states with lower gun ownership and stronger gun laws have the lowest suicide rates.

For National Suicide Prevention Week, which is held each year during National Suicide Prevention Awareness Month, we released our annual analysis of state-by-state suicide rates. Year after year, the analysis reveals that states with lower gun ownership and stronger gun laws have the lowest suicide rates. Conversely, the states with higher gun ownership and weaker gun laws have the highest suicide rates 

For more click here.

Some might say that gun violence is as American as Apple Pie. This idea is indicated by the fact that there are more guns in the US than people and Americans possess more guns than any other people in the world.

When gun violence occurs the politicians ask for people's "thoughts and prayers," as if thoughts and prayers will address the tragedy that continues to occur in any meaningful way. How about if instead of thoughts a prayers the politicians focus on gun safety laws like we do with automobiles, planes, and the misuse of substances.

The mortality rate from guns in the US is a significant public health problem and until it is managed as such the gun mortality rate is not likely to change.

New York State has the third lowest suicide rate in the U.S.

When I was in graduate school getting my MSW in the early 70s our class was divided into groups and we had to pick a social problem area to research, study, and report on to the whole class. My group picked suicide.

In my career I worked for 18 years as a "psychiatric assignment officer" in 3 large urban hospitals doing mental health and substance abuse evaluations and dispositions. I estimate over those 18 years I did over 14,000 suicide evaluations.

Over my 56 year career I have continued to follow the suicide data and recently found the suicide rate for 2022.

The states with the lowest suicide rates are NJ with 7.7/100,000 followed by MA with 8.3, NY with 8.5, ML with 9.5, and CA with 10.4.

The states with the highest suicide rates are MT with 28.7, AL with 27.6, WY with 25.6, NM with 24.7 and ND with 22.5

It is very interesting that suicide rates vary by as much as 3 - 4 times as much in the highest rate states from the lowest rate states. It is interesting that suicide rates are much higher in red states than in blue states.

Why do you suppose the rates vary so significantly from state to state?

Open letter to mental health professional colleagues as they witness the pain of their clients.

A colleague wrote in part : “This has been an ugly week of multiple clients upset with the executive orders. The thing that continues to strike me is how der Trumpenfuhrer embodies the sum of all fears…..I spent two hours on Zoom today with crying people in the midst of the total meltdown of their lives, having lost jobs in the past several months and now worried about the ways in which the executive orders will effect them and the world. It was an ugly day.”

My reply is below:

It seems very important for therapists to support one another in what they are observing and experiencing. Vicarious trauma may be on the rise in our profession when therapists witness and describe days like the one you just had.

Psychopaths like pain. Inflicting pain is the point because it makes them feel powerful. Perhaps one of the most challenging things for therapists to observe and attempt to mitigate is cruelty and sadism.

In recent days not only is cruelty and sadism being perpetrated but it is being normalized with "pardons" that lift external constraints and restrictions and allows those so inclined to behave in further cruel and sadistic ways with impunity.

As I learned working on inpatient psych units and psych ed, what works best with these behaviors is injections of Haldol and four point restraint with a skilled team trained to exert a "show of force". These tactics are used only after de-escalation techniques have failed.

After such interventions staff always met for a brief de-debriefing so that calm could be restored and confidence in maintaining safe order was reinforced.

As therapists we need to find ways to keep each other safe so we can keep our clients safe as best we can.

Remember, cruelty is not a byproduct of what is being perpetrated, but the cruelty is the point to dominate, coerce, and subjugate. It is important for us as MH professionals to confront it head on, lean into it, and mitigate it. Some of us will be harmed in the process, but in the end justice, compassion, dignity, and peace will be achieved.

Keep the faith. Stay strong. Be courageous, Do the right thing. Focus on what matters.

Psychotherapy outcomes for suicidality based on modality type

There is an interesting article published, 07/02/25, in the Clinical Psychology and Psychotherapy Journal reporting on a meta analysis of the effectiveness of individual, group, and family therapy on suicidality.

The topic is of great interest to me because in my career of 56 years as a Psychiatric Social Worker I estimate I have done over 15,000 suicide evaluations, as many as 11 in one day when working as a Psychiatric Assignment Officer in a large urban hospital in Rochester, NY.

Based on my clinical experience and observation I already realized that a combination of modalities is the most effective treatment plan in most cases and in fact that is what the meta analysis found. When individual therapy was combined with group and/or family therapy outcomes were better.

This meta-analysis highlights that combined psychotherapy approaches, integrating individual sessions with group or family sessions, yields significantly higher effect sizes, reducing the risk of suicide attempts by 50%. These findings support the adoption of combined therapeutic strategies in clinical settings to effectively address suicidality. (https://onlinelibrary.wiley.com/doi/10.1002/cpp.70112?af=R, accessed on 07/03/25)

I am currently working with a family where the mother has been hospitalized twice in the last year for suicide attempts. I have used a combination of individual sessions with the four family members as well as combination sessions.

The therapeutic work has taken many twists and turns and what one might expect has turned out to not be accurate and what one might not expect emerged. Murray Bowen describes families where there is a schizophrenic member in which roles can change and the person labeled “schizophrenic” turns out to be one of the healthier members of the family whereas the “healthier appearing” family member starts showing signs of significant psychiatric symptoms.

Dr. Bowen’s teaching led to the appreciation of the system’s view of mental illness and contributed to an understanding of the strategic family therapy phrase, “What is the function of the symptom for the system?”

So what does suicidality in a family member indicate about the family system? Can the family system be ignored as we focus on the symptomatic member alone? If we ignore the social context of our client will we achieve as good an outcome ameliorating the suicidality of the identified patient? Now we have some research that validates practice wisdom which indicates that focusing on the individual’s suicidality alone will not get as good an outcome as taking into account the individual’s interpersonal relationships.

Lastly, and it's a whole other topic, how do we chart and bill for such work and how does compliance with a medical model and its practice hamper and constrain effective therapy?

Should psychological fitness be a standard for holding public office?

People who would be red-flagged for employment at my agency were elected to the two top positions in the American government which makes me question the mental health of the American public as well.

When people with mental illness reach high levels of public office and have concomitant power to make policy and engage in actions which affect millions of people, it would seem that psychological fitness might be a standard to use in the selection process. Police officers in major cities go through more psychological evaluation for their jobs than politicians who make policy to govern the police officers' actions.

Could a standard of psychological fitness be politicized and misused and abused? Yes, there is a huge potential there, and yet if we see psychological standards being increasingly used in other human service professions in criminal justice, ministry, counseling and mental health, education, would it be too much to ask that our political leaders also be subjected to such evaluations?

The argument that voters will decide is not reliable judge of fitness because most voters are naive when it comes to a candidates psychological fitness.

For more click here.

Longer term psychotherapy works according to a study published in JAMA

A study which appeared in the October 1, 2008 issue of the Journal of the American Medical Association which found that long term psychodynamic psychotherapy works. Here is a snippet from the article:

People with complex mental disorders or personality disorders would benefit from long-term psychodynamic psychotherapy that lasts at least a year or longer, according to new research.

Published in the Oct. 1 issue of the Journal of the American Medical Association, the German study found that compared to the more commonly used short-term therapy, long-term psychotherapy left people better off. In fact, the number of therapy sessions the patients had was directly correlated to improvements in symptoms.

"Long-term psychodynamic psychotherapy was significantly superior to shorter forms of psychotherapy applied in the control groups. This was true with regard to overall effectiveness, target problems, and personality functioning," said the study's lead author, Falk Leichsenring, a professor of psychotherapy research in the department of psychosomatic medicine and psychotherapy at the University of Giessen in Germany.

"With regard to overall effectiveness, on average, patients with complex mental disorders were better off after treatment with long-term psychodynamic psychotherapy than 96 percent of the patients in the comparison groups. Thus, this meta-analysis provides evidence that long-term psychodynamic psychotherapy is an effective treatment for complex mental disorders," said Leichsenring.

"This study provides a great value for doctors and for patients, and one would hope could have an influence on policy decisions," added Dr. Charles Goodstein, a clinical professor of psychiatry at the New York University School of Medicine and Langone Medical Center in New York City.

Symbolic threat leads to faulty generalizations out of touch with reality

Across six studies, we found that people commonly exaggerate the presence of certain groups – including ethnic and sexual minorities – simply because they are perceived as ideologically threatening. Psychologists call this feeling – that groups hold different values and worldviews from the mainstream, thereby jeopardizing the status quo – “symbolic threat.”

From an article on The Conversation on 06/09/2022 entitled "People overestimate groups they find threatening- when "sizing up others," bias creeps in.

"They're eating the cats! They're eating the dogs!" Donald Trump in presidential debate with Kamala Harris in 2024.

How crazy are your beliefs? Are you aware of them? Can you manage them realistically? Being self aware is one of the first skills of spiritual intelligence. Socrates said an unexamined life is not worth living, and the humorist said an unlived life is not worth examining.

AI psychosis can lead to suicide

The parents of a teenager who died by suicide have filed a wrongful death suit against ChatGPT owner OpenAI, saying the chatbot discussed ways he could end his life after he expressed suicidal thoughts. The lawsuit comes amid reports of people developing distorted thoughts after interacting with AI chatbots, a phenomenon dubbed “AI psychosis.” John Yang speaks with Dr. Joseph Pierre to learn more.

For more click here.

AI had taken over health care

Peter Simons writes in his article "Doctors: Patients Don't Want You To Use AI" on 08/18/25 on the Mad In America website:

There’s a deep divide between how patients and doctors view the use of artificial intelligence (AI). Doctors are overwhelmingly in favor of using AI: two-thirds of doctors have already incorporated it into their practice. But patients are concerned about AI’s tendency to make up false information and fear AI use may further reduce an already dismissive and unsympathetic medical interaction to something completely robotic.

This divide exists in other fields too, where corporate executives believe that AI has improved customer service, but actual customers disagree, with 88% preferring human interaction, and almost half say “their biggest frustration has been not being able to reach a human.”

The back room jargon in the health care field is the importance of treating the record and not the patient. Modern health care has turned into disease management and less on patient care.

How to manage this poor patient care? Limit your interactions with health care professionals which are increasingly being recorded and be careful about the information you share. Find other resources for understanding and support.

Book Review - The Book Of Ruth by Jane Hamilton

While it's not a self-help book, reading Jane Hamilton's The Book of Ruth can offer several psychotherapeutic benefits, primarily by fostering empathy and providing a powerful narrative for exploring themes of trauma, resilience, and personal growth. The novel is not a manual for therapy, but it can serve as a catalyst for self-reflection and understanding.

Here are some of the potential psychotherapeutic benefits of reading The Book of Ruth:

• Empathy and Understanding of Trauma: The novel provides a deeply personal and raw account of a character, Ruth, who endures a life of hardship and emotional abuse. By immersing yourself in her perspective, you can develop a deeper sense of empathy for individuals who have experienced trauma, particularly those from marginalized or difficult backgrounds. Ruth's story challenges the reader to look beyond surface judgments and understand the complex reasons behind her choices and struggles.

• Exploring Family Dynamics and Cycles of Abuse: The book's central conflict revolves around the toxic and abusive relationship between Ruth and her mother, May. By witnessing this dynamic, readers can gain insight into the destructive nature of family dysfunction and the ways in which trauma can be passed down through generations. This can be particularly therapeutic for readers who have their own difficult family histories, as it may provide a framework for understanding and processing their experiences.

• The Power of Resilience: Despite the immense suffering she endures, Ruth demonstrates a quiet yet profound resilience. She finds solace and strength in unexpected places, such as her correspondence with her aunt and her love for literature. Her journey from passivity to a form of self-rescue highlights the human capacity to survive and even grow in the face of overwhelming adversity. This can be a source of hope and inspiration for readers facing their own challenges.

• The Quest for Identity and Self-Worth: A major theme of the novel is Ruth's struggle to define herself outside of the expectations and labels placed upon her by her family and community. She is constantly told she is a "loser" and is overshadowed by her "brilliant" brother. Her journey of self-discovery, from a timid and passive young woman to someone who can piece together her own story, is a powerful narrative about finding one's voice and recognizing one's own value.

• The Role of Narrative in Healing: The novel is revealed to be a story that Ruth herself has written. This framing device suggests that the act of telling one's own story can be a form of therapy and a path to forgiveness. By creating her own narrative, Ruth is able to process her trauma and take ownership of her life. This can be a powerful lesson for readers about the importance of giving voice to their own experiences.

In summary, The Book of Ruth offers a harrowing but ultimately hopeful look at the human spirit. While it's a work of fiction, its exploration of themes like trauma, family relationships, and resilience can serve as a valuable tool for introspection and empathy, providing a unique form of psychotherapeutic benefit.

Violent attack on CDC goes largely unnoticed

“It’s been a struggle to process what happened at the CDC just a few days ago. The facts are coming in: one officer died, 500 rounds fired, 200 bullets made contact with 6 CDC buildings, hundreds of staff sheltered in place for hours. The intention is undeniable: this was an attempted massacre.”

This was the opening of an August 13 Substack column and video discussing the deafening silence after the deadly attack last week on the Centers for Disease Control and Prevention in Atlanta, a joint effort by resident physician Kristein Panthagan, emergency physician Megan Ranny (also Dean of Yale School of Public Health) and epidemiologist Kateyn Jetelina of Your Local Epidemiologist.

“The state of the world feels unrecognizable,” they wrote. “We are living headline to headline, tragedy to tragedy…Our world is swallowed whole by the endless churn of violence and crisis we’ve come to accept as ordinary. We are drowning in the abnormal…”

In a LinkedIn post, Jeletina wrote: “As horrific as it was to have 500 bullets fired toward the CDC, what’s been equally painful is what followed (or rather, what didn’t). The silence. The indifference. It's been deafening. Especially after all that public health has given over the past six years.”

For more click here.

The CDC has done great work in making the public health of Americans better than it would otherwise be without their good work. However the attacks by MAGA, DOGE, and Robert F. Kennedy, Jr. have cultivated animosity, and vilification by the scientifically illiterate who resent limits being put on their life threatening behaviors.

Our society will enjoy a higher quality of life for all if we support our public health programs.

Female veterinarians have a suicide rate 3.5 times the national average.

Parenting - Predictability nurtures secure children.

 

One of the key components of mentally healthy functioning is security. Security comes from predictability from the perspective of the child. Can the child trust their caretakers to meet their needs and treat them fairly?

Does the parent mean what they say and say what they mean? Is the parent reliable and dependable? If so, the child grows up feeling secure and competent in meeting life's expectations and requirements.

In structural family therapy the therapist focuses on the family hierarchy, good boundaries, regulated management of emotional expression, and the provision of predicted routines. This means that the therapist often parents the parents so they can better enact their parenting roles with their children to achieve more satisfying and fulfilling family relationships.

Parents should not say things to children they don't mean and aren't likely to follow through with. Honesty is a significant virtue to cultivate in ourselves and in our relationships.

Do chat bots cripple social skill development in children and teens?

 

For more from this Scientific American article click here.

There are similar concerns about the crimpling of human social skills when people resort to on-line social media to meet their needs for social connection.

Parenting - telling the children about the plan to divorce

 

Linda McCullough Moore's book of short stories, An Episode Of Grace, begins with the story entitled, "You choose," which begins with this paragraph:

"I’m driving on Route 91, going ten miles over the limit, on the way to my divorce, or, at least, to its announcement. My husband Jake and I decided we would tell the kids tonight. We’ve waited way too long. Our marriage died of natural causes years ago. We are planning that our children will be shocked beyond surprise, but we both know better. Any hesitation that we have about telling them isn’t fear of their surprise; it’s knowing that once we say the words, out loud, to them, it will be official, carved in stone, irreversible. But, of course, that’s what we want."

The children's' names are Jonah who is 11 and Adam who is 6.

Of all the questions I get asked as a couple counselor and a family therapist by people going through a divorce are when and how to tell the kids?

My stock answer is "Don't tell them anything until you know specifically what the plan is unless they ask."

Kids being narcissistic in a healthy way first ask when told their parents are separating is "What's going to happen to me?" Parents need to have the answer to provide the child with whatever sense of security and predictability they are able.

The narrator in this story has her plan in place and has coordinated the telling the children with her husband and as she travels to the meeting with the children she gets stuck in a snow storm and as the various events unfold her ambivalence about divorcing her husband grows in poignant ways.

The ambivalence partners usually feel about a break-up with the concomitant anger, sadness, fear, hope, sense of failure and regret, are things the therapist witnesses and, hopefully, clarifies with the client(s) into some sort of coherent story that makes sense to themselves primarily and then to others affected.

The key question, often overlooked, in the emotional turmoil is, "What is the purpose of this relationship?" The genuine answers to this question usually lie at an unconscious level that the individual is not aware of and doesn't understand. 

The understandings of one's motivations, choices, and responsibilities are key to growth towards greater maturity so that the individual does not jump from the proverbial frying pan into the fire and engage in what Dr. Freud called the "repetition compulsion" to merely re-enact the same scenario over again.

The narrator of the story recognizes that telling the children about the impending divorce is a milestone in the process which she determines as a point of no return. It is an action which will make the rupture permanent and complete. The finality and the closure seems to heighten her apprehension about the decision to divorce rather than mollify it and liberate her.

What will she do when she gets her car unstuck from the snow and reschedules the meeting with her their husband and maybe soon to be ex- husband?

Pop quiz - Parenting styles

What is the most effective parenting style?

A. Authoritarian

B. Permissive

C. Uninvolved

D. Authoritative

For more click here.

New York State has third lowest suicide rate in the US after New Jersey and Massachussetts.

 Based on recent data, the suicide rate in the United States is significantly higher than the homicide rate.

• Suicide Rate: In 2022, the age-adjusted suicide rate was 14.2 per 100,000 people.

• Homicide Rate: In 2023, the homicide rate was 5.9 per 100,000 people. Other data for 2023 shows a rate of 6.8 per 100,000 people.

In terms of total deaths, there are nearly two times as many suicides as homicides in the U.S. For example, in 2022, there were over 49,400 suicides compared to around 24,800 homicides.

In my career as a Psychiatric Social Worker I have done over 15,000 suicide evaluations most of them as a Psychiatric Assignment Officer in urban hospital emergency rooms.

Suicide rates vary greatly by region and other demographic characteristics. Men kill themselves three times more often than women but women attempt suicide three times more often than men. The reason for the discrepancy between suicide death rates is due to the means of the attempt. Men most often use guns while women use ODs and cutting.

New York State consistently has one of the lowest suicide rates in the United States. While the specific ranking can vary slightly depending on the year and the source of the data, New York is typically in the bottom three alongside states like New Jersey and Massachusetts.

For example, according to data from 2021, New York's suicide rate was 7.9 per 100,000 people, placing it among the lowest rates in the country. This is in stark contrast to states with the highest rates, such as Wyoming, Montana, and Alaska, which often have rates three to four times higher.

Suicide rates seem more influenced by the availability of social infrastructure than any other factor. When people are desperate do they have a place to turn? Is there help for what is distressing them so much that they would rather end their lives than go on living. New York, New Jersey, and Massachusetts have much better health and human services than other states.

Withdrawal symptoms from discontinuing antidepressants worse the longer they are taken

From PsyBlog 08/06/25

The longer a person takes antidepressants, the more likely they are to experience withdrawal symptoms when coming off them.

People who have taken them for more than two years are at a 10 times higher risk of experiencing withdrawal symptoms compared to short-term users (less than six months).

For long-term users, those symptoms are likely to be more severe and take longer to resolve.

Around half may suffer withdrawal symptoms when coming off antidepressants (although some think the true rate is nearer 15 percent).

Withdrawal symptoms include anxiety, dizziness, headaches, nausea, depression and suicidal thoughts.

It has been my experience after 56 years of practice as a psychiatric social worker that anti-depressant in some situations can be helpful but they are not a panacea for what too easily is diagnosed as "depression." There are many different types of depression and multiple factors that contribute to it. Studies show that in general counseling is more helpful in the long run than medications. In general anyone started on an anti- depressant should also obtain an evaluation of the depression by a qualified mental health clinician.

Themes from The Best American Science And Nature Writing 2024

The themes that have emerged for me from The Best American Science and Nature Writing 2024  are:

1. The earth is getting warmer and having negative consequences for the ecological balances which we humans have become accustomed to.
2. This climate warming is having negative consequences up to and ending in death for many living things.
3. A small group of under-supported scientists are studying what's happening and their findings are largely ignored or dismissed by the decision makers except in a few instances.
4. Science journalism is one way of informing and educating people about what is happening to them which is outside their level of awareness because the changes are insidious except when they culminate in catastrophic weather events.

Some observers have noted that because of these four things social anxiety and tension has risen contributing to political polarization and the rise of autocracies exemplified by the "strong man" leader who promises to "fix everything" and make people safe and more secure. This political solution is delusional because it doesn't address the underlying problem which is human caused climate change.

What will help? A correct diagnosis of the problem causing the rise in anxiety and plans that are effective in addressing the creation and maintenance of the problem. This requires cooperation, collaboration, and joint efforts around the planet. Isolation and nationalism will not help, but only maintain and increase the problem. There needs to be a shift from the emphasis on private wealth and profit to a sharing and creation of health giving commons. This is a huge shift in values especially in the richest country in the world, the US. What will bring this shift in values in the US population? The worsening of circumstances until people have to find a better way to live if they are to survive. And then a transformation into cooperative, collaborative, mutually satisfying democratic processes.

PS - The Best American Science and Nature Writing 2024 is the August 2024 selected read of the Allnonfiction Book Discussion Group. If you are interested in joining the Allnonfiction Book Discussion Group you can find more about it here.

Use of EHRs (Electronic Health Records)

Those of us with a more cynical sense of humor use to talk about "treating the chart". Treating the chart becomes more important as a means of complying with system expectations and requirements and often is used in measuring provider performance. This system is very dysfunctional and contributes to poorer patient care. As such, an argument might be made that the use of EHRs is unethical because of the skewed values and consequences for patient care.

When I reopened my private practice in May of 2024, I attempted to use the Simple Practice practice management system which includes their EHR templates. I quickly abandoned most of it because it seemed to interfere with my client care rather than enhance it. I went back to keeping my own notes on paper for the most part and sometimes computer based files which only I control and designed. The only thing I use it for now is billing.

https://mailchi.mp/openminds.com/daily-executive-briefing-4323228?e=f8bccd7a14

"most EHR systems weren’t built with the clinician in mind. They were built to get electronic billing information to payers and health plans and the results reflect those early designs. A study found that primary care practitioners spend more than 50% of their workday using their EHR—355 minutes (5.9 hours) of an 11.4 hour workday (see Primary Care Doctors Spend More Than 50% Of Workday On Documenting In The EHR). Of those 355 minutes, 75% were spent in the office during office hours and 25% were spent after hours. These data show that three tasks consume the most time: documentation (24%), reviewing chart notes (17%), and prescription refills and results management (16%)."

Teen suicide is on the decline, new federal data shows

From NPR on 08/04/25:

The new report shows that the prevalence of serious suicidal thoughts in 12-to-17-year-olds fell from nearly 13% in 2021 to 10% in 2024. And the prevalence of suicide attempts by teens also fell slightly — from 3.6% to 2.7%.
--------------
The report also found that the share of teens with an episode of major depression in the past year fell during this time — from 21% to 15%. But only about 60% of teens with a recent episode of depression got treatment.

And 2.6 million teens still had thoughts of suicide in 2024, notes Hannah Wesolowski, chief of advocacy with the National Alliance on Mental Illness.

"That's 1 in 10 kids, which is still far too high in this country," she adds. "So we're making progress, but we're not making progress fast enough."

The report also found that 700,000 adolescents did attempt suicide in the past year.

Access to treatment is still very difficult for most families due to lack of providers, poor insurance coverage, high co-pays.

I would hypothesize that the suicide rate will continue to decline due to the heightened awareness of the negative impacts of smart phone social media addiction and the limiting of smart phones in schools.

Keep the faith. Stay strong. Be courageous. Tell the truth. Do the right thing. Focus on what matters in an age of cruelty in the US.

The following article was written and published on davidgmarkham.substack.com on 01/26/25. Not much has changed other than the national well being deteriorating further in the US.

A colleague wrote in part : “This has been an ugly week of multiple clients upset with the executive orders. The thing that continues to strike me is how der Trumpenfuhrer embodies the sum of all fears…..I spent two hours on Zoom today with crying people in the midst of the total meltdown of their lives, having lost jobs in the past several months and now worried about the ways in which the executive orders will effect them and the world. It was an ugly day.”

My reply is below:

It seems very important for therapists to support one another in what they are observing and experiencing. Vicarious trauma may be on the rise in our profession when therapists witness and describe days like the one you just had.

Psychopaths like pain. Inflicting pain is the point because it makes them feel powerful. Perhaps one of the most challenging things for therapists to observe and attempt to mitigate is cruelty and sadism.

In recent days not only is cruelty and sadism being perpetrated but it is being normalized with "pardons" that lift external constraints and restrictions and allows those so inclined to behave in further cruel and sadistic ways with impunity.

As I learned working on inpatient psych units and psych ed what works best with these behaviors is injections of Haldol and four point restraint with a skilled team trained to exert a "show of force". These tactics are used only after de-escalation techniques have failed.

After such interventions staff always met for a brief de-debriefing so that calm could be restored and confidence in maintaining safe order was reinforced.

As therapists we need to find ways to keep each other safe so we can keep our clients safe as best we can.

Remember, cruelty is not a byproduct of what is being perpetrated, but the cruelty is the point to dominate, coerce, and subjugate. It is important for us as MH professionals to confront it head on, lean into it, and mitigate it. Some of us will be harmed in the process, but in the end justice, compassion, dignity, and peace will be achieved.

Keep the faith. Stay strong. Be courageous, Do the right thing. Focus on what matters.

Ageism, death denial, and wisdom

What is the role of the wise elder in our contemporary society? There is a difference between growing old and growing up. Growing old is inevitable, and growing up is optional.

The youth culture idolizes immortality foolishly. As one grows up one comes to terms with limits, failure, and death. In growing up a person can come to face their demise with equanimity and the peace that comes from the satisfaction and fulfillment of completion.

Age discrimination is based on the denial of death in our culture. We don't want to think about it, understand it, respect it, let alone welcome it. We avoid it, deny it,  and discriminate against anything that reminds us of it.

Age discrimination fundamentally is death discrimination which is crazy and mentally unhealthy. Wisdom comes from knowing that all things die. It is part of the life cycle. The concern should not be about death because death is natural. The concern is how to do it well and honor it and welcome it because of a life well lived. This wisdom is something that a youth idolizing society denigrates, dismisses, marginalizes and thereby creates unnecessary anxiety and social tension.

As elders who have come to terms with the downside of our life cycle and learned how to enjoy it and value it, we have much to offer to the younger members of our society. We, as elderly psychotherapists, have much to offer a society which is very much in need of our wisdom developed from thoughtful lives productively lived.

What are the three most important lessons you have learned so far inyour life that enlighten you and may be of help to others?

Major cause of perinatal maternal death is behavioral health problems

 

The major cause of maternal mortality in the US are behavioral health conditions accounting for almost 23% of all perinatal deaths.

Mental health care for pregnant women can be life saving. It also seems the SSRI antidepressant medications are safe in general and the benefits outweigh any risks.

For more click here and here.

Differentiation of self as an indicator of functioning

Question: Have you experienced/observed age discrimination in our field? In what ways? I am giving a CE training on the topic and would love to hear more about people's lived experiences with this!

Answer: Interestingly in my 56 year career as a Psychiatric Social Worker I have never experienced what I would consider "age" discrimination, but I have encountered often what could be called "experience" discrimination especially when I was over 50 looking for higher level positions when the people interviewing me had less experience, competence, and skills that I did. They were usually courteous and somewhat dismissive and I knew they were never going to hire me because I could easily do their jobs. It is very interesting how many mediocre people are threatened by competence.

Further answer:

Another factor even less talked about than experience is the level of differentiation in a hierarchical emotional system. Using Bowen's concept of differentiation of self (DOS) as applied to emotional systems having a subordinate more differentiated than a superordinate in an emotional system is toxic ground for all kinds of dysfunction.

This perverse hierarchy caused me much distress until I learned about emotional systems and had names for the dynamics being played out. The strain was still there but I became much better at managing it.  However, over the course of my 56 year career I resigned from three jobs because of my lack of satisfaction with the incompetence of my supervisor.

We don't have many words for this phenomenon but the one that often comes to mind is being "underemployed" or "overemployed" or years ago it was known as the "the Peter Principle." when a person is promoted to their level of incompetence.

Question: Is a national government an emotional system?

Answer: Yes, a national government is an emotional system. Of course, we have three branches of government and so we can consider the emotional system of the executive branch, the legislative branch, and the judicial branch.

A symptom of the perverse hierarchies based on differentiation based on differentiation of self is the resignations on principle. Of particular note is the number of resignations of very competent people in Trump's cabinet in his first term. Can you imagine Rex Tillerson the CEO of Exxon working successfully for Donald Trump just as one example?

In congress there have been a number of resignations because of incompetence of the leadership, notably, Liz Cheney, Adam Kinzinger and many others.

We could reflect on this dynamic much more extensively, but  I am not sure if it is necessary and I don't want to turn this into a political discussion. The focus of attention is on how emotional systems function at all levels of society.

As an exercise when I was learning about Bowen theory, in one class we discussed the level of differentiation of the various presidents and the success of their administrations. While highly speculative, it was very informative about the theory.

When you observe any organization and you attempt to ascertain the level of differentiation of the leaders at various organizational levels I find the concept extremely helpful. I also have used the concept in hiring and promoting people in the organizations I managed when I had hiring and firing authority. Facilitating the enhancement of a person's level of differentiation is one of the most important purposes of psychotherapy and supervision. This presumes that the therapist and supervisor are at a higher level of differentiation than the client or the supervisee. Enhancing the therapist's level of differentiation is one of the reasons that psychotherapists should engage in their own therapy. Self awareness and understanding of what makes one tick is an important factor in an effective therapist and supervisor.

A good book that deals with this concept is Edwin Friedman's book, Generation To Generation, in which Friedman applies Bowenian concepts to church organizations. Another of Friedman's books that address organizational and societal dynamics from a Bowenian perspective is Failure Of Nerve which was published posthumously after his death.

Bibliotherapy - Object lessons by Anna Quindlen

Anna Quindlen's Object Lessons is a coming-of-age novel set in suburban New York City during the 1960s. It tells the story of twelve-year-old Maggie Scanlan as she navigates a pivotal summer marked by significant changes within her large, Irish-Catholic family and in her own life.

Summary of Object Lessons

The novel centers on the Scanlan family, dominated by the wealthy and imposing patriarch, John Scanlan. Maggie is particularly close to her grandfather, who attempts to impart "object lessons" – life lessons – to her. However, Maggie's world is in flux. Her family dynamic is strained by her Italian-American mother, Connie, who feels like an outsider within the Irish clan and struggles with isolation and a distant relationship with her husband, Tommy (John Scanlan's son).

As the summer progresses, several events challenge Maggie's perception of her seemingly stable world. Her powerful grandfather suffers a stroke, leading to his eventual death, which deeply impacts the family's hierarchy and emotional landscape. Maggie witnesses her parents' struggles, discovers uncomfortable truths about her own conception, and grapples with the unraveling of her friendship with her best friend, Debbie, as they drift into different social circles and confront challenging adolescent experiences, including peer pressure and even a brush with delinquency. Through these experiences, Maggie begins to shed her childhood innocence and gain a more complex understanding of family, identity, and the adult world.

Therapeutic Benefits of Reading Object Lessons

Reading Object Lessons can offer several therapeutic benefits, particularly for those reflecting on their own coming-of-age or family dynamics:

• Validation of Adolescent Experiences: The novel realistically portrays the often confusing and emotionally charged period of adolescence. Readers, especially those who experienced similar transitions, can find validation in Maggie's struggles with identity, shifting friendships, and the growing awareness of adult complexities. This can foster a sense of "I am not alone," which, as Anna Quindlen herself has noted, is a significant benefit of reading.

• Exploration of Family Dynamics: Quindlen's keen observation of family relationships, particularly the complexities of a multi-generational, somewhat dysfunctional family, can be cathartic. Readers might recognize echoes of their own family challenges, power struggles, and unspoken tensions. This can lead to greater understanding and empathy for their own family members and their past.

• Processing Change and Loss: A central theme is the impact of change and loss, particularly with the grandfather's illness and death. The novel demonstrates how individuals and families cope with grief, shifts in power, and the redefinition of relationships. This can be beneficial for readers who are experiencing or have experienced similar losses, offering a fictional space to process these emotions.

• Understanding Intergenerational Conflict and Cultural Differences: The novel subtly explores the tensions between Irish and Italian cultural backgrounds, particularly through Connie's experience as an outsider. This can provide insight into the challenges of navigating different cultural expectations within a family and the impact of prejudice, even within seemingly homogenous communities.

• Empathy and Perspective-Taking: By immersing themselves in Maggie's perspective, readers develop empathy for the characters and their struggles. Seeing events through a young girl's eyes, while simultaneously understanding the adult world around her, can broaden one's perspective on human behavior and motivations.

Reflection on Personal Growth and Resilience: Maggie's journey is one of self-discovery and resilience. Despite the unsettling changes, she finds her voice and begins to forge her own identity. This can inspire readers to reflect on their own journeys of growth and the strength they've found in overcoming challenges.

This book might be of help to parents of adolescents and to people interested in and working with family systems.