the conversation.
What about the moments when you find yourself driving down the street without any recollection of having passed the last few blocks? Or the times you’ve locked the car door with your keys in the ignition? On those occasions your brain may have slipped into the default mode, which controls processes like remembering and daydreaming that are not required for a directed task. Imaging studies show that interconnected regions of the brain dubbed the “default network” grow more active with age, indicating that as we age we spend more time daydreaming.

THE GOOD NEWS ABOUT "THE MORE MATURE" BRAIN

At The Center for BrainHealth, as at Harvard, we are discovering that the more mature brain actually has advantages over its younger counterpart. These findings came as a surprise to many people, who were accustomed to seeing “senior moments”—groping for the right word or taking longer to articulate your thoughts—as a sign that the brain was on the skids. Yet even in professions where youth is valued, testing has shown that maturity has advantages.

For example, in a study of air-traffic controllers and airline pilots, those between ages 50 and 69 took longer than those under 50 to master new equipment, but once they had, they made fewer mistakes using it. (Keep this in mind when you’re trying to conquer a new computer program or adapt to a new car!) The mastery that comes with maturity is due to changes in your glands as well as your brain. Declining levels of testosterone—even in women—result in better impulse control. The end of the hormonal roller coaster of menopause may also contribute to emotional stability. After midlife, people are less likely to have emotional issues like mood swings and neuroses that interfere with cognitive function.

Most importantly, the wealth of knowledge from decades of learning and life experience enables you to better assess new situations. At midlife, most people are more adept at making financial decisions and getting to the heart of issues than they were when they were younger.

In most people, these abilities improve with age:

Inductive reasoning. Older people are less likely to rush to judgment and more likely to reach the right conclusion based on the information. This is an enormous help in everyday problem solving, from planning the most efficient way to do your errands to managing your staff at work.

Verbal abilities. In middle age, you continue to expand your vocabulary and hone your ability to express yourself.

Spatial reasoning. Remember those quizzes that require you to identify an object that has been turned around? You are likely to score better on them in your 50s and 60s than you did in your teens. And you may be better at some aspects of driving, too, because you are better able to assess the distance between your car and other objects on the road.

Basic math. You may be better at splitting the check and figuring the tip when you’re lunching with friends, simply because you’ve been doing it for so many years.

Accentuating the positive. The amygdala, the area of the brain that consolidates emotion and memory, is less responsive to negatively charged situations in older people than in younger ones, which may explain why studies have shown that people over 60 tend to brood less.

Attaining contentment. Years ago, researchers were surprised to find that people seem to be more satisfied with their lives as they age, despite the losses that accumulate with passing years. This is probably because they tend to minimize the negative, accept their limitations and use their experience to compensate for them, and set reasonable goals for the future. Dr. Yankner notes that this trait may be innate, because it is prevalent even in the United States and other Western nations, which tend to value youth over age.

The Brain: A Good Introduction

One of my favorite journals, New Scientist, has an excellent introduction to the brain and how it works.

The brain is the most complex organ in the human body. It produces our every thought, action, memory, feeling and experience of the world. This jelly-like mass of tissue, weighing in at around 1.4 kilograms, contains a staggering one hundred billion nerve cells, or neurons.

The complexity of the connectivity between these cells is mind-boggling. Each neuron can make contact with thousands or even tens of thousands of others, via tiny structures called synapses. Our brains form a million new connections for every second of our lives. The pattern and strength of the connections is constantly changing and no two brains are alike.

It is in these changing connections that memories are stored, habits learned and personalities shaped, by reinforcing certain patterns of brain activity, and losing others. To read the article, click here.

Addictionary: Language of Addiction

The language of addiction is always evolving. Maybe we need an addictionary. See the full story on NPR here.

For example, when the word "alcohol" was written or spoken in early 19th-century America. it was often used in the chemical and medical sense. This is from an article about drawing out the essence of stramonium, or jimson weed: "The virtues of stramonium," the New England Journal of Medicine reported in January of 1818, "appear to be seated in an extractive principle, which dissolves in water and alcohol."

Image of words used in addiction work

The word "cocaine" had different connotations as well. In the 1860s, for instance, a substance termed "cocaine" was advertised by a Boston company as a topical treatment to prevent hair loss.

Over time these words – "alcohol", "cocaine" and others, including "drugs" and" intoxicated" – became more closely associated with substance use, abuse and addiction in American popular culture.

image of word alcoholism prevalence

"'Alcoholism' made its debut in the lexicon around 1900, associated almost exclusively with 'crime' and 'dreams' – coincidentally around the time that Sigmund Freud's The Interpretation of Dreams was published," Recovery.org notes. "However, the association with crime was soon eclipsed by concern over 'chronic' alcoholism and 'death'/'deaths' related to alcoholism, which ballooned in the 1920s during the height of the prohibition movement." Documentarian Ken Burns echoes this in his series, Prohibition. One of the tragic unintended consequences of the nationwide crackdown on alcohol was an increase in dangerous, unregulated spirits — leading to 1,000 deaths a year.

Beliefs Shape Our Reality

This month's issue of New Scientist includes a thought-provoking article on beliefs and our view of reality.

Surprisingly large numbers of people also hold beliefs that a psychiatrist would class as delusional. In 2011, psychologist Peter Halligan at Cardiff University assessed how common such beliefs were in the UK (see below for the top 10 delusions). He found that more than 90 per cent of people held at least one, to some extent. They included the belief that a celebrity is secretly in love with you, that you are not in control of some of your actions, and that people say or do things that contain special messages for you (Psychopathology, vol 44, p 106).
None of Halligan's subjects were troubled by their strange beliefs. Nonetheless, the fact that they are so common suggests that the "feeling of rightness" that accompanies belief is not always a reliable guide to reality.

The Top 10 Delusions

1. Your body, or part of your body, is misshapen or ugly 46.4%
2. You are not in control of some of your actions 44.3%
3. You are an exceptionally gifted person that others do not recognise 40.5%
4. Certain places are duplicated, i.e. are in two different locations at the same time 38.7%
5. People say or do things that contain special messages for you 38.5%
6. Certain people are out to harm or discredit you 33.8%
7. Your thoughts are not fully under your control 33.6%
8. There is another person who looks and acts like you 32.7%
9. Some people are duplicated, i.e. are in two places at the same time 26.2%
10. People you know disguise themselves as others to manipulate or influence you 24.9%

One of the most interesting things about belief is that it varies enormously from person to person, especially on issues that really matter such as politics and religion. According to research by Gerard Saucier of the University of Oregon, these myriad differences can be boiled down to five basic "dimensions" (Journal of Personality and Social Psychology, vol 104, p 921). At their core, he says, these concern what we consider to be worthy sources of value and goodness in life, whether it be a concept, an object, a supernatural being or a historical person. Your belief system is the aggregate of your position on each of these five dimensions, which are independent of each other.

1. Traditional religiousness: level of belief in mainstream theological systems such as Christianity and Islam
2. Subjective spirituality: level of belief in non-material phenomena such as spirits, astrology and the paranormal
3. Unmitigated self-interest: belief in the idea that hedonism is a source of value and goodness in life
4. Communal rationalism: belief in the importance of common institutions and the exercise of reason
5. Inequality aversion: level of tolerance of inequality in society, a proxy of the traditional left-right political split

To read the full article, click here.

Identifying the Effective Psychiatrist

This essay on my philosophy began as a statement, but gradually the essay morphed into a series of questions. As I began to write, I started to feel as though I should have written this many years ago. I began to experience a deep sense of gratitude toward the many individuals who have taught me with such patience, kindness, and wisdom for so many years. I realized that my philosophy should reflect my desire to be a good psychiatrist. This blog post also appears on my philosophy page.

Practicing medicine is a privilege granted to very few individuals, and I am indeed fortunate. Within the field of medicine, working in psychiatry requires more than an understanding of anatomy and organ systems, because psychiatry is about the mind, the brain, the self, and human experience.
Like any other professional, I believe in high ethical standards, sound knowledge of my field, and the importance of practicing wisely and compassionately. Beyond the obvious nostrums and philosophical cliches, however, I want to be one of the good psychiatrists. As I thought about this lately, I began to wonder: how does one identify and recognize a really good psychiatrist? What makes a good psychiatrist? If I made a list of the most important aspects of a psychiatrist’s professional philosophy, what would that look like?

In 2006 an article was published in the Journal of Affective Disorders showing that good psychiatrists prescribing placebos (sugar pills) had better results than poor psychiatrists prescribing actual medication. Over 120 patients were divided into two groups, one group that received sugar pills and another group that received full strength psychiatric medication for depression. At the same time, each psychiatrist was rated on a number personal qualities: verbal fluency, interpersonal perception, expressiveness, warmth, acceptance, empathy, and the ability to focus on the other person. When results were analyzed, the psychiatrists strong in these personal qualities had the best results, even when the “medication” they prescribed was not medication at all.

The effective psychiatrists were fluent, clear, and expressive in speaking, and they had an accurate feel for their patients. Rather than being distant and aloof, the good psychiatrists were warm, friendly, and accepting. The good psychiatrists empathized well, spent more time with their patients, were more thoughtful in their strategies, and formed strong therapeutic partnerships. The point of the study was that having a good psychiatrist makes a difference in recovery.

Although medication can be extremely helpful in psychiatric care, treatment is not all about medication. The combination of the right medication, the right psychotherapy, and the right psychiatrist is the key to success.

Research has shown for generations that some clinicians consistently produce better results than others, regardless of the type of psychotherapy or theoretical orientation of the practitioner. Hundreds of studies have shown that the differences between types of psychotherapy is very small, but the psychiatrist providing the psychotherapy is critically important.

Over the past fifteen years, extensive research has given us a solid body of evidence about the qualities and actions of effective psychiatrists. Based on the psychotherapy research of Dr. Bruce Wampold of The University of Wisconsin, I have formulated here an inventory that provides the basis for judging whether a psychiatrist is likely to be effective.

  • Effective psychiatrists demonstrate a sophisticated set of interpersonal skills, including verbal fluency, perceptiveness of others, emotional intelligence, expressiveness, warmth, and acceptance. Given these gifts, the most effective psychiatrists are those who are first excellent physicians, well trained in medicine, competent to practice at the highest levels.

  • Effective psychiatrists are inquisitive, questioning, and seeking new knowledge constantly. They embrace science while at the same time possessing the humility to know how little we really know.

  • Patients of effective psychiatrists feel understood, trust the psychiatrist, and believe the psychiatrist can help. The psychiatrist creates these conditions in the first moments in both speech and action. In the initial contacts, patients are very sensitive to cues of acceptance, understanding, and expertise. Although these conditions are necessary throughout therapy, they are most critical in the initial interaction to ensure engagement in the therapeutic process.

  • Effective psychiatrists are able to form a working alliance with a broad range of patients. The working alliance involves the therapeutic bond, but also importantly agreement about the task of goals of therapy. The working alliance is described as collaborative, purposeful work on the part of the patient and the psychiatrist. The effective psychiatrist builds on the patient’s initial trust and belief to form this alliance and the alliance becomes solidly established early in therapy.

  • Effective psychiatrists provide an acceptable and practical explanation for the patient’s distress. The patient wants an explanation for his or her symptoms or problems. There are several considerations involved in providing the explanation. First, the explanation must be consistent with the healing practice. On the medical side, the explanation is biological, and in psychotherapy the explanation is psychological. Second, the explanation must be acceptable and compatible with the patient’s attitudes, values, culture, and worldview. Third, the explanation must provide a strategy by which the patient can overcome difficulties and solve life’s problems. These three factors together make for a strong therapeutic alliance.

  • The effective psychiatrist provides a treatment plan that is consistent with the explanation provided to the patient. Once the patient accepts the explanation, the treatment plan will make sense and patient compliance will be increased. The treatment plan must involve healthy actions—the effective psychiatrist promotes healing by replacing failed strategies with effective strategies. At the same time, strong defenses will replace weak defenses, and healthy practices will replace self-defeating behaviors.

  • The effective psychiatrist is influential, persuasive, and convincing. The psychiatrist presents the explanation and the treatment plan in a way that convinces the patient that the explanation is correct and that following through with the treatment will benefit the patient. This process leads to patient hopefulness, increased expectancy for mastery, and healthy actions. These characteristics are essential for forming a strong working alliance.

  • The effective psychiatrist is honest and authentic. Authenticity refers to communication to the patient that the psychiatrist truly wants to know how the patient is doing. The best psychiatrists tend not to use checklists, scales, and paper measures. Instead, they talk and listen openly and honestly.

  • The effective psychiatrist is flexible and will be patient if resistance to the treatment is apparent or the patient is slow to make progress. Although the effective psychiatrist is persuasive, persuasion can be a process that takes time. The good psychiatrist pays attention, takes in new information, test hypotheses about the patient, and is willing to be wrong. A good psychiatrist will seek second opinions, refer to other specialists, and even take calculated risks such as trying a new approach or a newly released medication.

  • The effective psychiatrist does not avoid difficult material in therapy. Doctor and patient must use such difficulties therapeutically. We all tend to avoid material that is difficult. The effective psychiatrist senses avoidance is taking place and does not collude to avoid the material. Instead, the psychiatrist will discuss the difficult material and address difficult problems. Sometimes conversations can be difficult, and at times the relationship between doctor and patient can be strained, but this is part of the work of therapy. The good psychiatrist can use skill, experience, and compassion to overcome these barriers to recovery.

  • The effective psychiatrist communicates hope and optimism. Sometimes this is easy to do, and sometimes it’s difficult. The working partnership must maintain hope and optimism in the face of chronic illness, relapses, lack of consistent progress, and many other difficulties. Effective psychiatrists acknowledge these issues and still communicate hope that the patient will achieve realistic goals in the long run. This communication is not blind faith or Pollyanna optimism, but rather a firm belief that together the psychiatrist and patient will work successfully. At the same time, effective psychiatrists mobilize patient strengths and resources to facilitate the patient’s ability to solve his or her own problems. The best doctors know that the patient, through his or her work, is responsible for therapeutic progress, creating a sense of mastery.

  • Effective psychiatrists are aware of the patient’s characteristics and context. This is a tall order with many categories: culture, race, ethnicity, spirituality, sexual orientation, age, physical health, motivation for change, and beyond. Furthermore, the effective psychiatrist is aware of how his own background, personality, and beliefs figure into the relationship.

  • The effective psychiatrist is aware of his or her own psychological process and does not inject his or her own material into the therapy process unless such actions are deliberate and therapeutic.

  • The effective psychiatrist is aware of the best research evidence related to the particular patient, in terms of treatment, problems, and social context. It is very important to understand the biological, social, and psychological basis of the patient’s problem.

  • The effective psychiatrist seeks always to improve, always to be a student. Hippocrates said, “The life so short, the craft so long to learn,” and truer words were never spoken.

  • Finally, the good psychiatrist must possess both humility and a sense of humor. We will never know enough, or be wise enough, to have all the answers. We cannot take ourselves too seriously, lest we become arrogant, prideful, and set ourselves apart from those who have graced us with the privilege of being socially sanctioned healers.

Development of skill in psychiatry involves intensive practice and unceasing professional growth. Patients are sometimes our best and most effective teachers. A few years ago I taught a seminar for third year students at the University of Texas Southwestern Medical School, “Psychiatric Nightmares, Disasters, and Catastrophes.” The entire content of the seminar consisted of mistakes I’d made, errors I had committed, and pitfalls that these students likely would encounter, sooner or later, in their medical careers.

I told the story of a patient with whom I’d had a terrible, angry argument, and how guilty I felt for years about my lack of composure—only to have the patient return, two years later, to ask me for a job at the hospital and tell me that she had been shaken into reality by our confrontation. I told them the story of the patient who overdosed and came to the ICU, and how I was baffled by the case—until I realized that the patient had diabetes, and was actually in a diabetic coma, not a drug-induced state.

I told them about the patient who came to the doorstep of my home on a Sunday afternoon, bearing in her arms her injured pet cat, hoping that I could help. I told them about an elderly man from New Orleans who was my patient in the middle of the night as Hurricane Katrina washed away his home.

And I told them about the time when I was called to the ER to examine a beautiful young woman, a Duke University cheerleader, who had bruised her shoulder. When I approached her to examine the injury, and she undid her gown and dropped it with a smile, I calmly reached into the pocket of my white coat for my stethoscope, only to realize that I then stuck my reflex hammer in my ear.

These encounters are the building blocks of the effective psychiatrist’s life. I’ve come to realize that most of the learning happens after we graduate. As Dr. Stead used to say at Duke, “Medical school is where you stay for four years until you’re old enough to become a doctor.”

Treatment Philosophy

My work includes general psychiatric problems like anxiety, depression, attention deficit disorder, substance abuse, family conflict, childhood behavior, stress, and other issues. Many people know me through my work as a specialist in the treatment of alcoholism and other addictions or chemical dependencies.

My approach to psychiatric practice reflects many years studying human nature and working to help people who are having a hard time in life. By the time most people see a psychiatrist, they are worried, or they are sad, or they are very confused about something I will just call “the problem,” or “the complaint.” Let me make some general comments about my approach, and then I will discuss my thinking on the use of medications.

People seek psychiatric help for a variety of problems, but everyone wants the same result: to feel better, to think more clearly, to rediscover satisfaction and happiness, and to regain a sense of self control and personal freedom. The problem may be related to mood, energy level, motivation, sleep, worry, relationships, anger, troubled behavior, obsessions, compulsions -- it’s a long list. People who drink too much, use drugs, or misuse prescription medication are often using these chemicals to find relief. Alcoholism and substance abuse are widespread in our culture.

Dealing with life is never easy.

Most persons first try to solve the problem or deal with the complaint on their own. Frustrated that things aren’t improving, they may seek advice from others. Sometimes a person hides the problem or lives in silence with the complaint. They may read a book, go to a support group, consult the internet, or try a new religious practice. We all have problems and complaints, and we all do the best we can to solve the dilemmas of life. When someone calls me about consultation, I almost always hear them say that they have a problem, they have tried to solve the problem, and they are looking for someone who knows how to help make things better.

One of the individuals consulting with me said, “I feel like I’m in a box, and the directions for getting out of the box are printed -- on the outside of the box.”

A successful airline pilot, a Vietnam combat veteran, said, “Doc, I’m out of altitude, airspeed, and ideas.”

Often the person seeking help has waited so long that demoralization has begun to set in, and they are beginning to lose hope. This doesn’t mean that the individual is suicidal or, in fact, any more unhappy than many of the people at the workplace or in the neighborhood. It means that they are resigned to always feeling this way, never feeling any better than this. Demoralization means a state of mind in which a person considers accepting fate, giving up, and abandoning the idea that things can get better.

Fear, anger, resentment, feeling constantly wounded, feeling overwhelmed, feeling unappreciated, feeling worthless -- all of these emotions are part of our lives. But when we feel negative all the time, or most of the time, most days, then we need help. There are very few emotional problems that defy intelligent therapy and reasonable efforts toward a solution.

When I meet someone for the first time in consultation, I have three major concerns. First, I want to get to know the person and hear about the problem are the complaint. My first question usually is simply, “How can I help?” or “What brings you to see me?” Second, I want to explore the individual’s point of view or understanding of the problem, including what solutions have been attempted. Third, I want to consider what we can do, working together, to improve the situation. I tend to focus more on results than on reasons. I’m not always sure about why things happen, but I am very focused on what we can do now. Sometimes I explain in detail how the brain works, and sometimes I discuss how life works. The process of recovery involves growth, change, and even personal transformation.

Research shows that psychotherapy can help, medication can help, and intelligent problem solving helps. Psychotherapy is not for everyone, and medication is not for everyone, but the vast majority of people who want help can find it. One of my favorite expressions is, “You have to do it yourself, but you can’t do it alone.”

Over the years I have developed a style that I call “sober conversation.” The word “sober” does not apply just to alcohol and addictions. To be sober is to be serious, to focus on what is most important, and to try to get it right. I believe in the importance of what we care about, and in this regard I have seriously studied the specific problem of human will. I call it “the problem of human will” because we are often confused about what we will ourselves to do, or not to do. When I work as a psychotherapist, I am most interested in what people care about, how their beliefs and assumptions about life have been formed, and where they feel stuck or at odds with themselves. Sometimes we have conflicting feelings about the same thing. For example, someone wants to take life in a certain direction, but he or she feels conflicted about it. Or someone tries to solve a problem, not realizing that it’s part of a bigger problem, or a different kind of problem. My definition of psychotherapy is that it is a form of personal consultation, focused on the situation of the client, with the goal of solving problems and feeling better.

Not everyone is cut out for in-depth or long-term conversation. Some people like to come for a few visits, and some like to keep going for weeks, or even months on a weekly basis. Some people prefer to come two or three times a week because they want to do the work and get on with whatever is next. Some people come for an hour, and some come for an afternoon.

Psychotherapy does take time, because the process is basically two people getting to know each other in the context of a specific purpose. Psychotherapy at its best is about taking life seriously, getting it right, and feeling the satisfaction that comes from clarity of thought, commitment to integrity, and comfort with the complexity of one’s own emotions and ideas. Some say that psychotherapy is a dying art, and this may be true. Psychiatrists today (and perhaps psychologists as well) do not receive the extensive training in psychotherapy that we did thirty years ago. Many psychiatrists and psychologists are not interested in psychotherapy. And many psychotherapists are not really very good or very well trained. Today there are thousands of people who call themselves “life coaches,” and anyone can hang out a shingle and call himself a “life coach.” There are several private organizations that offer “certifications,” but there are no license requirements, there is no government regulation, and no educational standard that is generally accepted. For these reasons, I think the concept makes sense, but in practice let the buyer beware -- caveat emptor!

Medications can be very helpful in treating some specific psychiatric problems. Today we have excellent medications for anxiety, depression, moodswings, insomnia, attention deficit disorder, and other conditions. Bipolar disorder, for example, is a devastating condition that can be very effectively managed with medication, restoring individuals to a life of normalcy and stability. I have absolutely no doubt about the value of psychiatric medications. I also believe that what is most important is getting the right diagnosis and the correct strategy for intervention and treatment. I see many people who have been misdiagnosed, and even mistreated, because they have not been well assessed. Assessment can take time, and I never jump to conclusions about diagnosis. After knowing someone for a few weeks, together we may decide that we see the condition in a different way.

Psychiatric medications are powerful, effective tools when used properly, but they also have side-effects, and they are expensive. Getting the right medication for the right diagnosis is extremely important. And there is an old saying from Hippocrates, creator of The Hippocratic Oath: “It is more important to know what sort of person has a disease than to know what sort of disease a person has.“

Thoughts and Reflections

My mission in life is to use my skills as a physician (M.D.) and psychotherapist to help people. As a psychiatrist, I serve individuals and families across a wide range of conditions and diagnoses. To read more about my professional credentials and to read my biographical sketch, click here. When I assembled this website five years ago, I didn't have a blog, and I didn't update very often. Recently I've decided to be a bit more spontaneous, adding thoughts and reflections here from time to time. This blog will reflect some of my continuing thinking, learning, and exploration.


Psychiatry as a medical specialty is a vast—and often uncharted—territory. The basic education of a psychiatrist is highly scientific and technical. The first two years of medical school are purely basic science: anatomy, physiology, biochemistry, microbiology, and so on. The last two years include brief exposure to psychiatry and psychology, but most of the time is devoted to medicine, surgery, ob-gyn, and pediatrics. Internship and residency years in psychiatry involve patient care, but the psychiatrist’s true education begins after graduation. As the venerable Dr. Eugene Stead used to tell us at Duke, “Medical school is where you stay until you’re old enough to learn how to be a doctor.” The education of the good psychiatrist is a process that lasts a lifetime.

Thanks for reading!