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%.
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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.