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Psychoanalytic theory and the young child
I recently ran into a colleague who asked me whether I was still writing my column. I said yes and that I was currently writing an article on Selma H. Fraiberg. His response, "You don’t hear that name very much anymore," disappointed me. I responded by saying whenever a colleague, friend, or family member is having a baby, I send them a copy of "The Magic Years" with a clear statement that both parents must read it. It is clearly the best book on child rearing ever written in my opinion.
Ms. Fraiberg, creator of "The Magic Years," was a master’s in social work–trained psychoanalyst affiliated with the department of psychiatry at the University of California, San Francisco, who translated numerous concepts about babies, parents, and the first few years of life with wonderful examples of the type of incidents that every parent faces. She was highly regarded 50 years ago and received a great deal of praise for her book. But, at that time, there was a lot of prejudice against nonmedical degree psychoanalysts, and her book was not regarded as highly as I believe it should have been.
When I was a resident, I was required to read "The Magic Years," understand it, and be able to discuss it. Our teachers were concerned that we were busy being residents but also having children, and we really had to understand child rearing so that we could serve as resources for our residents and our analytic trainees.
Ms. Fraiberg translated psychoanalytic theory into child-rearing guidance in the book by looking at three age ranges: the first 18 months, 18 months to 3 years, and 3-6 years. Some of the examples are still fresh today, even though the book was published originally in 1959.
Dr. T. Berry Brazelton, the renowned pediatrician, wrote an introduction to the 50th anniversary of the book (New York: Scribner, 2008) saying that Ms. Fraiberg "makes each stage of emotional and mental development come alive!" I agree wholeheartedly. Furthermore, I would say that the concepts in the book can inform psychiatrists in our efforts to help our patients. After all, raising children (and growing up) is fraught with pitfalls. As Freud said early in his career, there are three impossible professions: governing nations, raising children, and psychoanalysis.
How the magic unfolds
Parents are often confused by things that children do or say, imaginary friends and animals – frustrating the child by pointing out reality when the child needs that imaginary friend or animal to survive. To the child, these imaginary friends and animals are not silly at all. A good example is what a niece of Ms. Fraiberg’s called the "Laughing Tiger."
Her niece, who was 2 years, 8 months old at the time, created the Laughing Tiger and many other imaginary companions at a time when she was afraid of ferocious animals. The niece’s "imaginary tiger gives her a kind of control over a danger which earlier had left her helpless and anxious," Ms. Fraiberg wrote. Instead of viewing this companion as problematic, it makes more sense to see this use of imagination as a healthy sign. Indeed, the child "can maintain his human ties and his good contact with reality while he maintains his imaginary world," she writes. "Moreover, it can be demonstrated that the child’s contact with the real world is strengthened by his periodic excursions into fantasy."
Virtually every chapter of the book is filled with insights that explain how young children interpret their world, which makes it invaluable for new parents. As we all know too well, the pitfalls in raising a child and growing up are many. I have not referred back to it for personal reasons in recent years. After all, my children are 54, 52, and 50 years old. But my wife and I did make very liberal use of the book throughout the years – while all of our friends were using Dr. Spock to help them navigate the waters of child rearing.
Mastering fear
Ms. Fraiberg gently guides the reader in an understanding of the child’s developing mind, why they cry, why they have tantrums, why they use imagination and how to help mom deal with the child’s anxiety. Take the example of a 2-year-old who was afraid of the family vacuum cleaner. Some young children control their fear of what must seem like loud monsters to them by learning to control the switch. But this toddler, who was known for his tendency to carry around a pocket-size screwdriver, was not satisfied with that solution. He had another idea: "Tiny screws and wheels were removed and lost in this frantic search," Ms. Fraiberg wrote. "...Finally, this limping monster issued its dying croak and succumbed without giving up its secret."
After a couple of years, the youngster’s "drive to investigate" was motivated by factors other than anxiety. Instead, he found investigation, discovery, and reconstruction to be pleasures in themselves. Interestingly, this child grew up to be a physicist.
There are many lessons here for psychoanalysts and our patients. One is that children experience things in which adults have no conscious memory. This means that we can help patients become better parents if we can get them to empathize with the child’s fears and frustrations.
Attachment, active handling
Ms. Fraiberg tells the story of an infant who developed an extremely severe sleep disturbance when she was 8 months old. Around 11 p.m. nightly, the infant woke up screaming, despite her parents’ efforts to calm her down. When her parents checked on her, the baby clung to her mother.
The episodes started after the baby woke up one night when the parents were out and had left her in the care of a babysitter. These meltdowns came in contrast to the child’s earlier reactions to her parents’ absence: "She never seemed to mind before if she wakened and saw a babysitter instead of us," Ms. Fraiberg quotes the parents as saying. "We just didn’t expect anything like this." What might explain this sudden new reaction?
"We know that the attachment to the mother is especially strong at this stage of development and a strange face may disturb the child at this age, even when encountered in the daytime," she writes. "The reaction to the strange face, as we have seen, is an indication of the discrimination of the mother as a person and the recognition of her as the person who gives satisfactions and protection. The stranger’s face that appears when mother’s face is expected produces anxiety because it symbolizes the absence or loss of the mother."
As you can see from that scenario, Ms. Fraiberg lets the mother know how essential she is and how early the child is distressed by the mother’s disappearance. In general, some people argue that they have to go on with their lives and that the baby will have to learn to be away from their mothers. We have to help our patients understand that the learning process is a burden for the infant. Some kids take a long time to learn how to separate from mom. Ms. Fraiberg helped the baby under discussion overcome her anxiety through nursery games in which her mother would hide her face one minute and return the next. She said the game allowed the baby to "work out the problem in her waking hours so that gradually the sleep disturbance disappeared."
Ms. Fraiberg also applies psychoanalytic theory to explain why a 9-month-old with a healthy appetite stopped eating and went on what she calls a "food strike" that lasted for 3 days. The child’s mother – who wanted the meals to be neat and orderly events – had been feeding the baby. So what brought the strike to an end?
One day the child’s father took over the feeding, and to the parents’ surprise, the baby started eating again. The mother immediately blamed herself, but the child’s behavior had nothing to do with her, per se. When the baby’s father tried to feed him, he grabbed the spoon and "plastered his face with strained carrots. Papa seemed quite unconcerned." When the baby turned his cup upside down, allowing his milk to spill all over the floor, the father took the messiness in stride.
This scenario was in stark contrast to those that emerged when the baby’s mother was in charge. When the baby tried to snatch the spoon from his mother, she got an extra spoon. When he tried to play with his milk cup, she moved it out of reach. As soon as the baby’s father allowed him to have freedom in feeding himself, the strike ended.
The explanation for the baby’s behavior changes is rooted in child development theory, Ms. Fraiberg writes. "...A certain amount of active handling of objects is absolutely necessary for the child in discovering and learning about the world around him," she says.
The period of 18 months to 3 years is dominated by words. If the child wishes something, he will use whatever words he has learned up until then, not knowing that they might not have any relationship to what he’s wishing for. If he wants something, he demands it or screams. He does not have language that is precise in any way. He uses words that he hopes will satisfy his wishes.
When the child acquires the word "bye-bye," he "begins to take the departures of his parents with more grace." The acquisition of language also makes it possible for the child to show more self-control and plays a role in the formation of his conscience.
I consider myself a developmental psychiatrist, an area in which child development is essential to all therapeutic engagement. Much can be learned about the patient if we know about his childhood and parents. I often see the patient doing to his child what his parents did to him. Patients are always shocked when I point this out to them, and the process of understanding how they got to where they are occurs. I call it therapeutic living. The book is so important because it tries to help parents learn how to handle tough developmental moments and periods. The section on toilet training is classic.
Please read "The Magic Years," and get your colleagues and students to read it as well. Ms. Fraiberg was a true master of the analytic method.
Dr. Fink is a psychiatrist and consultant, and professor of psychiatry at Temple University, Philadelphia.
I recently ran into a colleague who asked me whether I was still writing my column. I said yes and that I was currently writing an article on Selma H. Fraiberg. His response, "You don’t hear that name very much anymore," disappointed me. I responded by saying whenever a colleague, friend, or family member is having a baby, I send them a copy of "The Magic Years" with a clear statement that both parents must read it. It is clearly the best book on child rearing ever written in my opinion.
Ms. Fraiberg, creator of "The Magic Years," was a master’s in social work–trained psychoanalyst affiliated with the department of psychiatry at the University of California, San Francisco, who translated numerous concepts about babies, parents, and the first few years of life with wonderful examples of the type of incidents that every parent faces. She was highly regarded 50 years ago and received a great deal of praise for her book. But, at that time, there was a lot of prejudice against nonmedical degree psychoanalysts, and her book was not regarded as highly as I believe it should have been.
When I was a resident, I was required to read "The Magic Years," understand it, and be able to discuss it. Our teachers were concerned that we were busy being residents but also having children, and we really had to understand child rearing so that we could serve as resources for our residents and our analytic trainees.
Ms. Fraiberg translated psychoanalytic theory into child-rearing guidance in the book by looking at three age ranges: the first 18 months, 18 months to 3 years, and 3-6 years. Some of the examples are still fresh today, even though the book was published originally in 1959.
Dr. T. Berry Brazelton, the renowned pediatrician, wrote an introduction to the 50th anniversary of the book (New York: Scribner, 2008) saying that Ms. Fraiberg "makes each stage of emotional and mental development come alive!" I agree wholeheartedly. Furthermore, I would say that the concepts in the book can inform psychiatrists in our efforts to help our patients. After all, raising children (and growing up) is fraught with pitfalls. As Freud said early in his career, there are three impossible professions: governing nations, raising children, and psychoanalysis.
How the magic unfolds
Parents are often confused by things that children do or say, imaginary friends and animals – frustrating the child by pointing out reality when the child needs that imaginary friend or animal to survive. To the child, these imaginary friends and animals are not silly at all. A good example is what a niece of Ms. Fraiberg’s called the "Laughing Tiger."
Her niece, who was 2 years, 8 months old at the time, created the Laughing Tiger and many other imaginary companions at a time when she was afraid of ferocious animals. The niece’s "imaginary tiger gives her a kind of control over a danger which earlier had left her helpless and anxious," Ms. Fraiberg wrote. Instead of viewing this companion as problematic, it makes more sense to see this use of imagination as a healthy sign. Indeed, the child "can maintain his human ties and his good contact with reality while he maintains his imaginary world," she writes. "Moreover, it can be demonstrated that the child’s contact with the real world is strengthened by his periodic excursions into fantasy."
Virtually every chapter of the book is filled with insights that explain how young children interpret their world, which makes it invaluable for new parents. As we all know too well, the pitfalls in raising a child and growing up are many. I have not referred back to it for personal reasons in recent years. After all, my children are 54, 52, and 50 years old. But my wife and I did make very liberal use of the book throughout the years – while all of our friends were using Dr. Spock to help them navigate the waters of child rearing.
Mastering fear
Ms. Fraiberg gently guides the reader in an understanding of the child’s developing mind, why they cry, why they have tantrums, why they use imagination and how to help mom deal with the child’s anxiety. Take the example of a 2-year-old who was afraid of the family vacuum cleaner. Some young children control their fear of what must seem like loud monsters to them by learning to control the switch. But this toddler, who was known for his tendency to carry around a pocket-size screwdriver, was not satisfied with that solution. He had another idea: "Tiny screws and wheels were removed and lost in this frantic search," Ms. Fraiberg wrote. "...Finally, this limping monster issued its dying croak and succumbed without giving up its secret."
After a couple of years, the youngster’s "drive to investigate" was motivated by factors other than anxiety. Instead, he found investigation, discovery, and reconstruction to be pleasures in themselves. Interestingly, this child grew up to be a physicist.
There are many lessons here for psychoanalysts and our patients. One is that children experience things in which adults have no conscious memory. This means that we can help patients become better parents if we can get them to empathize with the child’s fears and frustrations.
Attachment, active handling
Ms. Fraiberg tells the story of an infant who developed an extremely severe sleep disturbance when she was 8 months old. Around 11 p.m. nightly, the infant woke up screaming, despite her parents’ efforts to calm her down. When her parents checked on her, the baby clung to her mother.
The episodes started after the baby woke up one night when the parents were out and had left her in the care of a babysitter. These meltdowns came in contrast to the child’s earlier reactions to her parents’ absence: "She never seemed to mind before if she wakened and saw a babysitter instead of us," Ms. Fraiberg quotes the parents as saying. "We just didn’t expect anything like this." What might explain this sudden new reaction?
"We know that the attachment to the mother is especially strong at this stage of development and a strange face may disturb the child at this age, even when encountered in the daytime," she writes. "The reaction to the strange face, as we have seen, is an indication of the discrimination of the mother as a person and the recognition of her as the person who gives satisfactions and protection. The stranger’s face that appears when mother’s face is expected produces anxiety because it symbolizes the absence or loss of the mother."
As you can see from that scenario, Ms. Fraiberg lets the mother know how essential she is and how early the child is distressed by the mother’s disappearance. In general, some people argue that they have to go on with their lives and that the baby will have to learn to be away from their mothers. We have to help our patients understand that the learning process is a burden for the infant. Some kids take a long time to learn how to separate from mom. Ms. Fraiberg helped the baby under discussion overcome her anxiety through nursery games in which her mother would hide her face one minute and return the next. She said the game allowed the baby to "work out the problem in her waking hours so that gradually the sleep disturbance disappeared."
Ms. Fraiberg also applies psychoanalytic theory to explain why a 9-month-old with a healthy appetite stopped eating and went on what she calls a "food strike" that lasted for 3 days. The child’s mother – who wanted the meals to be neat and orderly events – had been feeding the baby. So what brought the strike to an end?
One day the child’s father took over the feeding, and to the parents’ surprise, the baby started eating again. The mother immediately blamed herself, but the child’s behavior had nothing to do with her, per se. When the baby’s father tried to feed him, he grabbed the spoon and "plastered his face with strained carrots. Papa seemed quite unconcerned." When the baby turned his cup upside down, allowing his milk to spill all over the floor, the father took the messiness in stride.
This scenario was in stark contrast to those that emerged when the baby’s mother was in charge. When the baby tried to snatch the spoon from his mother, she got an extra spoon. When he tried to play with his milk cup, she moved it out of reach. As soon as the baby’s father allowed him to have freedom in feeding himself, the strike ended.
The explanation for the baby’s behavior changes is rooted in child development theory, Ms. Fraiberg writes. "...A certain amount of active handling of objects is absolutely necessary for the child in discovering and learning about the world around him," she says.
The period of 18 months to 3 years is dominated by words. If the child wishes something, he will use whatever words he has learned up until then, not knowing that they might not have any relationship to what he’s wishing for. If he wants something, he demands it or screams. He does not have language that is precise in any way. He uses words that he hopes will satisfy his wishes.
When the child acquires the word "bye-bye," he "begins to take the departures of his parents with more grace." The acquisition of language also makes it possible for the child to show more self-control and plays a role in the formation of his conscience.
I consider myself a developmental psychiatrist, an area in which child development is essential to all therapeutic engagement. Much can be learned about the patient if we know about his childhood and parents. I often see the patient doing to his child what his parents did to him. Patients are always shocked when I point this out to them, and the process of understanding how they got to where they are occurs. I call it therapeutic living. The book is so important because it tries to help parents learn how to handle tough developmental moments and periods. The section on toilet training is classic.
Please read "The Magic Years," and get your colleagues and students to read it as well. Ms. Fraiberg was a true master of the analytic method.
Dr. Fink is a psychiatrist and consultant, and professor of psychiatry at Temple University, Philadelphia.
I recently ran into a colleague who asked me whether I was still writing my column. I said yes and that I was currently writing an article on Selma H. Fraiberg. His response, "You don’t hear that name very much anymore," disappointed me. I responded by saying whenever a colleague, friend, or family member is having a baby, I send them a copy of "The Magic Years" with a clear statement that both parents must read it. It is clearly the best book on child rearing ever written in my opinion.
Ms. Fraiberg, creator of "The Magic Years," was a master’s in social work–trained psychoanalyst affiliated with the department of psychiatry at the University of California, San Francisco, who translated numerous concepts about babies, parents, and the first few years of life with wonderful examples of the type of incidents that every parent faces. She was highly regarded 50 years ago and received a great deal of praise for her book. But, at that time, there was a lot of prejudice against nonmedical degree psychoanalysts, and her book was not regarded as highly as I believe it should have been.
When I was a resident, I was required to read "The Magic Years," understand it, and be able to discuss it. Our teachers were concerned that we were busy being residents but also having children, and we really had to understand child rearing so that we could serve as resources for our residents and our analytic trainees.
Ms. Fraiberg translated psychoanalytic theory into child-rearing guidance in the book by looking at three age ranges: the first 18 months, 18 months to 3 years, and 3-6 years. Some of the examples are still fresh today, even though the book was published originally in 1959.
Dr. T. Berry Brazelton, the renowned pediatrician, wrote an introduction to the 50th anniversary of the book (New York: Scribner, 2008) saying that Ms. Fraiberg "makes each stage of emotional and mental development come alive!" I agree wholeheartedly. Furthermore, I would say that the concepts in the book can inform psychiatrists in our efforts to help our patients. After all, raising children (and growing up) is fraught with pitfalls. As Freud said early in his career, there are three impossible professions: governing nations, raising children, and psychoanalysis.
How the magic unfolds
Parents are often confused by things that children do or say, imaginary friends and animals – frustrating the child by pointing out reality when the child needs that imaginary friend or animal to survive. To the child, these imaginary friends and animals are not silly at all. A good example is what a niece of Ms. Fraiberg’s called the "Laughing Tiger."
Her niece, who was 2 years, 8 months old at the time, created the Laughing Tiger and many other imaginary companions at a time when she was afraid of ferocious animals. The niece’s "imaginary tiger gives her a kind of control over a danger which earlier had left her helpless and anxious," Ms. Fraiberg wrote. Instead of viewing this companion as problematic, it makes more sense to see this use of imagination as a healthy sign. Indeed, the child "can maintain his human ties and his good contact with reality while he maintains his imaginary world," she writes. "Moreover, it can be demonstrated that the child’s contact with the real world is strengthened by his periodic excursions into fantasy."
Virtually every chapter of the book is filled with insights that explain how young children interpret their world, which makes it invaluable for new parents. As we all know too well, the pitfalls in raising a child and growing up are many. I have not referred back to it for personal reasons in recent years. After all, my children are 54, 52, and 50 years old. But my wife and I did make very liberal use of the book throughout the years – while all of our friends were using Dr. Spock to help them navigate the waters of child rearing.
Mastering fear
Ms. Fraiberg gently guides the reader in an understanding of the child’s developing mind, why they cry, why they have tantrums, why they use imagination and how to help mom deal with the child’s anxiety. Take the example of a 2-year-old who was afraid of the family vacuum cleaner. Some young children control their fear of what must seem like loud monsters to them by learning to control the switch. But this toddler, who was known for his tendency to carry around a pocket-size screwdriver, was not satisfied with that solution. He had another idea: "Tiny screws and wheels were removed and lost in this frantic search," Ms. Fraiberg wrote. "...Finally, this limping monster issued its dying croak and succumbed without giving up its secret."
After a couple of years, the youngster’s "drive to investigate" was motivated by factors other than anxiety. Instead, he found investigation, discovery, and reconstruction to be pleasures in themselves. Interestingly, this child grew up to be a physicist.
There are many lessons here for psychoanalysts and our patients. One is that children experience things in which adults have no conscious memory. This means that we can help patients become better parents if we can get them to empathize with the child’s fears and frustrations.
Attachment, active handling
Ms. Fraiberg tells the story of an infant who developed an extremely severe sleep disturbance when she was 8 months old. Around 11 p.m. nightly, the infant woke up screaming, despite her parents’ efforts to calm her down. When her parents checked on her, the baby clung to her mother.
The episodes started after the baby woke up one night when the parents were out and had left her in the care of a babysitter. These meltdowns came in contrast to the child’s earlier reactions to her parents’ absence: "She never seemed to mind before if she wakened and saw a babysitter instead of us," Ms. Fraiberg quotes the parents as saying. "We just didn’t expect anything like this." What might explain this sudden new reaction?
"We know that the attachment to the mother is especially strong at this stage of development and a strange face may disturb the child at this age, even when encountered in the daytime," she writes. "The reaction to the strange face, as we have seen, is an indication of the discrimination of the mother as a person and the recognition of her as the person who gives satisfactions and protection. The stranger’s face that appears when mother’s face is expected produces anxiety because it symbolizes the absence or loss of the mother."
As you can see from that scenario, Ms. Fraiberg lets the mother know how essential she is and how early the child is distressed by the mother’s disappearance. In general, some people argue that they have to go on with their lives and that the baby will have to learn to be away from their mothers. We have to help our patients understand that the learning process is a burden for the infant. Some kids take a long time to learn how to separate from mom. Ms. Fraiberg helped the baby under discussion overcome her anxiety through nursery games in which her mother would hide her face one minute and return the next. She said the game allowed the baby to "work out the problem in her waking hours so that gradually the sleep disturbance disappeared."
Ms. Fraiberg also applies psychoanalytic theory to explain why a 9-month-old with a healthy appetite stopped eating and went on what she calls a "food strike" that lasted for 3 days. The child’s mother – who wanted the meals to be neat and orderly events – had been feeding the baby. So what brought the strike to an end?
One day the child’s father took over the feeding, and to the parents’ surprise, the baby started eating again. The mother immediately blamed herself, but the child’s behavior had nothing to do with her, per se. When the baby’s father tried to feed him, he grabbed the spoon and "plastered his face with strained carrots. Papa seemed quite unconcerned." When the baby turned his cup upside down, allowing his milk to spill all over the floor, the father took the messiness in stride.
This scenario was in stark contrast to those that emerged when the baby’s mother was in charge. When the baby tried to snatch the spoon from his mother, she got an extra spoon. When he tried to play with his milk cup, she moved it out of reach. As soon as the baby’s father allowed him to have freedom in feeding himself, the strike ended.
The explanation for the baby’s behavior changes is rooted in child development theory, Ms. Fraiberg writes. "...A certain amount of active handling of objects is absolutely necessary for the child in discovering and learning about the world around him," she says.
The period of 18 months to 3 years is dominated by words. If the child wishes something, he will use whatever words he has learned up until then, not knowing that they might not have any relationship to what he’s wishing for. If he wants something, he demands it or screams. He does not have language that is precise in any way. He uses words that he hopes will satisfy his wishes.
When the child acquires the word "bye-bye," he "begins to take the departures of his parents with more grace." The acquisition of language also makes it possible for the child to show more self-control and plays a role in the formation of his conscience.
I consider myself a developmental psychiatrist, an area in which child development is essential to all therapeutic engagement. Much can be learned about the patient if we know about his childhood and parents. I often see the patient doing to his child what his parents did to him. Patients are always shocked when I point this out to them, and the process of understanding how they got to where they are occurs. I call it therapeutic living. The book is so important because it tries to help parents learn how to handle tough developmental moments and periods. The section on toilet training is classic.
Please read "The Magic Years," and get your colleagues and students to read it as well. Ms. Fraiberg was a true master of the analytic method.
Dr. Fink is a psychiatrist and consultant, and professor of psychiatry at Temple University, Philadelphia.
What will be our legacies?
Several weeks ago, I heard a talk by my good friend Joel Yager on the topic of legacies. He delivered it to a large group of psychiatric leaders who were in their 70s and 80s and might be concerned about how they will be remembered.
As I looked around the room, I realized that almost all present had some thoughts about this topic, and I got the impression that many of them had not resolved this problem within their own minds. However, it was clear that they all had struggled with this question. My impressions were confirmed by the tenor of the question-and-answer period that followed the presentation.
This month, I will be 80 years old. My father died when he was 70, so I consider my longevity to be quite an achievement. But clearly, longevity and legacy are very different. We have to have a methodology for figuring out what our legacy will be. Those of us who are really serious about trying to work this out must sit down and begin to make a list of what we’ve done, what counts, and what is important.
First of all, we have to look at the question from a personal point of view. I am proud of my sons and my daughter. As I’ve mentioned before, my oldest son is a psychiatrist – and I might have had something to do with his choice of a career. My other two sons – and my daughter – have chosen other paths to fulfillment, and I salute them for that.
When I think about the crowning part of my career, I might say, "I chaired three departments of psychiatry." Somehow, saying this doesn’t sound particularly impressive.
Joel asks us to respond to the question: "What are you most proud of?" I immediately responded by saying "being elected president of the APA," yet there are so many greater presidents who served than I. As a young psychiatrist, I met a few great psychiatrists who served as American Psychiatric Association president, including Francis Braceland, Karl Menninger, and Henry Brosin – men who had something to say and said it with their strength, stamina, and productivity. One interesting moment occurred when I was sent by the National Institute of Mental Health to do an evaluation of the programs at the Menninger Clinic in Topeka, Kan. It was freezing out, and I was being driven from one building to another when I saw a large man in a fur-collared coat emerge from one of the buildings, and my driver said: "That’s Dr. Karl out for his daily walk." For me, that is part of his legacy.
In thinking about our legacies, how do our writings, books, papers, articles, and essays figure into the picture? Certainly, the writing we do as part of our contribution to the field often helps to define our legacies. I’ve written one article that helped my career and our field, "The Enigma of Stigma," (Psychiatr. Ann. 1983;669-90). I delivered this article as a talk in 1982 at a meeting of the American College of Psychiatrists, and then I used the theme of defeating stigma during my tenure as APA president that same year. Out of the 270 articles I’ve written, that is the one I value the most.
I am also hoping that my work with medical students also will be part of my legacy.
At this point, I am asking myself: Should I focus on putting my life in order? Or should I keep plugging along and continue fighting against stigma on behalf of people with mental illness so that my kids will be able to say with pride: "He was my Dad"?
I think I’ll do both.
Dr. Fink is a psychiatrist and consultant in Philadelphia and professor of psychiatry at Temple University.
Several weeks ago, I heard a talk by my good friend Joel Yager on the topic of legacies. He delivered it to a large group of psychiatric leaders who were in their 70s and 80s and might be concerned about how they will be remembered.
As I looked around the room, I realized that almost all present had some thoughts about this topic, and I got the impression that many of them had not resolved this problem within their own minds. However, it was clear that they all had struggled with this question. My impressions were confirmed by the tenor of the question-and-answer period that followed the presentation.
This month, I will be 80 years old. My father died when he was 70, so I consider my longevity to be quite an achievement. But clearly, longevity and legacy are very different. We have to have a methodology for figuring out what our legacy will be. Those of us who are really serious about trying to work this out must sit down and begin to make a list of what we’ve done, what counts, and what is important.
First of all, we have to look at the question from a personal point of view. I am proud of my sons and my daughter. As I’ve mentioned before, my oldest son is a psychiatrist – and I might have had something to do with his choice of a career. My other two sons – and my daughter – have chosen other paths to fulfillment, and I salute them for that.
When I think about the crowning part of my career, I might say, "I chaired three departments of psychiatry." Somehow, saying this doesn’t sound particularly impressive.
Joel asks us to respond to the question: "What are you most proud of?" I immediately responded by saying "being elected president of the APA," yet there are so many greater presidents who served than I. As a young psychiatrist, I met a few great psychiatrists who served as American Psychiatric Association president, including Francis Braceland, Karl Menninger, and Henry Brosin – men who had something to say and said it with their strength, stamina, and productivity. One interesting moment occurred when I was sent by the National Institute of Mental Health to do an evaluation of the programs at the Menninger Clinic in Topeka, Kan. It was freezing out, and I was being driven from one building to another when I saw a large man in a fur-collared coat emerge from one of the buildings, and my driver said: "That’s Dr. Karl out for his daily walk." For me, that is part of his legacy.
In thinking about our legacies, how do our writings, books, papers, articles, and essays figure into the picture? Certainly, the writing we do as part of our contribution to the field often helps to define our legacies. I’ve written one article that helped my career and our field, "The Enigma of Stigma," (Psychiatr. Ann. 1983;669-90). I delivered this article as a talk in 1982 at a meeting of the American College of Psychiatrists, and then I used the theme of defeating stigma during my tenure as APA president that same year. Out of the 270 articles I’ve written, that is the one I value the most.
I am also hoping that my work with medical students also will be part of my legacy.
At this point, I am asking myself: Should I focus on putting my life in order? Or should I keep plugging along and continue fighting against stigma on behalf of people with mental illness so that my kids will be able to say with pride: "He was my Dad"?
I think I’ll do both.
Dr. Fink is a psychiatrist and consultant in Philadelphia and professor of psychiatry at Temple University.
Several weeks ago, I heard a talk by my good friend Joel Yager on the topic of legacies. He delivered it to a large group of psychiatric leaders who were in their 70s and 80s and might be concerned about how they will be remembered.
As I looked around the room, I realized that almost all present had some thoughts about this topic, and I got the impression that many of them had not resolved this problem within their own minds. However, it was clear that they all had struggled with this question. My impressions were confirmed by the tenor of the question-and-answer period that followed the presentation.
This month, I will be 80 years old. My father died when he was 70, so I consider my longevity to be quite an achievement. But clearly, longevity and legacy are very different. We have to have a methodology for figuring out what our legacy will be. Those of us who are really serious about trying to work this out must sit down and begin to make a list of what we’ve done, what counts, and what is important.
First of all, we have to look at the question from a personal point of view. I am proud of my sons and my daughter. As I’ve mentioned before, my oldest son is a psychiatrist – and I might have had something to do with his choice of a career. My other two sons – and my daughter – have chosen other paths to fulfillment, and I salute them for that.
When I think about the crowning part of my career, I might say, "I chaired three departments of psychiatry." Somehow, saying this doesn’t sound particularly impressive.
Joel asks us to respond to the question: "What are you most proud of?" I immediately responded by saying "being elected president of the APA," yet there are so many greater presidents who served than I. As a young psychiatrist, I met a few great psychiatrists who served as American Psychiatric Association president, including Francis Braceland, Karl Menninger, and Henry Brosin – men who had something to say and said it with their strength, stamina, and productivity. One interesting moment occurred when I was sent by the National Institute of Mental Health to do an evaluation of the programs at the Menninger Clinic in Topeka, Kan. It was freezing out, and I was being driven from one building to another when I saw a large man in a fur-collared coat emerge from one of the buildings, and my driver said: "That’s Dr. Karl out for his daily walk." For me, that is part of his legacy.
In thinking about our legacies, how do our writings, books, papers, articles, and essays figure into the picture? Certainly, the writing we do as part of our contribution to the field often helps to define our legacies. I’ve written one article that helped my career and our field, "The Enigma of Stigma," (Psychiatr. Ann. 1983;669-90). I delivered this article as a talk in 1982 at a meeting of the American College of Psychiatrists, and then I used the theme of defeating stigma during my tenure as APA president that same year. Out of the 270 articles I’ve written, that is the one I value the most.
I am also hoping that my work with medical students also will be part of my legacy.
At this point, I am asking myself: Should I focus on putting my life in order? Or should I keep plugging along and continue fighting against stigma on behalf of people with mental illness so that my kids will be able to say with pride: "He was my Dad"?
I think I’ll do both.
Dr. Fink is a psychiatrist and consultant in Philadelphia and professor of psychiatry at Temple University.
Eliminating bullying hinges on changing the culture
Concern is growing that adults in the United States are overreacting to bullying that takes place every day in schools and communities across the country. Some point with alarm to the enactment of antibullying laws in states such as Indiana, which – among other things – require the state’s department of education to develop guidelines to help schools and safe school communities establish bullying prevention programs.
Indiana’s antibullying law came in the wake of the horrific suicides of two adolescent girls. In one case, a 14-year-old West Lafayette, Ind., girl reportedly hanged herself in early April from a tree, after leaving a note addressed to her 8th-grade classmates that said, "Its [sic] bullying that killed me. Please get justice."
About 1 month later, a 14-year-old 7th-grader in Marion, Ind., reportedly committed suicide by using a tie to hang herself on a set a bleachers on her school grounds. The Marion girl’s family and friends cite bullying as the factor that motivated her to act.
For the victims, bullying is indeed a very serious problem. Young people don’t know where to go or what to do or whom to talk with about their dilemma. Far too often, the attacks on their fragile egos prove too much to bear. Those who do survive often suffer more severe mental health problems, such as long-term depression, poor mental and physical health, and suicidal thoughts, than do their peers who are not bullied.
Antibullying laws criticized
Emily Bazelon, a journalist and an attorney who some say has become an authority on bullying, has written a new book on the topic called "Sticks and Stones: Defeating the Culture of Bullying and Rediscovering the Power of Character and Empathy" (New York: Random House, 2013). In the book, Ms. Bazelon argues against antibullying laws that push toward criminalization and define bullying too broadly. She contends that much of the conflict that occurs between youngsters is something short of bullying and says she does not want to see bullies stigmatized.
As I’ve written before, being a bully is a strong predictor of delinquency. For example, a prospective study of 503 boys who were followed from ages 6 through 19 years found that the strongest predictor of delinquency was being a bully at age 10 years. More than 32% of bullies become delinquents, compared with 22.5% of nonbullies, the study showed (J. Aggress. Confl. Peace Res. 2011 [doi: 10.1108/17596591111132882]).
A more recent study of 5,614 adolescents aged 16-18 years conducted by researchers in Greece found no socioeconomic associations for victimization. However, they did find that lower school performance and unemployment of the father was far more likely among perpetrators and that "economic inactivity of the mother" was more likely in students who were both victims and perpetrators. "These results were largely confirmed when we focused on high frequency behaviors only," the researchers wrote (Child Adolesc. Psychiatry Ment. Health 2012;6:8). "In addition, being overweight increased the risk of frequent victimization."
I agree with Ms. Bazelon that criminalizing bullying is going too far and overpolicing children is wrong. We are not a police state, and we do not want children growing up fearing that they will be arrested for "being kids." Ms. Bazelon is correct on that score. Legislators are not child development experts and often go too far.
There are ways to approach the problem, and spare the bully and the victim. The Olweus bullying prevention program, created by Dan Olweus, Ph.D., a Swedish psychologist, really works when all the players are brought together to change the culture so that bullying does not happen.
The method involves four basic rules. First, every adult, from the janitor to the principal, must agree to be part of this program. Second, the children have to be alerted at an assembly, and classroom discussions about every bullying event must take place in the school. Bullying meetings takes precedence over all other activities.
Third, the bully must become an antihero. The school has to learn that hurting smaller kids is a no-no and will stop. Currently, the bully is the hero; he uses his power and impresses many of the other children in the schoolyard.
Finally, schools must get the parents to buy into the process. This is the most difficult part of the Olweus project because, far too often, parents approve of bullying as a normal activity of children.
Does time really heal?
Many years ago, I was sitting across from my house on a Saturday morning, when a gang of kids saw me and one of them decided to make me his punching bag. I left that encounter with a black eye, a bloody nose, and a fat lip.
When I was able to slip away, I ran into my house, where my mother went to work trying to put my face back in some order. Meanwhile, my father kept pacing up and down the room, muttering, "Why didn’t you kick him in the crotch?" over and over again. I could have, but doing so never occurred to me. In my mind, the most important thing was to get away from the barrage of punches.
I can remember the incident very clearly, even though it occurred more than 65 years ago. The idea of defending yourself when you are being bullied clearly went from theory to my kitchen. The problem is that this kind of pressure from home only causes the intimidated, dominated victim to become more frightened and feel more humiliated by his or her classmates.
On the other hand, when the antibullying message comes from the top school administrator, the result can prove powerful, as my 5-year-old granddaughter recently learned.
It seems that my granddaughter, who is in kindergarten, told another girl in her class that she was not welcome to play with her and her group. Later that day, the principal called my granddaughter into her office and said. "We don’t do that here." My granddaughter was shocked, as was I when I heard about the incident from my daughter. Exclusion is the method most often used by girls when they bully a classmate.
Girls also are more likely to experience cyberbullying, and these results also can prove tragic. Recently, a 12-year-old girl in New York who was found hanged in her home reportedly left behind a suicide note that mentioned online bullying.
Bullying is a power game. The bully usually finds a kid he knows he can get the better of. He is bigger and dominates the victim, takes his lunch money, hits him, kicks the victim, or makes the victim do things that he will be ashamed of for many years to come. These kinds of events last in the victim’s mind for a long time. Sometimes, the bully makes the victim do things that they would be too embarrassed to tell anyone about which gets into the area of hazing, another form of bullying (Int. J. Adolesc. Med. Health 2008;20:235-9).
Both the bully and the victim get hurt. The bully begins to feel very powerful and thinks that he can do anything to anyone. It can be intoxicating for some kids and harmful to the school. The way in which he acts in class and speaks to the teacher emboldens the bully so that he begins to feel he has the power to dominate and control others.
Psychopathology grows out of bullying, as does youth murder. In my work in the area of preventing youth murder, bullying is often an antecedent to "going home to get a gun" and is one of the markers for actually committing the act of ending a life. I believe the bully sacrifices some of his humanity to the power and control he achieves in dominating others.
We have to do something to get kids to talk to one another. Can the bully learn the damage he does to the victim? A psychopath will laugh in the victim’s face, especially if the victim cries. Teenagers don’t usually have a capacity for expressing themselves, but the bully who has to hear about the extent to which he hurt others can learn a powerful lesson.
The Olweus system is not the only strategy that can be used to stop bullying, but it is considered the best. Everyone in the school must be work collaboratively in this effort. The key is to find a way to change the culture so that being a perpetrator, a victim – or even a bystander – is totally unacceptable.
We can do this!
Dr. Fink is a psychiatrist and consultant in Philadelphia and professor of psychiatry at Temple University.
Concern is growing that adults in the United States are overreacting to bullying that takes place every day in schools and communities across the country. Some point with alarm to the enactment of antibullying laws in states such as Indiana, which – among other things – require the state’s department of education to develop guidelines to help schools and safe school communities establish bullying prevention programs.
Indiana’s antibullying law came in the wake of the horrific suicides of two adolescent girls. In one case, a 14-year-old West Lafayette, Ind., girl reportedly hanged herself in early April from a tree, after leaving a note addressed to her 8th-grade classmates that said, "Its [sic] bullying that killed me. Please get justice."
About 1 month later, a 14-year-old 7th-grader in Marion, Ind., reportedly committed suicide by using a tie to hang herself on a set a bleachers on her school grounds. The Marion girl’s family and friends cite bullying as the factor that motivated her to act.
For the victims, bullying is indeed a very serious problem. Young people don’t know where to go or what to do or whom to talk with about their dilemma. Far too often, the attacks on their fragile egos prove too much to bear. Those who do survive often suffer more severe mental health problems, such as long-term depression, poor mental and physical health, and suicidal thoughts, than do their peers who are not bullied.
Antibullying laws criticized
Emily Bazelon, a journalist and an attorney who some say has become an authority on bullying, has written a new book on the topic called "Sticks and Stones: Defeating the Culture of Bullying and Rediscovering the Power of Character and Empathy" (New York: Random House, 2013). In the book, Ms. Bazelon argues against antibullying laws that push toward criminalization and define bullying too broadly. She contends that much of the conflict that occurs between youngsters is something short of bullying and says she does not want to see bullies stigmatized.
As I’ve written before, being a bully is a strong predictor of delinquency. For example, a prospective study of 503 boys who were followed from ages 6 through 19 years found that the strongest predictor of delinquency was being a bully at age 10 years. More than 32% of bullies become delinquents, compared with 22.5% of nonbullies, the study showed (J. Aggress. Confl. Peace Res. 2011 [doi: 10.1108/17596591111132882]).
A more recent study of 5,614 adolescents aged 16-18 years conducted by researchers in Greece found no socioeconomic associations for victimization. However, they did find that lower school performance and unemployment of the father was far more likely among perpetrators and that "economic inactivity of the mother" was more likely in students who were both victims and perpetrators. "These results were largely confirmed when we focused on high frequency behaviors only," the researchers wrote (Child Adolesc. Psychiatry Ment. Health 2012;6:8). "In addition, being overweight increased the risk of frequent victimization."
I agree with Ms. Bazelon that criminalizing bullying is going too far and overpolicing children is wrong. We are not a police state, and we do not want children growing up fearing that they will be arrested for "being kids." Ms. Bazelon is correct on that score. Legislators are not child development experts and often go too far.
There are ways to approach the problem, and spare the bully and the victim. The Olweus bullying prevention program, created by Dan Olweus, Ph.D., a Swedish psychologist, really works when all the players are brought together to change the culture so that bullying does not happen.
The method involves four basic rules. First, every adult, from the janitor to the principal, must agree to be part of this program. Second, the children have to be alerted at an assembly, and classroom discussions about every bullying event must take place in the school. Bullying meetings takes precedence over all other activities.
Third, the bully must become an antihero. The school has to learn that hurting smaller kids is a no-no and will stop. Currently, the bully is the hero; he uses his power and impresses many of the other children in the schoolyard.
Finally, schools must get the parents to buy into the process. This is the most difficult part of the Olweus project because, far too often, parents approve of bullying as a normal activity of children.
Does time really heal?
Many years ago, I was sitting across from my house on a Saturday morning, when a gang of kids saw me and one of them decided to make me his punching bag. I left that encounter with a black eye, a bloody nose, and a fat lip.
When I was able to slip away, I ran into my house, where my mother went to work trying to put my face back in some order. Meanwhile, my father kept pacing up and down the room, muttering, "Why didn’t you kick him in the crotch?" over and over again. I could have, but doing so never occurred to me. In my mind, the most important thing was to get away from the barrage of punches.
I can remember the incident very clearly, even though it occurred more than 65 years ago. The idea of defending yourself when you are being bullied clearly went from theory to my kitchen. The problem is that this kind of pressure from home only causes the intimidated, dominated victim to become more frightened and feel more humiliated by his or her classmates.
On the other hand, when the antibullying message comes from the top school administrator, the result can prove powerful, as my 5-year-old granddaughter recently learned.
It seems that my granddaughter, who is in kindergarten, told another girl in her class that she was not welcome to play with her and her group. Later that day, the principal called my granddaughter into her office and said. "We don’t do that here." My granddaughter was shocked, as was I when I heard about the incident from my daughter. Exclusion is the method most often used by girls when they bully a classmate.
Girls also are more likely to experience cyberbullying, and these results also can prove tragic. Recently, a 12-year-old girl in New York who was found hanged in her home reportedly left behind a suicide note that mentioned online bullying.
Bullying is a power game. The bully usually finds a kid he knows he can get the better of. He is bigger and dominates the victim, takes his lunch money, hits him, kicks the victim, or makes the victim do things that he will be ashamed of for many years to come. These kinds of events last in the victim’s mind for a long time. Sometimes, the bully makes the victim do things that they would be too embarrassed to tell anyone about which gets into the area of hazing, another form of bullying (Int. J. Adolesc. Med. Health 2008;20:235-9).
Both the bully and the victim get hurt. The bully begins to feel very powerful and thinks that he can do anything to anyone. It can be intoxicating for some kids and harmful to the school. The way in which he acts in class and speaks to the teacher emboldens the bully so that he begins to feel he has the power to dominate and control others.
Psychopathology grows out of bullying, as does youth murder. In my work in the area of preventing youth murder, bullying is often an antecedent to "going home to get a gun" and is one of the markers for actually committing the act of ending a life. I believe the bully sacrifices some of his humanity to the power and control he achieves in dominating others.
We have to do something to get kids to talk to one another. Can the bully learn the damage he does to the victim? A psychopath will laugh in the victim’s face, especially if the victim cries. Teenagers don’t usually have a capacity for expressing themselves, but the bully who has to hear about the extent to which he hurt others can learn a powerful lesson.
The Olweus system is not the only strategy that can be used to stop bullying, but it is considered the best. Everyone in the school must be work collaboratively in this effort. The key is to find a way to change the culture so that being a perpetrator, a victim – or even a bystander – is totally unacceptable.
We can do this!
Dr. Fink is a psychiatrist and consultant in Philadelphia and professor of psychiatry at Temple University.
Concern is growing that adults in the United States are overreacting to bullying that takes place every day in schools and communities across the country. Some point with alarm to the enactment of antibullying laws in states such as Indiana, which – among other things – require the state’s department of education to develop guidelines to help schools and safe school communities establish bullying prevention programs.
Indiana’s antibullying law came in the wake of the horrific suicides of two adolescent girls. In one case, a 14-year-old West Lafayette, Ind., girl reportedly hanged herself in early April from a tree, after leaving a note addressed to her 8th-grade classmates that said, "Its [sic] bullying that killed me. Please get justice."
About 1 month later, a 14-year-old 7th-grader in Marion, Ind., reportedly committed suicide by using a tie to hang herself on a set a bleachers on her school grounds. The Marion girl’s family and friends cite bullying as the factor that motivated her to act.
For the victims, bullying is indeed a very serious problem. Young people don’t know where to go or what to do or whom to talk with about their dilemma. Far too often, the attacks on their fragile egos prove too much to bear. Those who do survive often suffer more severe mental health problems, such as long-term depression, poor mental and physical health, and suicidal thoughts, than do their peers who are not bullied.
Antibullying laws criticized
Emily Bazelon, a journalist and an attorney who some say has become an authority on bullying, has written a new book on the topic called "Sticks and Stones: Defeating the Culture of Bullying and Rediscovering the Power of Character and Empathy" (New York: Random House, 2013). In the book, Ms. Bazelon argues against antibullying laws that push toward criminalization and define bullying too broadly. She contends that much of the conflict that occurs between youngsters is something short of bullying and says she does not want to see bullies stigmatized.
As I’ve written before, being a bully is a strong predictor of delinquency. For example, a prospective study of 503 boys who were followed from ages 6 through 19 years found that the strongest predictor of delinquency was being a bully at age 10 years. More than 32% of bullies become delinquents, compared with 22.5% of nonbullies, the study showed (J. Aggress. Confl. Peace Res. 2011 [doi: 10.1108/17596591111132882]).
A more recent study of 5,614 adolescents aged 16-18 years conducted by researchers in Greece found no socioeconomic associations for victimization. However, they did find that lower school performance and unemployment of the father was far more likely among perpetrators and that "economic inactivity of the mother" was more likely in students who were both victims and perpetrators. "These results were largely confirmed when we focused on high frequency behaviors only," the researchers wrote (Child Adolesc. Psychiatry Ment. Health 2012;6:8). "In addition, being overweight increased the risk of frequent victimization."
I agree with Ms. Bazelon that criminalizing bullying is going too far and overpolicing children is wrong. We are not a police state, and we do not want children growing up fearing that they will be arrested for "being kids." Ms. Bazelon is correct on that score. Legislators are not child development experts and often go too far.
There are ways to approach the problem, and spare the bully and the victim. The Olweus bullying prevention program, created by Dan Olweus, Ph.D., a Swedish psychologist, really works when all the players are brought together to change the culture so that bullying does not happen.
The method involves four basic rules. First, every adult, from the janitor to the principal, must agree to be part of this program. Second, the children have to be alerted at an assembly, and classroom discussions about every bullying event must take place in the school. Bullying meetings takes precedence over all other activities.
Third, the bully must become an antihero. The school has to learn that hurting smaller kids is a no-no and will stop. Currently, the bully is the hero; he uses his power and impresses many of the other children in the schoolyard.
Finally, schools must get the parents to buy into the process. This is the most difficult part of the Olweus project because, far too often, parents approve of bullying as a normal activity of children.
Does time really heal?
Many years ago, I was sitting across from my house on a Saturday morning, when a gang of kids saw me and one of them decided to make me his punching bag. I left that encounter with a black eye, a bloody nose, and a fat lip.
When I was able to slip away, I ran into my house, where my mother went to work trying to put my face back in some order. Meanwhile, my father kept pacing up and down the room, muttering, "Why didn’t you kick him in the crotch?" over and over again. I could have, but doing so never occurred to me. In my mind, the most important thing was to get away from the barrage of punches.
I can remember the incident very clearly, even though it occurred more than 65 years ago. The idea of defending yourself when you are being bullied clearly went from theory to my kitchen. The problem is that this kind of pressure from home only causes the intimidated, dominated victim to become more frightened and feel more humiliated by his or her classmates.
On the other hand, when the antibullying message comes from the top school administrator, the result can prove powerful, as my 5-year-old granddaughter recently learned.
It seems that my granddaughter, who is in kindergarten, told another girl in her class that she was not welcome to play with her and her group. Later that day, the principal called my granddaughter into her office and said. "We don’t do that here." My granddaughter was shocked, as was I when I heard about the incident from my daughter. Exclusion is the method most often used by girls when they bully a classmate.
Girls also are more likely to experience cyberbullying, and these results also can prove tragic. Recently, a 12-year-old girl in New York who was found hanged in her home reportedly left behind a suicide note that mentioned online bullying.
Bullying is a power game. The bully usually finds a kid he knows he can get the better of. He is bigger and dominates the victim, takes his lunch money, hits him, kicks the victim, or makes the victim do things that he will be ashamed of for many years to come. These kinds of events last in the victim’s mind for a long time. Sometimes, the bully makes the victim do things that they would be too embarrassed to tell anyone about which gets into the area of hazing, another form of bullying (Int. J. Adolesc. Med. Health 2008;20:235-9).
Both the bully and the victim get hurt. The bully begins to feel very powerful and thinks that he can do anything to anyone. It can be intoxicating for some kids and harmful to the school. The way in which he acts in class and speaks to the teacher emboldens the bully so that he begins to feel he has the power to dominate and control others.
Psychopathology grows out of bullying, as does youth murder. In my work in the area of preventing youth murder, bullying is often an antecedent to "going home to get a gun" and is one of the markers for actually committing the act of ending a life. I believe the bully sacrifices some of his humanity to the power and control he achieves in dominating others.
We have to do something to get kids to talk to one another. Can the bully learn the damage he does to the victim? A psychopath will laugh in the victim’s face, especially if the victim cries. Teenagers don’t usually have a capacity for expressing themselves, but the bully who has to hear about the extent to which he hurt others can learn a powerful lesson.
The Olweus system is not the only strategy that can be used to stop bullying, but it is considered the best. Everyone in the school must be work collaboratively in this effort. The key is to find a way to change the culture so that being a perpetrator, a victim – or even a bystander – is totally unacceptable.
We can do this!
Dr. Fink is a psychiatrist and consultant in Philadelphia and professor of psychiatry at Temple University.
Is developing a DSM-5 for primary care a good idea?
When I first learned that a DSM-5 for primary care physicians was underway, I thought this sounded like a reasonable and sensible idea. After all, most mental health diagnoses are made by family medicine doctors, internists, and pediatricians. And there is a primary care version of the DSM-IV. So why not continue to make it easier for these physicians to make the correct diagnosis and referrals to appropriate mental health specialists?
However, I continue to be disturbed by the idea that primary care physicians are equipped to treat patients with mental illness. First, primary care doctors generally know very little about serious mental illness. In fact, they probably know as much about our treatments as I know about treating cardiac disease. Our disorders require significant study and clinical experience, which the average primary care physician does not have.
Second, continuing the assumption that they understand illnesses we are trained to treat will continue to make our specialty less relevant. Over the last 50 years, we already ceded much of our profession, not only to medical doctors in other specialties but also to a host of mental health professionals with credentials ranging from bachelor’s degrees to doctorates. When psychoanalysis dominated psychiatry in America, our tendency was to invite everyone in to partake in the care of our patients. In the early 1960s and 1970s, big upheavals were occurring in the therapeutic and biological sides of psychiatry. The result is that we turned family and group therapy, as well as many other treatment modalities, over to the psychologists.
Furthermore, psychiatry failed to embrace electroconvulsive therapy as encouraged (Can. J. Psychiatry 2011;56:3-4) to do so by another great Fink (no relation, by the way). Also, cognitive-behavioral therapy and all of its ramifications were spurned by most practicing psychiatrists.
A patient whom I’ve treated for 7 or 8 years gradually overcame his post-traumatic stress disorder after discovering that his early life traumas had led to his condition. Toward the end of my work with him, he asked whether I would mind if he would go to see a therapist he heard of who used eye movement desensitization and reprocessing, or EMDR (Nurs. Times 2012;108:24-6). Of course I didn’t mind, I told him.
The patient came to his next appointment with me and announced that it would be his last. The psychologist had cured him. I congratulated the patient and sent him on his way, and did not try to convince him that the miracle was tied to our long, tedious work together. But I felt badly, and decided to go and find out about EMDR myself.
The psychologist was a delightful Ph.D. I tried out all of her gadgets, and I did get to relax. But I could not understand theoretically what was going on, nor did I tell her that was why I was there. Imagine how patients will feel being cared for by someone who does not do therapy, and uses lots of drugs, gadgetry, and pounds of reassurance. This is comparable to what could happen with primary care physicians who rely on their own version of the DSM. Over a period of years, those reading primary care versions might consider themselves proficient as therapists – with little or no basic grounding in the therapeutic process.
Being able to make a diagnosis is sometimes the smallest important part of the patient encounter. Perhaps requiring the primary care physician to take a course, or several courses for that matter, aimed at making the manual and subsequent activities clear, would allow for a deeper understanding about psychiatric treatments.
Early in my academic career, I was asked to prepare and give courses to nonpsychiatrists. Very few people signed up. The same people signed up year after year, and they never quite felt competent to do the work. The rest of the primary care physicians wanted courses in cardiology and other "more scientific" courses, which in many ways fit easier into their medical school education curricula.
Why do we want to give away our distinction as the diagnostician of mental disorders? Is this going to help psychiatry?
The fourth reason I’m opposed to this is economic. Why create a large cadre of competitors even greater than we have now? This will surely be converted by health insurance companies into a new reason to cut our fees even more and to work out more plans to include the GP on the team (after all, he knows the patient better than we do. There is so much he can contribute to a better understanding of the patient, his or her family, the context or circumstances of some of his or her behaviors, and so on).
I very much resented the splitting of therapy between the doctor and the nonphysician. Now I am surrounded by master-level psychologists and social workers (MSWs) whose practices are burgeoning. I am also told by many graduating residents that they are being hired by other personnel, psychiatrists, MSWs, and so on, into their practices. How does the primary care physician fit into this mix?
I can hear the telephone conversation now. The primary care physician calls up and says, "I have a patient I’d like to bring over for you to see." The psychiatrist says, "I can’t now. I’m seeing a patient." The primary care physician says, "Thanks. I’ll call Jim. I’m free now, and want to come over and sit with you to see if my diagnosis is correct. Goodbye." Suddenly, you’ve got a new partner, but his name is not on the door.
All the specialties in psychiatry could complicate the process further. Some psychiatrists might be uncomfortable saying to the primary care physician, "I don’t know much about geriatric psychiatry, so you take care of the elderly person." We could then turn over to primary care, other specialties such as addiction psychiatry. Where would it end?
Of course, there is a shortage of psychiatrists. And we do need to figure out how to expand the work force, perhaps with more residency slots. We could use an injection of funds from the federal government, like we got in 1969-1970. This injection enabled us to expand academic programs and make them better.
Finally, I am worried that this new diagnostic manual will encourage a greater use of psychotropics for a field that in 50 years has converted from 100% psychotherapy to one dominated by medications. Primary care physicians believe it’s their duty to give the patient a prescription at the end of each visit. These developments could mark the sad end of our proud profession.
I recently had a high fever and went to the emergency department. The first thing they did was to give me intravenous antibiotics. In the meantime, I spent 3 days in the hospital. The antibiotics did their work without me or my doctor having any idea why I got such a high fever. We never did find out the possible source of the infection.
Similarly, in our psychiatric EDs, if a patient comes in and says he’s hearing voices, he gets a shot of risperidone. By the time he is transported to another part of the hospital, the entire diagnostic process has been destroyed. The jump to medicines in general medicine and psychiatry is not good.
So, I am clearly opposed to the preparation and sale of this book. It could do more harm than good.
Dr. Fink is a psychiatrist and consultant in Philadelphia and professor of psychiatry at Temple University. He can be reached at [email protected]. This column, "Fink! Still at Large," appears regularly in Clinical Psychiatry News.
When I first learned that a DSM-5 for primary care physicians was underway, I thought this sounded like a reasonable and sensible idea. After all, most mental health diagnoses are made by family medicine doctors, internists, and pediatricians. And there is a primary care version of the DSM-IV. So why not continue to make it easier for these physicians to make the correct diagnosis and referrals to appropriate mental health specialists?
However, I continue to be disturbed by the idea that primary care physicians are equipped to treat patients with mental illness. First, primary care doctors generally know very little about serious mental illness. In fact, they probably know as much about our treatments as I know about treating cardiac disease. Our disorders require significant study and clinical experience, which the average primary care physician does not have.
Second, continuing the assumption that they understand illnesses we are trained to treat will continue to make our specialty less relevant. Over the last 50 years, we already ceded much of our profession, not only to medical doctors in other specialties but also to a host of mental health professionals with credentials ranging from bachelor’s degrees to doctorates. When psychoanalysis dominated psychiatry in America, our tendency was to invite everyone in to partake in the care of our patients. In the early 1960s and 1970s, big upheavals were occurring in the therapeutic and biological sides of psychiatry. The result is that we turned family and group therapy, as well as many other treatment modalities, over to the psychologists.
Furthermore, psychiatry failed to embrace electroconvulsive therapy as encouraged (Can. J. Psychiatry 2011;56:3-4) to do so by another great Fink (no relation, by the way). Also, cognitive-behavioral therapy and all of its ramifications were spurned by most practicing psychiatrists.
A patient whom I’ve treated for 7 or 8 years gradually overcame his post-traumatic stress disorder after discovering that his early life traumas had led to his condition. Toward the end of my work with him, he asked whether I would mind if he would go to see a therapist he heard of who used eye movement desensitization and reprocessing, or EMDR (Nurs. Times 2012;108:24-6). Of course I didn’t mind, I told him.
The patient came to his next appointment with me and announced that it would be his last. The psychologist had cured him. I congratulated the patient and sent him on his way, and did not try to convince him that the miracle was tied to our long, tedious work together. But I felt badly, and decided to go and find out about EMDR myself.
The psychologist was a delightful Ph.D. I tried out all of her gadgets, and I did get to relax. But I could not understand theoretically what was going on, nor did I tell her that was why I was there. Imagine how patients will feel being cared for by someone who does not do therapy, and uses lots of drugs, gadgetry, and pounds of reassurance. This is comparable to what could happen with primary care physicians who rely on their own version of the DSM. Over a period of years, those reading primary care versions might consider themselves proficient as therapists – with little or no basic grounding in the therapeutic process.
Being able to make a diagnosis is sometimes the smallest important part of the patient encounter. Perhaps requiring the primary care physician to take a course, or several courses for that matter, aimed at making the manual and subsequent activities clear, would allow for a deeper understanding about psychiatric treatments.
Early in my academic career, I was asked to prepare and give courses to nonpsychiatrists. Very few people signed up. The same people signed up year after year, and they never quite felt competent to do the work. The rest of the primary care physicians wanted courses in cardiology and other "more scientific" courses, which in many ways fit easier into their medical school education curricula.
Why do we want to give away our distinction as the diagnostician of mental disorders? Is this going to help psychiatry?
The fourth reason I’m opposed to this is economic. Why create a large cadre of competitors even greater than we have now? This will surely be converted by health insurance companies into a new reason to cut our fees even more and to work out more plans to include the GP on the team (after all, he knows the patient better than we do. There is so much he can contribute to a better understanding of the patient, his or her family, the context or circumstances of some of his or her behaviors, and so on).
I very much resented the splitting of therapy between the doctor and the nonphysician. Now I am surrounded by master-level psychologists and social workers (MSWs) whose practices are burgeoning. I am also told by many graduating residents that they are being hired by other personnel, psychiatrists, MSWs, and so on, into their practices. How does the primary care physician fit into this mix?
I can hear the telephone conversation now. The primary care physician calls up and says, "I have a patient I’d like to bring over for you to see." The psychiatrist says, "I can’t now. I’m seeing a patient." The primary care physician says, "Thanks. I’ll call Jim. I’m free now, and want to come over and sit with you to see if my diagnosis is correct. Goodbye." Suddenly, you’ve got a new partner, but his name is not on the door.
All the specialties in psychiatry could complicate the process further. Some psychiatrists might be uncomfortable saying to the primary care physician, "I don’t know much about geriatric psychiatry, so you take care of the elderly person." We could then turn over to primary care, other specialties such as addiction psychiatry. Where would it end?
Of course, there is a shortage of psychiatrists. And we do need to figure out how to expand the work force, perhaps with more residency slots. We could use an injection of funds from the federal government, like we got in 1969-1970. This injection enabled us to expand academic programs and make them better.
Finally, I am worried that this new diagnostic manual will encourage a greater use of psychotropics for a field that in 50 years has converted from 100% psychotherapy to one dominated by medications. Primary care physicians believe it’s their duty to give the patient a prescription at the end of each visit. These developments could mark the sad end of our proud profession.
I recently had a high fever and went to the emergency department. The first thing they did was to give me intravenous antibiotics. In the meantime, I spent 3 days in the hospital. The antibiotics did their work without me or my doctor having any idea why I got such a high fever. We never did find out the possible source of the infection.
Similarly, in our psychiatric EDs, if a patient comes in and says he’s hearing voices, he gets a shot of risperidone. By the time he is transported to another part of the hospital, the entire diagnostic process has been destroyed. The jump to medicines in general medicine and psychiatry is not good.
So, I am clearly opposed to the preparation and sale of this book. It could do more harm than good.
Dr. Fink is a psychiatrist and consultant in Philadelphia and professor of psychiatry at Temple University. He can be reached at [email protected]. This column, "Fink! Still at Large," appears regularly in Clinical Psychiatry News.
When I first learned that a DSM-5 for primary care physicians was underway, I thought this sounded like a reasonable and sensible idea. After all, most mental health diagnoses are made by family medicine doctors, internists, and pediatricians. And there is a primary care version of the DSM-IV. So why not continue to make it easier for these physicians to make the correct diagnosis and referrals to appropriate mental health specialists?
However, I continue to be disturbed by the idea that primary care physicians are equipped to treat patients with mental illness. First, primary care doctors generally know very little about serious mental illness. In fact, they probably know as much about our treatments as I know about treating cardiac disease. Our disorders require significant study and clinical experience, which the average primary care physician does not have.
Second, continuing the assumption that they understand illnesses we are trained to treat will continue to make our specialty less relevant. Over the last 50 years, we already ceded much of our profession, not only to medical doctors in other specialties but also to a host of mental health professionals with credentials ranging from bachelor’s degrees to doctorates. When psychoanalysis dominated psychiatry in America, our tendency was to invite everyone in to partake in the care of our patients. In the early 1960s and 1970s, big upheavals were occurring in the therapeutic and biological sides of psychiatry. The result is that we turned family and group therapy, as well as many other treatment modalities, over to the psychologists.
Furthermore, psychiatry failed to embrace electroconvulsive therapy as encouraged (Can. J. Psychiatry 2011;56:3-4) to do so by another great Fink (no relation, by the way). Also, cognitive-behavioral therapy and all of its ramifications were spurned by most practicing psychiatrists.
A patient whom I’ve treated for 7 or 8 years gradually overcame his post-traumatic stress disorder after discovering that his early life traumas had led to his condition. Toward the end of my work with him, he asked whether I would mind if he would go to see a therapist he heard of who used eye movement desensitization and reprocessing, or EMDR (Nurs. Times 2012;108:24-6). Of course I didn’t mind, I told him.
The patient came to his next appointment with me and announced that it would be his last. The psychologist had cured him. I congratulated the patient and sent him on his way, and did not try to convince him that the miracle was tied to our long, tedious work together. But I felt badly, and decided to go and find out about EMDR myself.
The psychologist was a delightful Ph.D. I tried out all of her gadgets, and I did get to relax. But I could not understand theoretically what was going on, nor did I tell her that was why I was there. Imagine how patients will feel being cared for by someone who does not do therapy, and uses lots of drugs, gadgetry, and pounds of reassurance. This is comparable to what could happen with primary care physicians who rely on their own version of the DSM. Over a period of years, those reading primary care versions might consider themselves proficient as therapists – with little or no basic grounding in the therapeutic process.
Being able to make a diagnosis is sometimes the smallest important part of the patient encounter. Perhaps requiring the primary care physician to take a course, or several courses for that matter, aimed at making the manual and subsequent activities clear, would allow for a deeper understanding about psychiatric treatments.
Early in my academic career, I was asked to prepare and give courses to nonpsychiatrists. Very few people signed up. The same people signed up year after year, and they never quite felt competent to do the work. The rest of the primary care physicians wanted courses in cardiology and other "more scientific" courses, which in many ways fit easier into their medical school education curricula.
Why do we want to give away our distinction as the diagnostician of mental disorders? Is this going to help psychiatry?
The fourth reason I’m opposed to this is economic. Why create a large cadre of competitors even greater than we have now? This will surely be converted by health insurance companies into a new reason to cut our fees even more and to work out more plans to include the GP on the team (after all, he knows the patient better than we do. There is so much he can contribute to a better understanding of the patient, his or her family, the context or circumstances of some of his or her behaviors, and so on).
I very much resented the splitting of therapy between the doctor and the nonphysician. Now I am surrounded by master-level psychologists and social workers (MSWs) whose practices are burgeoning. I am also told by many graduating residents that they are being hired by other personnel, psychiatrists, MSWs, and so on, into their practices. How does the primary care physician fit into this mix?
I can hear the telephone conversation now. The primary care physician calls up and says, "I have a patient I’d like to bring over for you to see." The psychiatrist says, "I can’t now. I’m seeing a patient." The primary care physician says, "Thanks. I’ll call Jim. I’m free now, and want to come over and sit with you to see if my diagnosis is correct. Goodbye." Suddenly, you’ve got a new partner, but his name is not on the door.
All the specialties in psychiatry could complicate the process further. Some psychiatrists might be uncomfortable saying to the primary care physician, "I don’t know much about geriatric psychiatry, so you take care of the elderly person." We could then turn over to primary care, other specialties such as addiction psychiatry. Where would it end?
Of course, there is a shortage of psychiatrists. And we do need to figure out how to expand the work force, perhaps with more residency slots. We could use an injection of funds from the federal government, like we got in 1969-1970. This injection enabled us to expand academic programs and make them better.
Finally, I am worried that this new diagnostic manual will encourage a greater use of psychotropics for a field that in 50 years has converted from 100% psychotherapy to one dominated by medications. Primary care physicians believe it’s their duty to give the patient a prescription at the end of each visit. These developments could mark the sad end of our proud profession.
I recently had a high fever and went to the emergency department. The first thing they did was to give me intravenous antibiotics. In the meantime, I spent 3 days in the hospital. The antibiotics did their work without me or my doctor having any idea why I got such a high fever. We never did find out the possible source of the infection.
Similarly, in our psychiatric EDs, if a patient comes in and says he’s hearing voices, he gets a shot of risperidone. By the time he is transported to another part of the hospital, the entire diagnostic process has been destroyed. The jump to medicines in general medicine and psychiatry is not good.
So, I am clearly opposed to the preparation and sale of this book. It could do more harm than good.
Dr. Fink is a psychiatrist and consultant in Philadelphia and professor of psychiatry at Temple University. He can be reached at [email protected]. This column, "Fink! Still at Large," appears regularly in Clinical Psychiatry News.
What should be the impact of the Newtown massacre on American psychiatry?
When America tries to make sense of irrational acts, very often, the question of mental illness arises. This question certainly arose after Adam Lanza committed the atrocity at Sandy Hook Elementary School in Newtown, Conn.
Typically, what happens after these kinds of horrific events is that commentators and others begin searching for clues to a diagnosis. In this case, Lanza’s older brother told authorities that his brother was autistic or had Asperger’s and a personality disorder.
Then came observations from people who actually knew nothing. They used words and phrases to describe the shooter such as "nonconformist," "distant," "couldn’t get to know him." Inevitably, others wondered whether Lanza suffered from undiagnosed schizophrenia. We have other diagnoses for people who act out violently and don’t need to lump everything into schizophrenia. And we try to treat these violent patients with a combination of drugs and psychotherapy.
The point is that such speculation allows the diagnosticians to begin to put together a story. What is the result of this speculation? Inevitably, it results in the stigma of mental illness and disdain for American psychiatry.
This is how the speculation goes: Why can’t we screen everyone and know who the potential killers are – and get the potential killers into therapy? We are elevated to the position of having the power to determine who is dangerous and who will hurt America. This back and forth usually sets off a rash of wise cracks about psychiatry. Once this ball gets rolling, no one is laughing.
The truth of the matter is this: The mentally ill are our weakest, most vulnerable citizens. And research clearly shows that they are more likely to be the victims of violence than are the perpetrators.
I’ve been fighting stigma for 3 decades, and I always think that we are making progress – until it starts all over again.
When some questions arose about the Virginia Tech and the Columbine shootings, we had to dig our way out of the castigations that took place at that time. I was invited to sit on a committee with all the presidents and deans of the 19 Pennsylvania universities. And I told them that the best they could do was to decide who was suspicious and watch that person for undue, negative behavior. They were frightened because after we are blamed, they are blamed.
What does it mean to fight stigma? One important lesson is that the mentally ill should be treated with as much dignity as any other human being is. I’m sad to say that we in the medical profession stigmatize the mentally ill, and we teach our students to do the same.
But the overarching problem is that people are afraid. They imagine that one of these horrific incidents will happen next in their neighborhood, and their parental instincts make them wonder how they might protect their children from the "crazy people" or lunatics. Once the stigma finger is pointed in our direction, we begin to see cartoons, late-night comedians, newspaper articles, and blog posts mocking our methodologies.
And what do we do? We defend ourselves by extolling our virtues, as well as the power of our new drugs and various therapies. Television news magazines broadcast exposés about our successes, perhaps with the help of medications. In the first 2 weeks after Newtown, we began to hear whining about cuts that psychiatry had sustained over the last 4-5 years in the recession, including budget cuts and the elimination of 3,222 psychiatric hospital beds.
Dr. Jeffrey Lieberman, president-elect of the American Psychiatric Association, addressed the access problem right after Newtown: "We have some treatments for mental illness that are highly effective, but they are not universally available," he was quoted as saying. "People don’t have much access to them."
Always on the defensive, that’s American psychiatry.
Indeed, a huge percentage of Americans are taking psychotropic drugs, but people want to hide their disabilities and avoid letting anyone know about them. Why? Because of stigma.
One idea that is becoming almost cliché is that our largest mental health facilities are the county jails. Why do we keep locking up people who are mentally ill? We could screen them in court and find far-less-expensive ways to help them with their basic problems, but we don’t. Instead, we blame.
Much can be done, but it will take committed, motivated people, including legislators and superintendents of prisons. I suppose that the only way to ever get a real collaborative effort is to experience the heartbreaking fallout from mass killings from time to time. We’ve seen the impact of Newtown on the gun-control debate, although the urgency of taking decisive steps on this front seems to be receding with the passage of time.
Again, one fact upon which all psychiatrists agree is that most seriously mentally ill patients are neither dangerous nor violent. But as I said above, generally, we can’t predict which ones will do something violent. We do know that patients with serious mental illness who are using alcohol and are provoked are more likely to act out in violent ways. If people know that a classmate or work colleague tends to act a bit strange, they don’t befriend or help him. Instead, they tend to isolate the person and avoid him, which further exacerbates his sense of isolation, paranoia, and anger.
It is imperative that we advocate for more psychiatric services. We need to train more psychiatrists. Our common goal must be to develop a true mental health system that works on behalf of patients with mental illness and their families.
Dr. Fink is a consultant and psychiatrist in Philadelphia and professor of psychiatry at Temple University. He can be reached at [email protected].
When America tries to make sense of irrational acts, very often, the question of mental illness arises. This question certainly arose after Adam Lanza committed the atrocity at Sandy Hook Elementary School in Newtown, Conn.
Typically, what happens after these kinds of horrific events is that commentators and others begin searching for clues to a diagnosis. In this case, Lanza’s older brother told authorities that his brother was autistic or had Asperger’s and a personality disorder.
Then came observations from people who actually knew nothing. They used words and phrases to describe the shooter such as "nonconformist," "distant," "couldn’t get to know him." Inevitably, others wondered whether Lanza suffered from undiagnosed schizophrenia. We have other diagnoses for people who act out violently and don’t need to lump everything into schizophrenia. And we try to treat these violent patients with a combination of drugs and psychotherapy.
The point is that such speculation allows the diagnosticians to begin to put together a story. What is the result of this speculation? Inevitably, it results in the stigma of mental illness and disdain for American psychiatry.
This is how the speculation goes: Why can’t we screen everyone and know who the potential killers are – and get the potential killers into therapy? We are elevated to the position of having the power to determine who is dangerous and who will hurt America. This back and forth usually sets off a rash of wise cracks about psychiatry. Once this ball gets rolling, no one is laughing.
The truth of the matter is this: The mentally ill are our weakest, most vulnerable citizens. And research clearly shows that they are more likely to be the victims of violence than are the perpetrators.
I’ve been fighting stigma for 3 decades, and I always think that we are making progress – until it starts all over again.
When some questions arose about the Virginia Tech and the Columbine shootings, we had to dig our way out of the castigations that took place at that time. I was invited to sit on a committee with all the presidents and deans of the 19 Pennsylvania universities. And I told them that the best they could do was to decide who was suspicious and watch that person for undue, negative behavior. They were frightened because after we are blamed, they are blamed.
What does it mean to fight stigma? One important lesson is that the mentally ill should be treated with as much dignity as any other human being is. I’m sad to say that we in the medical profession stigmatize the mentally ill, and we teach our students to do the same.
But the overarching problem is that people are afraid. They imagine that one of these horrific incidents will happen next in their neighborhood, and their parental instincts make them wonder how they might protect their children from the "crazy people" or lunatics. Once the stigma finger is pointed in our direction, we begin to see cartoons, late-night comedians, newspaper articles, and blog posts mocking our methodologies.
And what do we do? We defend ourselves by extolling our virtues, as well as the power of our new drugs and various therapies. Television news magazines broadcast exposés about our successes, perhaps with the help of medications. In the first 2 weeks after Newtown, we began to hear whining about cuts that psychiatry had sustained over the last 4-5 years in the recession, including budget cuts and the elimination of 3,222 psychiatric hospital beds.
Dr. Jeffrey Lieberman, president-elect of the American Psychiatric Association, addressed the access problem right after Newtown: "We have some treatments for mental illness that are highly effective, but they are not universally available," he was quoted as saying. "People don’t have much access to them."
Always on the defensive, that’s American psychiatry.
Indeed, a huge percentage of Americans are taking psychotropic drugs, but people want to hide their disabilities and avoid letting anyone know about them. Why? Because of stigma.
One idea that is becoming almost cliché is that our largest mental health facilities are the county jails. Why do we keep locking up people who are mentally ill? We could screen them in court and find far-less-expensive ways to help them with their basic problems, but we don’t. Instead, we blame.
Much can be done, but it will take committed, motivated people, including legislators and superintendents of prisons. I suppose that the only way to ever get a real collaborative effort is to experience the heartbreaking fallout from mass killings from time to time. We’ve seen the impact of Newtown on the gun-control debate, although the urgency of taking decisive steps on this front seems to be receding with the passage of time.
Again, one fact upon which all psychiatrists agree is that most seriously mentally ill patients are neither dangerous nor violent. But as I said above, generally, we can’t predict which ones will do something violent. We do know that patients with serious mental illness who are using alcohol and are provoked are more likely to act out in violent ways. If people know that a classmate or work colleague tends to act a bit strange, they don’t befriend or help him. Instead, they tend to isolate the person and avoid him, which further exacerbates his sense of isolation, paranoia, and anger.
It is imperative that we advocate for more psychiatric services. We need to train more psychiatrists. Our common goal must be to develop a true mental health system that works on behalf of patients with mental illness and their families.
Dr. Fink is a consultant and psychiatrist in Philadelphia and professor of psychiatry at Temple University. He can be reached at [email protected].
When America tries to make sense of irrational acts, very often, the question of mental illness arises. This question certainly arose after Adam Lanza committed the atrocity at Sandy Hook Elementary School in Newtown, Conn.
Typically, what happens after these kinds of horrific events is that commentators and others begin searching for clues to a diagnosis. In this case, Lanza’s older brother told authorities that his brother was autistic or had Asperger’s and a personality disorder.
Then came observations from people who actually knew nothing. They used words and phrases to describe the shooter such as "nonconformist," "distant," "couldn’t get to know him." Inevitably, others wondered whether Lanza suffered from undiagnosed schizophrenia. We have other diagnoses for people who act out violently and don’t need to lump everything into schizophrenia. And we try to treat these violent patients with a combination of drugs and psychotherapy.
The point is that such speculation allows the diagnosticians to begin to put together a story. What is the result of this speculation? Inevitably, it results in the stigma of mental illness and disdain for American psychiatry.
This is how the speculation goes: Why can’t we screen everyone and know who the potential killers are – and get the potential killers into therapy? We are elevated to the position of having the power to determine who is dangerous and who will hurt America. This back and forth usually sets off a rash of wise cracks about psychiatry. Once this ball gets rolling, no one is laughing.
The truth of the matter is this: The mentally ill are our weakest, most vulnerable citizens. And research clearly shows that they are more likely to be the victims of violence than are the perpetrators.
I’ve been fighting stigma for 3 decades, and I always think that we are making progress – until it starts all over again.
When some questions arose about the Virginia Tech and the Columbine shootings, we had to dig our way out of the castigations that took place at that time. I was invited to sit on a committee with all the presidents and deans of the 19 Pennsylvania universities. And I told them that the best they could do was to decide who was suspicious and watch that person for undue, negative behavior. They were frightened because after we are blamed, they are blamed.
What does it mean to fight stigma? One important lesson is that the mentally ill should be treated with as much dignity as any other human being is. I’m sad to say that we in the medical profession stigmatize the mentally ill, and we teach our students to do the same.
But the overarching problem is that people are afraid. They imagine that one of these horrific incidents will happen next in their neighborhood, and their parental instincts make them wonder how they might protect their children from the "crazy people" or lunatics. Once the stigma finger is pointed in our direction, we begin to see cartoons, late-night comedians, newspaper articles, and blog posts mocking our methodologies.
And what do we do? We defend ourselves by extolling our virtues, as well as the power of our new drugs and various therapies. Television news magazines broadcast exposés about our successes, perhaps with the help of medications. In the first 2 weeks after Newtown, we began to hear whining about cuts that psychiatry had sustained over the last 4-5 years in the recession, including budget cuts and the elimination of 3,222 psychiatric hospital beds.
Dr. Jeffrey Lieberman, president-elect of the American Psychiatric Association, addressed the access problem right after Newtown: "We have some treatments for mental illness that are highly effective, but they are not universally available," he was quoted as saying. "People don’t have much access to them."
Always on the defensive, that’s American psychiatry.
Indeed, a huge percentage of Americans are taking psychotropic drugs, but people want to hide their disabilities and avoid letting anyone know about them. Why? Because of stigma.
One idea that is becoming almost cliché is that our largest mental health facilities are the county jails. Why do we keep locking up people who are mentally ill? We could screen them in court and find far-less-expensive ways to help them with their basic problems, but we don’t. Instead, we blame.
Much can be done, but it will take committed, motivated people, including legislators and superintendents of prisons. I suppose that the only way to ever get a real collaborative effort is to experience the heartbreaking fallout from mass killings from time to time. We’ve seen the impact of Newtown on the gun-control debate, although the urgency of taking decisive steps on this front seems to be receding with the passage of time.
Again, one fact upon which all psychiatrists agree is that most seriously mentally ill patients are neither dangerous nor violent. But as I said above, generally, we can’t predict which ones will do something violent. We do know that patients with serious mental illness who are using alcohol and are provoked are more likely to act out in violent ways. If people know that a classmate or work colleague tends to act a bit strange, they don’t befriend or help him. Instead, they tend to isolate the person and avoid him, which further exacerbates his sense of isolation, paranoia, and anger.
It is imperative that we advocate for more psychiatric services. We need to train more psychiatrists. Our common goal must be to develop a true mental health system that works on behalf of patients with mental illness and their families.
Dr. Fink is a consultant and psychiatrist in Philadelphia and professor of psychiatry at Temple University. He can be reached at [email protected].
Making Sense of Violence at Psychiatric Hospitals
Three recent patient killings at a maximum security mental hospital in Maryland raise questions about prevention. What can be done to protect patients and staff in such hospitals?
I was dismayed to learn about the three tragic murders that took place in at the Clifton T. Perkins Hospital Center, a psychiatric state facility in Jessup, Md. The murders aroused a great deal of passion and discussion about why and how such things could happen amid so many safety precautions in psychiatric hospitals.
The occurrence of three such incidents within weeks of one another in the same hospital begs the question: "What is going on in that hospital?" It seems like a logical one that is being asked by all interested parties, particularly by the National Alliance on Mental Illness (NAMI) of Maryland.
In our search for a cause, I do not believe we can blame the hospital except with the issue of staff training. It is possible that the staff is unaware of what to look for when a patient is escalating; although, both patients with schizophrenia and those with mania give a lot of clues as they get angry or frustrated and feel the need to take it out on someone. Patients with paranoia are notorious for picking an enemy and relentlessly pursuing that person – usually not to his death – but with a great deal of violence. We also must keep in mind that as horrific as these incidents are, they are quite rare.
Each case must be looked at separately to discover underlying factors that led to the murder. In general, I think that certain provocations lead patients to act out against staff or other patients. And it is important to protect the patients and the staff from outbursts. This is best accomplished through staff training and in the daily groups that take place in most hospitals of this nature. Group meetings allow patients to report what they have observed, which is important data before something happens.
An Inadvertent Provocation
These issues remind me of an incident that occurred in my first year or residency about 55 years ago. It was in a private psychiatric hospital. I was in my office, which was located in a hallway leading to the patients’ day room in the recreation building.
At one point, I heard a sudden outburst of noise, so I went out to investigate. A large ring of people was yelling and jeering at a patient – who was in the middle of the ring. This fellow was my patient.
He was a very tall, muscular man with bleach-blond hair. The ring, it turns out, was made up of patients and staff. The patient looked very terrified.
I have no idea how I did it, but I walked right into the ring, took the patient by the arm, and led him into the building where his unit was located. We said nothing, but I think he was grateful to me for rescuing him. We walked up two flights of stairs, and I unlocked the door to his unit. Once safely in the unit, I made my mistake. I said very softly, "You know I’m going to have to take away your ground privileges."
He broke away from my grip on his arm, went over to the water fountain, which was electric and connected to pipes for the water. He ripped it off of its pipes and picked it up – that thing must have weighed about 250 pounds – and tossed it through the glass in the nursing station. Water was spritzing everywhere, and the staff was very upset. Ten attendants jumped on him, subdued him, and put him into the seclusion room. They had no idea that I had provoked the violent behavior. Over the years, I have reviewed this incident in my mind and have used it to teach residents not to provoke. It was clearly one of the stupidest things I’ve ever done.
I tried to analyze why I said it, and I feel sure it had to do with my own fear. Where did I get the guts to walk into the circle in the first place and get him back to his unit? I cannot comprehend this. Much of my behavior was tied to my effort to regain control of myself and the situation. Anyone reading this would know that that remark was gratuitous and totally unnecessary.
I tell the story to exemplify provocation. It does not have to be visible to everyone, but it strikes at weakness. Not only did the patient have the ignominy of being the target of bad treatment by 20-30 patients and staff members but had to be taken by the hand like a little boy to safety prior to my utterance. Over the years, I’ve realized that I was blaming him and further punishing him without even knowing what had initiated or instigated the event in the day room.
So, it is essential for us to try to understand the issue of provocation and learn how to avoid it. In this case, I did the American thing: I blamed the victim and punished him more for something with which he might have had nothing to do. Our job as a staff in a psychiatric hospital, school, or a court is to determine the facts and to help the patient – not provoke him.
If I were to investigate the murders at Perkins Hospital in Maryland, I would see whether we could find out what provoked these patients. They weren’t on alcohol or drugs. And we know that patients with serious mental illness are not generally violent. Something happened in each case that led to the violent outbursts and to the deaths.
NAMI of Maryland has become involved in this problem, and the organization has said some things that are valid and important, such as calling for "a specific focus on missing warning signs that may have existed, treatments and interventions that might have prevented the tragedy." It is looking for some general provocation or medication that can be blamed. I am suggesting that the problem lies in human error. Just as in my example, small units can make a huge difference. I might have gotten thrown into the nursing station instead of the water fountain. Our goal must be to find simple solutions to complex problems.
Another possible cause for the violence might lie in the relationship of the patients to one another. I can recall a patient who looked dangerous and scary to everyone. Who would share his bedroom? He was wild looking; the hair on his head and face made him look like someone out of a movie – scary and violent. He was not the kind of patient you would ask to sit down for an informal conversation. I can recall visitors commenting on his frightening appearance and asking that he not be put in the same room as their son or their husband.
NAMI released a statement after the third killing in Maryland. At one point, it reads: "In general, people with serious mental illness are not violent. Acts of violence are exceptional. When violence does occur, it is generally a sign that something has gone terribly wrong." These are important truths. As we try to better understand what went wrong in the hospital, we have to keep in mind that we are trying to deal with human beings who have gone out of control.
What grudge does one of these patients have against the other? Living in the tight quarters of a psychiatric unit, a great deal can happen or be said that might cause the other person to nurse a grudge and carry out his nefarious plan days or weeks later. The existence of three incidents within a year in the same institution looks very suspicious. The first thought people will have is that something is going wrong in the hospital. Some might speculate that a psychiatric attendant is being cruel to the patients, or something along those lines. Such speculation would be wrong, as I have said. We have to be fair, despite our zeal to find an explanation.
A Call for Compassion
For the last 20 years we have truly attempted to humanize the hospital care of serious mentally ill patients. We have closed large state hospitals, made smaller institutions, gotten rid of seclusion and restraint, and done away with many of the punitive treatment methods that we used decades ago. In hospitals that used to have hundreds of patients, there was never enough staff to care for them in a humane way. By and large, that is a condition that has been corrected throughout the United States.
Hospitalization of patients with serious mental illness is becoming rarer nowadays. The length of stays is short, and hospitalization is used for "stabilization" of the patient and rather than cure, as we used to do years ago. This change should reduce violence in the hospital. I am often the doctor in our hospital who suggests keeping the patient a little longer to try to better understand his or her condition and circumstances. I don’t like to discharge patients when we’ve done nothing for them and have no way to protect them when they are out in a public domain and are much more likely to be to provoked by family and friends in the street.
The basic question is: How can we prevent violent behavior from occurring in maximum security state hospitals? There are, in many states, state hospitals for the criminally insane that are dangerous places. Farview State Hospital in Waymart, Pa., was considered one such hospital. (It has been repurposed as a correctional facility.)
Here are a few rules aimed at reducing the kind of violence that occurred at the hospital in Maryland:
• Be sure that staff is sensitive and able to talk to patients.
• Train staff to recognize patient escalation and to search for causes before the explosion.
• Carefully select patients who are housed together on a unit. Do not risk mixing patients who truly look like they’re going to explode.
• Discharge patients who are troublemakers.
• Use daily group sessions of patients to discuss staff concerns about violence, and so on. We have learned over the last few decades to include patients in unit decision making.
These are just a few suggestions. All of us in psychiatry must pay attention to these problems. When events like this occur, they increase the stigma against psychiatry and exacerbate the ridicule too often heaped on us and our patients. So this is a community issue, and EVERY psychiatrist has a role to play in trying to discover a solution.
Dr. Fink is a psychiatrist and consultant in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia.
Three recent patient killings at a maximum security mental hospital in Maryland raise questions about prevention. What can be done to protect patients and staff in such hospitals?
I was dismayed to learn about the three tragic murders that took place in at the Clifton T. Perkins Hospital Center, a psychiatric state facility in Jessup, Md. The murders aroused a great deal of passion and discussion about why and how such things could happen amid so many safety precautions in psychiatric hospitals.
The occurrence of three such incidents within weeks of one another in the same hospital begs the question: "What is going on in that hospital?" It seems like a logical one that is being asked by all interested parties, particularly by the National Alliance on Mental Illness (NAMI) of Maryland.
In our search for a cause, I do not believe we can blame the hospital except with the issue of staff training. It is possible that the staff is unaware of what to look for when a patient is escalating; although, both patients with schizophrenia and those with mania give a lot of clues as they get angry or frustrated and feel the need to take it out on someone. Patients with paranoia are notorious for picking an enemy and relentlessly pursuing that person – usually not to his death – but with a great deal of violence. We also must keep in mind that as horrific as these incidents are, they are quite rare.
Each case must be looked at separately to discover underlying factors that led to the murder. In general, I think that certain provocations lead patients to act out against staff or other patients. And it is important to protect the patients and the staff from outbursts. This is best accomplished through staff training and in the daily groups that take place in most hospitals of this nature. Group meetings allow patients to report what they have observed, which is important data before something happens.
An Inadvertent Provocation
These issues remind me of an incident that occurred in my first year or residency about 55 years ago. It was in a private psychiatric hospital. I was in my office, which was located in a hallway leading to the patients’ day room in the recreation building.
At one point, I heard a sudden outburst of noise, so I went out to investigate. A large ring of people was yelling and jeering at a patient – who was in the middle of the ring. This fellow was my patient.
He was a very tall, muscular man with bleach-blond hair. The ring, it turns out, was made up of patients and staff. The patient looked very terrified.
I have no idea how I did it, but I walked right into the ring, took the patient by the arm, and led him into the building where his unit was located. We said nothing, but I think he was grateful to me for rescuing him. We walked up two flights of stairs, and I unlocked the door to his unit. Once safely in the unit, I made my mistake. I said very softly, "You know I’m going to have to take away your ground privileges."
He broke away from my grip on his arm, went over to the water fountain, which was electric and connected to pipes for the water. He ripped it off of its pipes and picked it up – that thing must have weighed about 250 pounds – and tossed it through the glass in the nursing station. Water was spritzing everywhere, and the staff was very upset. Ten attendants jumped on him, subdued him, and put him into the seclusion room. They had no idea that I had provoked the violent behavior. Over the years, I have reviewed this incident in my mind and have used it to teach residents not to provoke. It was clearly one of the stupidest things I’ve ever done.
I tried to analyze why I said it, and I feel sure it had to do with my own fear. Where did I get the guts to walk into the circle in the first place and get him back to his unit? I cannot comprehend this. Much of my behavior was tied to my effort to regain control of myself and the situation. Anyone reading this would know that that remark was gratuitous and totally unnecessary.
I tell the story to exemplify provocation. It does not have to be visible to everyone, but it strikes at weakness. Not only did the patient have the ignominy of being the target of bad treatment by 20-30 patients and staff members but had to be taken by the hand like a little boy to safety prior to my utterance. Over the years, I’ve realized that I was blaming him and further punishing him without even knowing what had initiated or instigated the event in the day room.
So, it is essential for us to try to understand the issue of provocation and learn how to avoid it. In this case, I did the American thing: I blamed the victim and punished him more for something with which he might have had nothing to do. Our job as a staff in a psychiatric hospital, school, or a court is to determine the facts and to help the patient – not provoke him.
If I were to investigate the murders at Perkins Hospital in Maryland, I would see whether we could find out what provoked these patients. They weren’t on alcohol or drugs. And we know that patients with serious mental illness are not generally violent. Something happened in each case that led to the violent outbursts and to the deaths.
NAMI of Maryland has become involved in this problem, and the organization has said some things that are valid and important, such as calling for "a specific focus on missing warning signs that may have existed, treatments and interventions that might have prevented the tragedy." It is looking for some general provocation or medication that can be blamed. I am suggesting that the problem lies in human error. Just as in my example, small units can make a huge difference. I might have gotten thrown into the nursing station instead of the water fountain. Our goal must be to find simple solutions to complex problems.
Another possible cause for the violence might lie in the relationship of the patients to one another. I can recall a patient who looked dangerous and scary to everyone. Who would share his bedroom? He was wild looking; the hair on his head and face made him look like someone out of a movie – scary and violent. He was not the kind of patient you would ask to sit down for an informal conversation. I can recall visitors commenting on his frightening appearance and asking that he not be put in the same room as their son or their husband.
NAMI released a statement after the third killing in Maryland. At one point, it reads: "In general, people with serious mental illness are not violent. Acts of violence are exceptional. When violence does occur, it is generally a sign that something has gone terribly wrong." These are important truths. As we try to better understand what went wrong in the hospital, we have to keep in mind that we are trying to deal with human beings who have gone out of control.
What grudge does one of these patients have against the other? Living in the tight quarters of a psychiatric unit, a great deal can happen or be said that might cause the other person to nurse a grudge and carry out his nefarious plan days or weeks later. The existence of three incidents within a year in the same institution looks very suspicious. The first thought people will have is that something is going wrong in the hospital. Some might speculate that a psychiatric attendant is being cruel to the patients, or something along those lines. Such speculation would be wrong, as I have said. We have to be fair, despite our zeal to find an explanation.
A Call for Compassion
For the last 20 years we have truly attempted to humanize the hospital care of serious mentally ill patients. We have closed large state hospitals, made smaller institutions, gotten rid of seclusion and restraint, and done away with many of the punitive treatment methods that we used decades ago. In hospitals that used to have hundreds of patients, there was never enough staff to care for them in a humane way. By and large, that is a condition that has been corrected throughout the United States.
Hospitalization of patients with serious mental illness is becoming rarer nowadays. The length of stays is short, and hospitalization is used for "stabilization" of the patient and rather than cure, as we used to do years ago. This change should reduce violence in the hospital. I am often the doctor in our hospital who suggests keeping the patient a little longer to try to better understand his or her condition and circumstances. I don’t like to discharge patients when we’ve done nothing for them and have no way to protect them when they are out in a public domain and are much more likely to be to provoked by family and friends in the street.
The basic question is: How can we prevent violent behavior from occurring in maximum security state hospitals? There are, in many states, state hospitals for the criminally insane that are dangerous places. Farview State Hospital in Waymart, Pa., was considered one such hospital. (It has been repurposed as a correctional facility.)
Here are a few rules aimed at reducing the kind of violence that occurred at the hospital in Maryland:
• Be sure that staff is sensitive and able to talk to patients.
• Train staff to recognize patient escalation and to search for causes before the explosion.
• Carefully select patients who are housed together on a unit. Do not risk mixing patients who truly look like they’re going to explode.
• Discharge patients who are troublemakers.
• Use daily group sessions of patients to discuss staff concerns about violence, and so on. We have learned over the last few decades to include patients in unit decision making.
These are just a few suggestions. All of us in psychiatry must pay attention to these problems. When events like this occur, they increase the stigma against psychiatry and exacerbate the ridicule too often heaped on us and our patients. So this is a community issue, and EVERY psychiatrist has a role to play in trying to discover a solution.
Dr. Fink is a psychiatrist and consultant in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia.
Three recent patient killings at a maximum security mental hospital in Maryland raise questions about prevention. What can be done to protect patients and staff in such hospitals?
I was dismayed to learn about the three tragic murders that took place in at the Clifton T. Perkins Hospital Center, a psychiatric state facility in Jessup, Md. The murders aroused a great deal of passion and discussion about why and how such things could happen amid so many safety precautions in psychiatric hospitals.
The occurrence of three such incidents within weeks of one another in the same hospital begs the question: "What is going on in that hospital?" It seems like a logical one that is being asked by all interested parties, particularly by the National Alliance on Mental Illness (NAMI) of Maryland.
In our search for a cause, I do not believe we can blame the hospital except with the issue of staff training. It is possible that the staff is unaware of what to look for when a patient is escalating; although, both patients with schizophrenia and those with mania give a lot of clues as they get angry or frustrated and feel the need to take it out on someone. Patients with paranoia are notorious for picking an enemy and relentlessly pursuing that person – usually not to his death – but with a great deal of violence. We also must keep in mind that as horrific as these incidents are, they are quite rare.
Each case must be looked at separately to discover underlying factors that led to the murder. In general, I think that certain provocations lead patients to act out against staff or other patients. And it is important to protect the patients and the staff from outbursts. This is best accomplished through staff training and in the daily groups that take place in most hospitals of this nature. Group meetings allow patients to report what they have observed, which is important data before something happens.
An Inadvertent Provocation
These issues remind me of an incident that occurred in my first year or residency about 55 years ago. It was in a private psychiatric hospital. I was in my office, which was located in a hallway leading to the patients’ day room in the recreation building.
At one point, I heard a sudden outburst of noise, so I went out to investigate. A large ring of people was yelling and jeering at a patient – who was in the middle of the ring. This fellow was my patient.
He was a very tall, muscular man with bleach-blond hair. The ring, it turns out, was made up of patients and staff. The patient looked very terrified.
I have no idea how I did it, but I walked right into the ring, took the patient by the arm, and led him into the building where his unit was located. We said nothing, but I think he was grateful to me for rescuing him. We walked up two flights of stairs, and I unlocked the door to his unit. Once safely in the unit, I made my mistake. I said very softly, "You know I’m going to have to take away your ground privileges."
He broke away from my grip on his arm, went over to the water fountain, which was electric and connected to pipes for the water. He ripped it off of its pipes and picked it up – that thing must have weighed about 250 pounds – and tossed it through the glass in the nursing station. Water was spritzing everywhere, and the staff was very upset. Ten attendants jumped on him, subdued him, and put him into the seclusion room. They had no idea that I had provoked the violent behavior. Over the years, I have reviewed this incident in my mind and have used it to teach residents not to provoke. It was clearly one of the stupidest things I’ve ever done.
I tried to analyze why I said it, and I feel sure it had to do with my own fear. Where did I get the guts to walk into the circle in the first place and get him back to his unit? I cannot comprehend this. Much of my behavior was tied to my effort to regain control of myself and the situation. Anyone reading this would know that that remark was gratuitous and totally unnecessary.
I tell the story to exemplify provocation. It does not have to be visible to everyone, but it strikes at weakness. Not only did the patient have the ignominy of being the target of bad treatment by 20-30 patients and staff members but had to be taken by the hand like a little boy to safety prior to my utterance. Over the years, I’ve realized that I was blaming him and further punishing him without even knowing what had initiated or instigated the event in the day room.
So, it is essential for us to try to understand the issue of provocation and learn how to avoid it. In this case, I did the American thing: I blamed the victim and punished him more for something with which he might have had nothing to do. Our job as a staff in a psychiatric hospital, school, or a court is to determine the facts and to help the patient – not provoke him.
If I were to investigate the murders at Perkins Hospital in Maryland, I would see whether we could find out what provoked these patients. They weren’t on alcohol or drugs. And we know that patients with serious mental illness are not generally violent. Something happened in each case that led to the violent outbursts and to the deaths.
NAMI of Maryland has become involved in this problem, and the organization has said some things that are valid and important, such as calling for "a specific focus on missing warning signs that may have existed, treatments and interventions that might have prevented the tragedy." It is looking for some general provocation or medication that can be blamed. I am suggesting that the problem lies in human error. Just as in my example, small units can make a huge difference. I might have gotten thrown into the nursing station instead of the water fountain. Our goal must be to find simple solutions to complex problems.
Another possible cause for the violence might lie in the relationship of the patients to one another. I can recall a patient who looked dangerous and scary to everyone. Who would share his bedroom? He was wild looking; the hair on his head and face made him look like someone out of a movie – scary and violent. He was not the kind of patient you would ask to sit down for an informal conversation. I can recall visitors commenting on his frightening appearance and asking that he not be put in the same room as their son or their husband.
NAMI released a statement after the third killing in Maryland. At one point, it reads: "In general, people with serious mental illness are not violent. Acts of violence are exceptional. When violence does occur, it is generally a sign that something has gone terribly wrong." These are important truths. As we try to better understand what went wrong in the hospital, we have to keep in mind that we are trying to deal with human beings who have gone out of control.
What grudge does one of these patients have against the other? Living in the tight quarters of a psychiatric unit, a great deal can happen or be said that might cause the other person to nurse a grudge and carry out his nefarious plan days or weeks later. The existence of three incidents within a year in the same institution looks very suspicious. The first thought people will have is that something is going wrong in the hospital. Some might speculate that a psychiatric attendant is being cruel to the patients, or something along those lines. Such speculation would be wrong, as I have said. We have to be fair, despite our zeal to find an explanation.
A Call for Compassion
For the last 20 years we have truly attempted to humanize the hospital care of serious mentally ill patients. We have closed large state hospitals, made smaller institutions, gotten rid of seclusion and restraint, and done away with many of the punitive treatment methods that we used decades ago. In hospitals that used to have hundreds of patients, there was never enough staff to care for them in a humane way. By and large, that is a condition that has been corrected throughout the United States.
Hospitalization of patients with serious mental illness is becoming rarer nowadays. The length of stays is short, and hospitalization is used for "stabilization" of the patient and rather than cure, as we used to do years ago. This change should reduce violence in the hospital. I am often the doctor in our hospital who suggests keeping the patient a little longer to try to better understand his or her condition and circumstances. I don’t like to discharge patients when we’ve done nothing for them and have no way to protect them when they are out in a public domain and are much more likely to be to provoked by family and friends in the street.
The basic question is: How can we prevent violent behavior from occurring in maximum security state hospitals? There are, in many states, state hospitals for the criminally insane that are dangerous places. Farview State Hospital in Waymart, Pa., was considered one such hospital. (It has been repurposed as a correctional facility.)
Here are a few rules aimed at reducing the kind of violence that occurred at the hospital in Maryland:
• Be sure that staff is sensitive and able to talk to patients.
• Train staff to recognize patient escalation and to search for causes before the explosion.
• Carefully select patients who are housed together on a unit. Do not risk mixing patients who truly look like they’re going to explode.
• Discharge patients who are troublemakers.
• Use daily group sessions of patients to discuss staff concerns about violence, and so on. We have learned over the last few decades to include patients in unit decision making.
These are just a few suggestions. All of us in psychiatry must pay attention to these problems. When events like this occur, they increase the stigma against psychiatry and exacerbate the ridicule too often heaped on us and our patients. So this is a community issue, and EVERY psychiatrist has a role to play in trying to discover a solution.
Dr. Fink is a psychiatrist and consultant in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia.
Another Complication of Asperger's: Prison?
A Virginia case involving an adolescent with Asperger’s who faces a 10-year prison sentence for assault raises questions about whether society can protect the impaired. What strategies can psychiatrists give patients to help them control their aggression?
It is difficult to grasp the complexities of this case. A statement from the Stafford County, Va., sheriff’s office says that the adolescent was charged with several counts, including one count of "knowingly disarming a police officer in performance of his official duties," after assaulting the officer last year in the parking lot of a high school.
According to the statement, a call came into the county’s sheriff’s office one morning last May saying that a "suspicious male," possibly in possession of a gun, was sitting on the grass outside a library, which was directly across from an elementary school. When police units arrived on the scene, they were unable to find the young man. At 20 minutes into the search, the statement says, a school resource officer saw the young man coming out of the woods behind the high school. When the officer asked for identification, the teenager reportedly "proceeded to attack and assault the deputy for no apparent reason."
After other officers arrived on the scene, the teenager was taken into custody, and the officer was transported to a hospital with a head laceration, cuts, abrasions, and a broken ankle. The officer reportedly had to retire because of his injuries. A gun was never found.
The young man, who is black and had been diagnosed with Asperger’s disorder and "pervasive developmental disorder – not otherwise specified," according to his mother’s blog, eventually was found guilty of assaulting a law enforcement officer. A jury recommended that he serve a 10.5-year sentence; as of this writing, he is scheduled to be sentenced on May 19.
This is one of those heart-wrenching cases that make us wish that the general public had a better understanding of mental illness, particularly disorders such as Asperger’s. Why would a person with a disability receive such a harsh sentence? Why did the officer fail to recognize that the young man was disturbed? What role did race play in the way the incident unfolded?
Press reports say that the young man’s mother is distraught and that she has received a great deal of support from the community to try to get her son freed. But the symbols of man’s inhumanity to man are emblazoned all over this case.
Asperger’s syndrome is characterized by occasional aggressive outbursts; poor social skills; failure to develop peer relationships; abnormal, nonverbal communication; and numerous other nuances. The failure to develop social skills would make a child in school an easy person to victimize. Children and adolescents with special needs are among the groups that are at great risk of being bullied, according to a paper published recently by Robin M. Kowalski, Ph.D., (Res. Autism Spectr. Disord. 2011 [doi:10.1016/jrasd.2011.01.007]). However, sorting through these issues is particularly challenging when it comes to young people with autism spectrum disorders, because often they are bullies themselves.
In fact, Dr. Kowalski found that – because these young people are able to use all kinds of electronic devices – they are both cyberbullied and cyberbullies. Of course, all kinds of bullying involve an imbalance of power. The failure of some people with Asperger’s to read social cues is critical. "Children with Asperger’s ... often fail to pick up on social cues that would allow for fluent social interactions, often lack verbal fluency, are frequently overly sensitive to particular auditory or tactile sensations, and are unyielding in their need for a routine, characteristics that make them likely candidates for bullying by others who see them as odd and different," she wrote. These patients "frequently behave in aggressive ways, which increases the probability that they might perpetrate bullying behaviors."
Asperger’s is difficult to treat, but some strategies have been identified that address some of the problematic behaviors these patients exhibit. For example, according to researchers in Virginia, a mindfulness-based strategy can help adolescents with Asperger’s shift their focus from the negative emotion triggered by the aggressive behavior to a neutral stimulus: the soles of their feet (Res. Autism Spectr. Disord. 2011;5:1103-9).
The study was very small – just three adolescent boys with Asperger’s participated. All had been on new-generation antipsychotics at least one time before enrolling in the study. All three showed minimal aggressive behaviors at school, but their parents found that they were unable to manage their aggressive behaviors at home or during community outings.
The boys’ mothers were trained to use the technique, called Soles of the Feet (SoF), 1 month before the beginning of baseline. For the first 5 days of the intervention, the researchers reported, each mother taught her son to use the procedure in daily 15-minute sessions. In some cases, the patients remained aggression free for 4 years.
In the SoF meditation, which is very concrete, the participant with severe mental limitations follows a series of steps that essentially wipe out his feelings of aggression. The person meditating is asked to divert attention from an emotionally arousing thought, event, or situation to a neutral part of the body. The individual is able to stop, focus his mind on his body, calm down, be in the present moment, and then make an informed choice about how to react to the thought, event, or situation that has triggered an arousal response.
I found the description of the SoF meditation interesting therapeutically, because the strategy builds on the idea that the Asperger’s syndrome patient has the ability to make choices. This technique also seems like a refinement of ideas advanced by my good friend Aaron (Tim) Beck, developer of cognitive-behavioral therapy (CBT).
These studies raise numerous questions for those of us in psychiatry. We are seeing a remarkable growth in the number of children diagnosed with Asperger’s syndrome, and it is now estimated that 10,000 children have autism and/or Asperger’s. This is a significant number. We know that there has been an expediential growth in the number of children diagnosed with autism, and I suspect we will see more Asperger’s syndrome as time goes by. We also should expect to find a great many adults with Asperger’s syndrome who have suffered with it their entire lives. That means that we can no longer make an assessment of mental retardation in every patient who lacks social skills. Asperger’s syndrome patients have the capacity to reason, learn, and think. However, we are woefully ignorant of their cognitive capabilities and skills. Finally, psychiatrists and other physicians have to learn more about autism and Asperger’s syndrome in order to keep up with the times.
The Virginia case raises several questions for us about the criminal justice system and how it responds to people with behaviors that are not understood. We’ll never know what exactly happened that day in Stafford County. But we do know that one of the problems with illnesses related to autism is that "even innocent behaviors can come off as malicious" ("Is Sitting While Autistic a Crime?" Newsweek, July 8, 2010). Cynics like to say that the largest mental hospital in America is the Los Angeles County Jail, where the cost of incarceration is close to $40,000 per patient. We have to get those in need of mental health care who are housed in our jails into treatment settings, where they can get the attention and medication that they need.
As humanists and caring physicians, we in psychiatry must educate the public about how mental illness works. This tragic case is a good example of our failure to do so in the law-enforcement community. We have to protect those whose conditions make it either tough or impossible for them to protect themselves.
Dr. Fink is a psychiatrist and consultant in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia. He has no conflicts of interest to disclose.
A Virginia case involving an adolescent with Asperger’s who faces a 10-year prison sentence for assault raises questions about whether society can protect the impaired. What strategies can psychiatrists give patients to help them control their aggression?
It is difficult to grasp the complexities of this case. A statement from the Stafford County, Va., sheriff’s office says that the adolescent was charged with several counts, including one count of "knowingly disarming a police officer in performance of his official duties," after assaulting the officer last year in the parking lot of a high school.
According to the statement, a call came into the county’s sheriff’s office one morning last May saying that a "suspicious male," possibly in possession of a gun, was sitting on the grass outside a library, which was directly across from an elementary school. When police units arrived on the scene, they were unable to find the young man. At 20 minutes into the search, the statement says, a school resource officer saw the young man coming out of the woods behind the high school. When the officer asked for identification, the teenager reportedly "proceeded to attack and assault the deputy for no apparent reason."
After other officers arrived on the scene, the teenager was taken into custody, and the officer was transported to a hospital with a head laceration, cuts, abrasions, and a broken ankle. The officer reportedly had to retire because of his injuries. A gun was never found.
The young man, who is black and had been diagnosed with Asperger’s disorder and "pervasive developmental disorder – not otherwise specified," according to his mother’s blog, eventually was found guilty of assaulting a law enforcement officer. A jury recommended that he serve a 10.5-year sentence; as of this writing, he is scheduled to be sentenced on May 19.
This is one of those heart-wrenching cases that make us wish that the general public had a better understanding of mental illness, particularly disorders such as Asperger’s. Why would a person with a disability receive such a harsh sentence? Why did the officer fail to recognize that the young man was disturbed? What role did race play in the way the incident unfolded?
Press reports say that the young man’s mother is distraught and that she has received a great deal of support from the community to try to get her son freed. But the symbols of man’s inhumanity to man are emblazoned all over this case.
Asperger’s syndrome is characterized by occasional aggressive outbursts; poor social skills; failure to develop peer relationships; abnormal, nonverbal communication; and numerous other nuances. The failure to develop social skills would make a child in school an easy person to victimize. Children and adolescents with special needs are among the groups that are at great risk of being bullied, according to a paper published recently by Robin M. Kowalski, Ph.D., (Res. Autism Spectr. Disord. 2011 [doi:10.1016/jrasd.2011.01.007]). However, sorting through these issues is particularly challenging when it comes to young people with autism spectrum disorders, because often they are bullies themselves.
In fact, Dr. Kowalski found that – because these young people are able to use all kinds of electronic devices – they are both cyberbullied and cyberbullies. Of course, all kinds of bullying involve an imbalance of power. The failure of some people with Asperger’s to read social cues is critical. "Children with Asperger’s ... often fail to pick up on social cues that would allow for fluent social interactions, often lack verbal fluency, are frequently overly sensitive to particular auditory or tactile sensations, and are unyielding in their need for a routine, characteristics that make them likely candidates for bullying by others who see them as odd and different," she wrote. These patients "frequently behave in aggressive ways, which increases the probability that they might perpetrate bullying behaviors."
Asperger’s is difficult to treat, but some strategies have been identified that address some of the problematic behaviors these patients exhibit. For example, according to researchers in Virginia, a mindfulness-based strategy can help adolescents with Asperger’s shift their focus from the negative emotion triggered by the aggressive behavior to a neutral stimulus: the soles of their feet (Res. Autism Spectr. Disord. 2011;5:1103-9).
The study was very small – just three adolescent boys with Asperger’s participated. All had been on new-generation antipsychotics at least one time before enrolling in the study. All three showed minimal aggressive behaviors at school, but their parents found that they were unable to manage their aggressive behaviors at home or during community outings.
The boys’ mothers were trained to use the technique, called Soles of the Feet (SoF), 1 month before the beginning of baseline. For the first 5 days of the intervention, the researchers reported, each mother taught her son to use the procedure in daily 15-minute sessions. In some cases, the patients remained aggression free for 4 years.
In the SoF meditation, which is very concrete, the participant with severe mental limitations follows a series of steps that essentially wipe out his feelings of aggression. The person meditating is asked to divert attention from an emotionally arousing thought, event, or situation to a neutral part of the body. The individual is able to stop, focus his mind on his body, calm down, be in the present moment, and then make an informed choice about how to react to the thought, event, or situation that has triggered an arousal response.
I found the description of the SoF meditation interesting therapeutically, because the strategy builds on the idea that the Asperger’s syndrome patient has the ability to make choices. This technique also seems like a refinement of ideas advanced by my good friend Aaron (Tim) Beck, developer of cognitive-behavioral therapy (CBT).
These studies raise numerous questions for those of us in psychiatry. We are seeing a remarkable growth in the number of children diagnosed with Asperger’s syndrome, and it is now estimated that 10,000 children have autism and/or Asperger’s. This is a significant number. We know that there has been an expediential growth in the number of children diagnosed with autism, and I suspect we will see more Asperger’s syndrome as time goes by. We also should expect to find a great many adults with Asperger’s syndrome who have suffered with it their entire lives. That means that we can no longer make an assessment of mental retardation in every patient who lacks social skills. Asperger’s syndrome patients have the capacity to reason, learn, and think. However, we are woefully ignorant of their cognitive capabilities and skills. Finally, psychiatrists and other physicians have to learn more about autism and Asperger’s syndrome in order to keep up with the times.
The Virginia case raises several questions for us about the criminal justice system and how it responds to people with behaviors that are not understood. We’ll never know what exactly happened that day in Stafford County. But we do know that one of the problems with illnesses related to autism is that "even innocent behaviors can come off as malicious" ("Is Sitting While Autistic a Crime?" Newsweek, July 8, 2010). Cynics like to say that the largest mental hospital in America is the Los Angeles County Jail, where the cost of incarceration is close to $40,000 per patient. We have to get those in need of mental health care who are housed in our jails into treatment settings, where they can get the attention and medication that they need.
As humanists and caring physicians, we in psychiatry must educate the public about how mental illness works. This tragic case is a good example of our failure to do so in the law-enforcement community. We have to protect those whose conditions make it either tough or impossible for them to protect themselves.
Dr. Fink is a psychiatrist and consultant in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia. He has no conflicts of interest to disclose.
A Virginia case involving an adolescent with Asperger’s who faces a 10-year prison sentence for assault raises questions about whether society can protect the impaired. What strategies can psychiatrists give patients to help them control their aggression?
It is difficult to grasp the complexities of this case. A statement from the Stafford County, Va., sheriff’s office says that the adolescent was charged with several counts, including one count of "knowingly disarming a police officer in performance of his official duties," after assaulting the officer last year in the parking lot of a high school.
According to the statement, a call came into the county’s sheriff’s office one morning last May saying that a "suspicious male," possibly in possession of a gun, was sitting on the grass outside a library, which was directly across from an elementary school. When police units arrived on the scene, they were unable to find the young man. At 20 minutes into the search, the statement says, a school resource officer saw the young man coming out of the woods behind the high school. When the officer asked for identification, the teenager reportedly "proceeded to attack and assault the deputy for no apparent reason."
After other officers arrived on the scene, the teenager was taken into custody, and the officer was transported to a hospital with a head laceration, cuts, abrasions, and a broken ankle. The officer reportedly had to retire because of his injuries. A gun was never found.
The young man, who is black and had been diagnosed with Asperger’s disorder and "pervasive developmental disorder – not otherwise specified," according to his mother’s blog, eventually was found guilty of assaulting a law enforcement officer. A jury recommended that he serve a 10.5-year sentence; as of this writing, he is scheduled to be sentenced on May 19.
This is one of those heart-wrenching cases that make us wish that the general public had a better understanding of mental illness, particularly disorders such as Asperger’s. Why would a person with a disability receive such a harsh sentence? Why did the officer fail to recognize that the young man was disturbed? What role did race play in the way the incident unfolded?
Press reports say that the young man’s mother is distraught and that she has received a great deal of support from the community to try to get her son freed. But the symbols of man’s inhumanity to man are emblazoned all over this case.
Asperger’s syndrome is characterized by occasional aggressive outbursts; poor social skills; failure to develop peer relationships; abnormal, nonverbal communication; and numerous other nuances. The failure to develop social skills would make a child in school an easy person to victimize. Children and adolescents with special needs are among the groups that are at great risk of being bullied, according to a paper published recently by Robin M. Kowalski, Ph.D., (Res. Autism Spectr. Disord. 2011 [doi:10.1016/jrasd.2011.01.007]). However, sorting through these issues is particularly challenging when it comes to young people with autism spectrum disorders, because often they are bullies themselves.
In fact, Dr. Kowalski found that – because these young people are able to use all kinds of electronic devices – they are both cyberbullied and cyberbullies. Of course, all kinds of bullying involve an imbalance of power. The failure of some people with Asperger’s to read social cues is critical. "Children with Asperger’s ... often fail to pick up on social cues that would allow for fluent social interactions, often lack verbal fluency, are frequently overly sensitive to particular auditory or tactile sensations, and are unyielding in their need for a routine, characteristics that make them likely candidates for bullying by others who see them as odd and different," she wrote. These patients "frequently behave in aggressive ways, which increases the probability that they might perpetrate bullying behaviors."
Asperger’s is difficult to treat, but some strategies have been identified that address some of the problematic behaviors these patients exhibit. For example, according to researchers in Virginia, a mindfulness-based strategy can help adolescents with Asperger’s shift their focus from the negative emotion triggered by the aggressive behavior to a neutral stimulus: the soles of their feet (Res. Autism Spectr. Disord. 2011;5:1103-9).
The study was very small – just three adolescent boys with Asperger’s participated. All had been on new-generation antipsychotics at least one time before enrolling in the study. All three showed minimal aggressive behaviors at school, but their parents found that they were unable to manage their aggressive behaviors at home or during community outings.
The boys’ mothers were trained to use the technique, called Soles of the Feet (SoF), 1 month before the beginning of baseline. For the first 5 days of the intervention, the researchers reported, each mother taught her son to use the procedure in daily 15-minute sessions. In some cases, the patients remained aggression free for 4 years.
In the SoF meditation, which is very concrete, the participant with severe mental limitations follows a series of steps that essentially wipe out his feelings of aggression. The person meditating is asked to divert attention from an emotionally arousing thought, event, or situation to a neutral part of the body. The individual is able to stop, focus his mind on his body, calm down, be in the present moment, and then make an informed choice about how to react to the thought, event, or situation that has triggered an arousal response.
I found the description of the SoF meditation interesting therapeutically, because the strategy builds on the idea that the Asperger’s syndrome patient has the ability to make choices. This technique also seems like a refinement of ideas advanced by my good friend Aaron (Tim) Beck, developer of cognitive-behavioral therapy (CBT).
These studies raise numerous questions for those of us in psychiatry. We are seeing a remarkable growth in the number of children diagnosed with Asperger’s syndrome, and it is now estimated that 10,000 children have autism and/or Asperger’s. This is a significant number. We know that there has been an expediential growth in the number of children diagnosed with autism, and I suspect we will see more Asperger’s syndrome as time goes by. We also should expect to find a great many adults with Asperger’s syndrome who have suffered with it their entire lives. That means that we can no longer make an assessment of mental retardation in every patient who lacks social skills. Asperger’s syndrome patients have the capacity to reason, learn, and think. However, we are woefully ignorant of their cognitive capabilities and skills. Finally, psychiatrists and other physicians have to learn more about autism and Asperger’s syndrome in order to keep up with the times.
The Virginia case raises several questions for us about the criminal justice system and how it responds to people with behaviors that are not understood. We’ll never know what exactly happened that day in Stafford County. But we do know that one of the problems with illnesses related to autism is that "even innocent behaviors can come off as malicious" ("Is Sitting While Autistic a Crime?" Newsweek, July 8, 2010). Cynics like to say that the largest mental hospital in America is the Los Angeles County Jail, where the cost of incarceration is close to $40,000 per patient. We have to get those in need of mental health care who are housed in our jails into treatment settings, where they can get the attention and medication that they need.
As humanists and caring physicians, we in psychiatry must educate the public about how mental illness works. This tragic case is a good example of our failure to do so in the law-enforcement community. We have to protect those whose conditions make it either tough or impossible for them to protect themselves.
Dr. Fink is a psychiatrist and consultant in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia. He has no conflicts of interest to disclose.
Another Complication of Asperger's: Prison?
A Virginia case involving an adolescent with Asperger’s who faces a 10-year prison sentence for assault raises questions about whether society can protect the impaired. What strategies can psychiatrists give patients to help them control their aggression?
It is difficult to grasp the complexities of this case. A statement from the Stafford County, Va., sheriff’s office says that the adolescent was charged with several counts, including one count of "knowingly disarming a police officer in performance of his official duties," after assaulting the officer last year in the parking lot of a high school.
According to the statement, a call came into the county’s sheriff’s office one morning last May saying that a "suspicious male," possibly in possession of a gun, was sitting on the grass outside a library, which was directly across from an elementary school. When police units arrived on the scene, they were unable to find the young man. At 20 minutes into the search, the statement says, a school resource officer saw the young man coming out of the woods behind the high school. When the officer asked for identification, the teenager reportedly "proceeded to attack and assault the deputy for no apparent reason."
After other officers arrived on the scene, the teenager was taken into custody, and the officer was transported to a hospital with a head laceration, cuts, abrasions, and a broken ankle. The officer reportedly had to retire because of his injuries. A gun was never found.
The young man, who is black and had been diagnosed with Asperger’s disorder and "pervasive developmental disorder – not otherwise specified," according to his mother’s blog, eventually was found guilty of assaulting a law enforcement officer. A jury recommended that he serve a 10.5-year sentence; as of this writing, he is scheduled to be sentenced on May 19.
This is one of those heart-wrenching cases that make us wish that the general public had a better understanding of mental illness, particularly disorders such as Asperger’s. Why would a person with a disability receive such a harsh sentence? Why did the officer fail to recognize that the young man was disturbed? What role did race play in the way the incident unfolded?
Press reports say that the young man’s mother is distraught and that she has received a great deal of support from the community to try to get her son freed. But the symbols of man’s inhumanity to man are emblazoned all over this case.
Asperger’s syndrome is characterized by occasional aggressive outbursts; poor social skills; failure to develop peer relationships; abnormal, nonverbal communication; and numerous other nuances. The failure to develop social skills would make a child in school an easy person to victimize. Children and adolescents with special needs are among the groups that are at great risk of being bullied, according to a paper published recently by Robin M. Kowalski, Ph.D., (Res. Autism Spectr. Disord. 2011 [doi:10.1016/jrasd.2011.01.007]). However, sorting through these issues is particularly challenging when it comes to young people with autism spectrum disorders, because often they are bullies themselves.
In fact, Dr. Kowalski found that – because these young people are able to use all kinds of electronic devices – they are both cyberbullied and cyberbullies. Of course, all kinds of bullying involve an imbalance of power. The failure of some people with Asperger’s to read social cues is critical. "Children with Asperger’s ... often fail to pick up on social cues that would allow for fluent social interactions, often lack verbal fluency, are frequently overly sensitive to particular auditory or tactile sensations, and are unyielding in their need for a routine, characteristics that make them likely candidates for bullying by others who see them as odd and different," she wrote. These patients "frequently behave in aggressive ways, which increases the probability that they might perpetrate bullying behaviors."
Asperger’s is difficult to treat, but some strategies have been identified that address some of the problematic behaviors these patients exhibit. For example, according to researchers in Virginia, a mindfulness-based strategy can help adolescents with Asperger’s shift their focus from the negative emotion triggered by the aggressive behavior to a neutral stimulus: the soles of their feet (Res. Autism Spectr. Disord. 2011;5:1103-9).
The study was very small – just three adolescent boys with Asperger’s participated. All had been on new-generation antipsychotics at least one time before enrolling in the study. All three showed minimal aggressive behaviors at school, but their parents found that they were unable to manage their aggressive behaviors at home or during community outings.
The boys’ mothers were trained to use the technique, called Soles of the Feet (SoF), 1 month before the beginning of baseline. For the first 5 days of the intervention, the researchers reported, each mother taught her son to use the procedure in daily 15-minute sessions. In some cases, the patients remained aggression free for 4 years.
In the SoF meditation, which is very concrete, the participant with severe mental limitations follows a series of steps that essentially wipe out his feelings of aggression. The person meditating is asked to divert attention from an emotionally arousing thought, event, or situation to a neutral part of the body. The individual is able to stop, focus his mind on his body, calm down, be in the present moment, and then make an informed choice about how to react to the thought, event, or situation that has triggered an arousal response.
I found the description of the SoF meditation interesting therapeutically, because the strategy builds on the idea that the Asperger’s syndrome patient has the ability to make choices. This technique also seems like a refinement of ideas advanced by my good friend Aaron (Tim) Beck, developer of cognitive-behavioral therapy (CBT).
These studies raise numerous questions for those of us in psychiatry. We are seeing a remarkable growth in the number of children diagnosed with Asperger’s syndrome, and it is now estimated that 10,000 children have autism and/or Asperger’s. This is a significant number. We know that there has been an expediential growth in the number of children diagnosed with autism, and I suspect we will see more Asperger’s syndrome as time goes by. We also should expect to find a great many adults with Asperger’s syndrome who have suffered with it their entire lives. That means that we can no longer make an assessment of mental retardation in every patient who lacks social skills. Asperger’s syndrome patients have the capacity to reason, learn, and think. However, we are woefully ignorant of their cognitive capabilities and skills. Finally, psychiatrists and other physicians have to learn more about autism and Asperger’s syndrome in order to keep up with the times.
The Virginia case raises several questions for us about the criminal justice system and how it responds to people with behaviors that are not understood. We’ll never know what exactly happened that day in Stafford County. But we do know that one of the problems with illnesses related to autism is that "even innocent behaviors can come off as malicious" ("Is Sitting While Autistic a Crime?" Newsweek, July 8, 2010). Cynics like to say that the largest mental hospital in America is the Los Angeles County Jail, where the cost of incarceration is close to $40,000 per patient. We have to get those in need of mental health care who are housed in our jails into treatment settings, where they can get the attention and medication that they need.
As humanists and caring physicians, we in psychiatry must educate the public about how mental illness works. This tragic case is a good example of our failure to do so in the law-enforcement community. We have to protect those whose conditions make it either tough or impossible for them to protect themselves.
Dr. Fink is a psychiatrist and consultant in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia. He has no conflicts of interest to disclose.
A Virginia case involving an adolescent with Asperger’s who faces a 10-year prison sentence for assault raises questions about whether society can protect the impaired. What strategies can psychiatrists give patients to help them control their aggression?
It is difficult to grasp the complexities of this case. A statement from the Stafford County, Va., sheriff’s office says that the adolescent was charged with several counts, including one count of "knowingly disarming a police officer in performance of his official duties," after assaulting the officer last year in the parking lot of a high school.
According to the statement, a call came into the county’s sheriff’s office one morning last May saying that a "suspicious male," possibly in possession of a gun, was sitting on the grass outside a library, which was directly across from an elementary school. When police units arrived on the scene, they were unable to find the young man. At 20 minutes into the search, the statement says, a school resource officer saw the young man coming out of the woods behind the high school. When the officer asked for identification, the teenager reportedly "proceeded to attack and assault the deputy for no apparent reason."
After other officers arrived on the scene, the teenager was taken into custody, and the officer was transported to a hospital with a head laceration, cuts, abrasions, and a broken ankle. The officer reportedly had to retire because of his injuries. A gun was never found.
The young man, who is black and had been diagnosed with Asperger’s disorder and "pervasive developmental disorder – not otherwise specified," according to his mother’s blog, eventually was found guilty of assaulting a law enforcement officer. A jury recommended that he serve a 10.5-year sentence; as of this writing, he is scheduled to be sentenced on May 19.
This is one of those heart-wrenching cases that make us wish that the general public had a better understanding of mental illness, particularly disorders such as Asperger’s. Why would a person with a disability receive such a harsh sentence? Why did the officer fail to recognize that the young man was disturbed? What role did race play in the way the incident unfolded?
Press reports say that the young man’s mother is distraught and that she has received a great deal of support from the community to try to get her son freed. But the symbols of man’s inhumanity to man are emblazoned all over this case.
Asperger’s syndrome is characterized by occasional aggressive outbursts; poor social skills; failure to develop peer relationships; abnormal, nonverbal communication; and numerous other nuances. The failure to develop social skills would make a child in school an easy person to victimize. Children and adolescents with special needs are among the groups that are at great risk of being bullied, according to a paper published recently by Robin M. Kowalski, Ph.D., (Res. Autism Spectr. Disord. 2011 [doi:10.1016/jrasd.2011.01.007]). However, sorting through these issues is particularly challenging when it comes to young people with autism spectrum disorders, because often they are bullies themselves.
In fact, Dr. Kowalski found that – because these young people are able to use all kinds of electronic devices – they are both cyberbullied and cyberbullies. Of course, all kinds of bullying involve an imbalance of power. The failure of some people with Asperger’s to read social cues is critical. "Children with Asperger’s ... often fail to pick up on social cues that would allow for fluent social interactions, often lack verbal fluency, are frequently overly sensitive to particular auditory or tactile sensations, and are unyielding in their need for a routine, characteristics that make them likely candidates for bullying by others who see them as odd and different," she wrote. These patients "frequently behave in aggressive ways, which increases the probability that they might perpetrate bullying behaviors."
Asperger’s is difficult to treat, but some strategies have been identified that address some of the problematic behaviors these patients exhibit. For example, according to researchers in Virginia, a mindfulness-based strategy can help adolescents with Asperger’s shift their focus from the negative emotion triggered by the aggressive behavior to a neutral stimulus: the soles of their feet (Res. Autism Spectr. Disord. 2011;5:1103-9).
The study was very small – just three adolescent boys with Asperger’s participated. All had been on new-generation antipsychotics at least one time before enrolling in the study. All three showed minimal aggressive behaviors at school, but their parents found that they were unable to manage their aggressive behaviors at home or during community outings.
The boys’ mothers were trained to use the technique, called Soles of the Feet (SoF), 1 month before the beginning of baseline. For the first 5 days of the intervention, the researchers reported, each mother taught her son to use the procedure in daily 15-minute sessions. In some cases, the patients remained aggression free for 4 years.
In the SoF meditation, which is very concrete, the participant with severe mental limitations follows a series of steps that essentially wipe out his feelings of aggression. The person meditating is asked to divert attention from an emotionally arousing thought, event, or situation to a neutral part of the body. The individual is able to stop, focus his mind on his body, calm down, be in the present moment, and then make an informed choice about how to react to the thought, event, or situation that has triggered an arousal response.
I found the description of the SoF meditation interesting therapeutically, because the strategy builds on the idea that the Asperger’s syndrome patient has the ability to make choices. This technique also seems like a refinement of ideas advanced by my good friend Aaron (Tim) Beck, developer of cognitive-behavioral therapy (CBT).
These studies raise numerous questions for those of us in psychiatry. We are seeing a remarkable growth in the number of children diagnosed with Asperger’s syndrome, and it is now estimated that 10,000 children have autism and/or Asperger’s. This is a significant number. We know that there has been an expediential growth in the number of children diagnosed with autism, and I suspect we will see more Asperger’s syndrome as time goes by. We also should expect to find a great many adults with Asperger’s syndrome who have suffered with it their entire lives. That means that we can no longer make an assessment of mental retardation in every patient who lacks social skills. Asperger’s syndrome patients have the capacity to reason, learn, and think. However, we are woefully ignorant of their cognitive capabilities and skills. Finally, psychiatrists and other physicians have to learn more about autism and Asperger’s syndrome in order to keep up with the times.
The Virginia case raises several questions for us about the criminal justice system and how it responds to people with behaviors that are not understood. We’ll never know what exactly happened that day in Stafford County. But we do know that one of the problems with illnesses related to autism is that "even innocent behaviors can come off as malicious" ("Is Sitting While Autistic a Crime?" Newsweek, July 8, 2010). Cynics like to say that the largest mental hospital in America is the Los Angeles County Jail, where the cost of incarceration is close to $40,000 per patient. We have to get those in need of mental health care who are housed in our jails into treatment settings, where they can get the attention and medication that they need.
As humanists and caring physicians, we in psychiatry must educate the public about how mental illness works. This tragic case is a good example of our failure to do so in the law-enforcement community. We have to protect those whose conditions make it either tough or impossible for them to protect themselves.
Dr. Fink is a psychiatrist and consultant in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia. He has no conflicts of interest to disclose.
A Virginia case involving an adolescent with Asperger’s who faces a 10-year prison sentence for assault raises questions about whether society can protect the impaired. What strategies can psychiatrists give patients to help them control their aggression?
It is difficult to grasp the complexities of this case. A statement from the Stafford County, Va., sheriff’s office says that the adolescent was charged with several counts, including one count of "knowingly disarming a police officer in performance of his official duties," after assaulting the officer last year in the parking lot of a high school.
According to the statement, a call came into the county’s sheriff’s office one morning last May saying that a "suspicious male," possibly in possession of a gun, was sitting on the grass outside a library, which was directly across from an elementary school. When police units arrived on the scene, they were unable to find the young man. At 20 minutes into the search, the statement says, a school resource officer saw the young man coming out of the woods behind the high school. When the officer asked for identification, the teenager reportedly "proceeded to attack and assault the deputy for no apparent reason."
After other officers arrived on the scene, the teenager was taken into custody, and the officer was transported to a hospital with a head laceration, cuts, abrasions, and a broken ankle. The officer reportedly had to retire because of his injuries. A gun was never found.
The young man, who is black and had been diagnosed with Asperger’s disorder and "pervasive developmental disorder – not otherwise specified," according to his mother’s blog, eventually was found guilty of assaulting a law enforcement officer. A jury recommended that he serve a 10.5-year sentence; as of this writing, he is scheduled to be sentenced on May 19.
This is one of those heart-wrenching cases that make us wish that the general public had a better understanding of mental illness, particularly disorders such as Asperger’s. Why would a person with a disability receive such a harsh sentence? Why did the officer fail to recognize that the young man was disturbed? What role did race play in the way the incident unfolded?
Press reports say that the young man’s mother is distraught and that she has received a great deal of support from the community to try to get her son freed. But the symbols of man’s inhumanity to man are emblazoned all over this case.
Asperger’s syndrome is characterized by occasional aggressive outbursts; poor social skills; failure to develop peer relationships; abnormal, nonverbal communication; and numerous other nuances. The failure to develop social skills would make a child in school an easy person to victimize. Children and adolescents with special needs are among the groups that are at great risk of being bullied, according to a paper published recently by Robin M. Kowalski, Ph.D., (Res. Autism Spectr. Disord. 2011 [doi:10.1016/jrasd.2011.01.007]). However, sorting through these issues is particularly challenging when it comes to young people with autism spectrum disorders, because often they are bullies themselves.
In fact, Dr. Kowalski found that – because these young people are able to use all kinds of electronic devices – they are both cyberbullied and cyberbullies. Of course, all kinds of bullying involve an imbalance of power. The failure of some people with Asperger’s to read social cues is critical. "Children with Asperger’s ... often fail to pick up on social cues that would allow for fluent social interactions, often lack verbal fluency, are frequently overly sensitive to particular auditory or tactile sensations, and are unyielding in their need for a routine, characteristics that make them likely candidates for bullying by others who see them as odd and different," she wrote. These patients "frequently behave in aggressive ways, which increases the probability that they might perpetrate bullying behaviors."
Asperger’s is difficult to treat, but some strategies have been identified that address some of the problematic behaviors these patients exhibit. For example, according to researchers in Virginia, a mindfulness-based strategy can help adolescents with Asperger’s shift their focus from the negative emotion triggered by the aggressive behavior to a neutral stimulus: the soles of their feet (Res. Autism Spectr. Disord. 2011;5:1103-9).
The study was very small – just three adolescent boys with Asperger’s participated. All had been on new-generation antipsychotics at least one time before enrolling in the study. All three showed minimal aggressive behaviors at school, but their parents found that they were unable to manage their aggressive behaviors at home or during community outings.
The boys’ mothers were trained to use the technique, called Soles of the Feet (SoF), 1 month before the beginning of baseline. For the first 5 days of the intervention, the researchers reported, each mother taught her son to use the procedure in daily 15-minute sessions. In some cases, the patients remained aggression free for 4 years.
In the SoF meditation, which is very concrete, the participant with severe mental limitations follows a series of steps that essentially wipe out his feelings of aggression. The person meditating is asked to divert attention from an emotionally arousing thought, event, or situation to a neutral part of the body. The individual is able to stop, focus his mind on his body, calm down, be in the present moment, and then make an informed choice about how to react to the thought, event, or situation that has triggered an arousal response.
I found the description of the SoF meditation interesting therapeutically, because the strategy builds on the idea that the Asperger’s syndrome patient has the ability to make choices. This technique also seems like a refinement of ideas advanced by my good friend Aaron (Tim) Beck, developer of cognitive-behavioral therapy (CBT).
These studies raise numerous questions for those of us in psychiatry. We are seeing a remarkable growth in the number of children diagnosed with Asperger’s syndrome, and it is now estimated that 10,000 children have autism and/or Asperger’s. This is a significant number. We know that there has been an expediential growth in the number of children diagnosed with autism, and I suspect we will see more Asperger’s syndrome as time goes by. We also should expect to find a great many adults with Asperger’s syndrome who have suffered with it their entire lives. That means that we can no longer make an assessment of mental retardation in every patient who lacks social skills. Asperger’s syndrome patients have the capacity to reason, learn, and think. However, we are woefully ignorant of their cognitive capabilities and skills. Finally, psychiatrists and other physicians have to learn more about autism and Asperger’s syndrome in order to keep up with the times.
The Virginia case raises several questions for us about the criminal justice system and how it responds to people with behaviors that are not understood. We’ll never know what exactly happened that day in Stafford County. But we do know that one of the problems with illnesses related to autism is that "even innocent behaviors can come off as malicious" ("Is Sitting While Autistic a Crime?" Newsweek, July 8, 2010). Cynics like to say that the largest mental hospital in America is the Los Angeles County Jail, where the cost of incarceration is close to $40,000 per patient. We have to get those in need of mental health care who are housed in our jails into treatment settings, where they can get the attention and medication that they need.
As humanists and caring physicians, we in psychiatry must educate the public about how mental illness works. This tragic case is a good example of our failure to do so in the law-enforcement community. We have to protect those whose conditions make it either tough or impossible for them to protect themselves.
Dr. Fink is a psychiatrist and consultant in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia. He has no conflicts of interest to disclose.
Another Complication of Asperger's: Prison?
A Virginia case involving an adolescent with Asperger’s who faces a 10-year prison sentence for assault raises questions about whether society can protect the impaired. What strategies can psychiatrists give patients to help them control their aggression?
It is difficult to grasp the complexities of this case. A statement from the Stafford County, Va., sheriff’s office says that the adolescent was charged with several counts, including one count of "knowingly disarming a police officer in performance of his official duties," after assaulting the officer last year in the parking lot of a high school.
According to the statement, a call came into the county’s sheriff’s office one morning last May saying that a "suspicious male," possibly in possession of a gun, was sitting on the grass outside a library, which was directly across from an elementary school. When police units arrived on the scene, they were unable to find the young man. At 20 minutes into the search, the statement says, a school resource officer saw the young man coming out of the woods behind the high school. When the officer asked for identification, the teenager reportedly "proceeded to attack and assault the deputy for no apparent reason."
After other officers arrived on the scene, the teenager was taken into custody, and the officer was transported to a hospital with a head laceration, cuts, abrasions, and a broken ankle. The officer reportedly had to retire because of his injuries. A gun was never found.
The young man, who is black and had been diagnosed with Asperger’s disorder and "pervasive developmental disorder – not otherwise specified," according to his mother’s blog, eventually was found guilty of assaulting a law enforcement officer. A jury recommended that he serve a 10.5-year sentence; as of this writing, he is scheduled to be sentenced on May 19.
This is one of those heart-wrenching cases that make us wish that the general public had a better understanding of mental illness, particularly disorders such as Asperger’s. Why would a person with a disability receive such a harsh sentence? Why did the officer fail to recognize that the young man was disturbed? What role did race play in the way the incident unfolded?
Press reports say that the young man’s mother is distraught and that she has received a great deal of support from the community to try to get her son freed. But the symbols of man’s inhumanity to man are emblazoned all over this case.
Asperger’s syndrome is characterized by occasional aggressive outbursts; poor social skills; failure to develop peer relationships; abnormal, nonverbal communication; and numerous other nuances. The failure to develop social skills would make a child in school an easy person to victimize. Children and adolescents with special needs are among the groups that are at great risk of being bullied, according to a paper published recently by Robin M. Kowalski, Ph.D., (Res. Autism Spectr. Disord. 2011 [doi:10.1016/jrasd.2011.01.007]). However, sorting through these issues is particularly challenging when it comes to young people with autism spectrum disorders, because often they are bullies themselves.
In fact, Dr. Kowalski found that – because these young people are able to use all kinds of electronic devices – they are both cyberbullied and cyberbullies. Of course, all kinds of bullying involve an imbalance of power. The failure of some people with Asperger’s to read social cues is critical. "Children with Asperger’s ... often fail to pick up on social cues that would allow for fluent social interactions, often lack verbal fluency, are frequently overly sensitive to particular auditory or tactile sensations, and are unyielding in their need for a routine, characteristics that make them likely candidates for bullying by others who see them as odd and different," she wrote. These patients "frequently behave in aggressive ways, which increases the probability that they might perpetrate bullying behaviors."
Asperger’s is difficult to treat, but some strategies have been identified that address some of the problematic behaviors these patients exhibit. For example, according to researchers in Virginia, a mindfulness-based strategy can help adolescents with Asperger’s shift their focus from the negative emotion triggered by the aggressive behavior to a neutral stimulus: the soles of their feet (Res. Autism Spectr. Disord. 2011;5:1103-9).
The study was very small – just three adolescent boys with Asperger’s participated. All had been on new-generation antipsychotics at least one time before enrolling in the study. All three showed minimal aggressive behaviors at school, but their parents found that they were unable to manage their aggressive behaviors at home or during community outings.
The boys’ mothers were trained to use the technique, called Soles of the Feet (SoF), 1 month before the beginning of baseline. For the first 5 days of the intervention, the researchers reported, each mother taught her son to use the procedure in daily 15-minute sessions. In some cases, the patients remained aggression free for 4 years.
In the SoF meditation, which is very concrete, the participant with severe mental limitations follows a series of steps that essentially wipe out his feelings of aggression. The person meditating is asked to divert attention from an emotionally arousing thought, event, or situation to a neutral part of the body. The individual is able to stop, focus his mind on his body, calm down, be in the present moment, and then make an informed choice about how to react to the thought, event, or situation that has triggered an arousal response.
I found the description of the SoF meditation interesting therapeutically, because the strategy builds on the idea that the Asperger’s syndrome patient has the ability to make choices. This technique also seems like a refinement of ideas advanced by my good friend Aaron (Tim) Beck, developer of cognitive-behavioral therapy (CBT).
These studies raise numerous questions for those of us in psychiatry. We are seeing a remarkable growth in the number of children diagnosed with Asperger’s syndrome, and it is now estimated that 10,000 children have autism and/or Asperger’s. This is a significant number. We know that there has been an expediential growth in the number of children diagnosed with autism, and I suspect we will see more Asperger’s syndrome as time goes by. We also should expect to find a great many adults with Asperger’s syndrome who have suffered with it their entire lives. That means that we can no longer make an assessment of mental retardation in every patient who lacks social skills. Asperger’s syndrome patients have the capacity to reason, learn, and think. However, we are woefully ignorant of their cognitive capabilities and skills. Finally, psychiatrists and other physicians have to learn more about autism and Asperger’s syndrome in order to keep up with the times.
The Virginia case raises several questions for us about the criminal justice system and how it responds to people with behaviors that are not understood. We’ll never know what exactly happened that day in Stafford County. But we do know that one of the problems with illnesses related to autism is that "even innocent behaviors can come off as malicious" ("Is Sitting While Autistic a Crime?" Newsweek, July 8, 2010). Cynics like to say that the largest mental hospital in America is the Los Angeles County Jail, where the cost of incarceration is close to $40,000 per patient. We have to get those in need of mental health care who are housed in our jails into treatment settings, where they can get the attention and medication that they need.
As humanists and caring physicians, we in psychiatry must educate the public about how mental illness works. This tragic case is a good example of our failure to do so in the law-enforcement community. We have to protect those whose conditions make it either tough or impossible for them to protect themselves.
A Virginia case involving an adolescent with Asperger’s who faces a 10-year prison sentence for assault raises questions about whether society can protect the impaired. What strategies can psychiatrists give patients to help them control their aggression?
It is difficult to grasp the complexities of this case. A statement from the Stafford County, Va., sheriff’s office says that the adolescent was charged with several counts, including one count of "knowingly disarming a police officer in performance of his official duties," after assaulting the officer last year in the parking lot of a high school.
According to the statement, a call came into the county’s sheriff’s office one morning last May saying that a "suspicious male," possibly in possession of a gun, was sitting on the grass outside a library, which was directly across from an elementary school. When police units arrived on the scene, they were unable to find the young man. At 20 minutes into the search, the statement says, a school resource officer saw the young man coming out of the woods behind the high school. When the officer asked for identification, the teenager reportedly "proceeded to attack and assault the deputy for no apparent reason."
After other officers arrived on the scene, the teenager was taken into custody, and the officer was transported to a hospital with a head laceration, cuts, abrasions, and a broken ankle. The officer reportedly had to retire because of his injuries. A gun was never found.
The young man, who is black and had been diagnosed with Asperger’s disorder and "pervasive developmental disorder – not otherwise specified," according to his mother’s blog, eventually was found guilty of assaulting a law enforcement officer. A jury recommended that he serve a 10.5-year sentence; as of this writing, he is scheduled to be sentenced on May 19.
This is one of those heart-wrenching cases that make us wish that the general public had a better understanding of mental illness, particularly disorders such as Asperger’s. Why would a person with a disability receive such a harsh sentence? Why did the officer fail to recognize that the young man was disturbed? What role did race play in the way the incident unfolded?
Press reports say that the young man’s mother is distraught and that she has received a great deal of support from the community to try to get her son freed. But the symbols of man’s inhumanity to man are emblazoned all over this case.
Asperger’s syndrome is characterized by occasional aggressive outbursts; poor social skills; failure to develop peer relationships; abnormal, nonverbal communication; and numerous other nuances. The failure to develop social skills would make a child in school an easy person to victimize. Children and adolescents with special needs are among the groups that are at great risk of being bullied, according to a paper published recently by Robin M. Kowalski, Ph.D., (Res. Autism Spectr. Disord. 2011 [doi:10.1016/jrasd.2011.01.007]). However, sorting through these issues is particularly challenging when it comes to young people with autism spectrum disorders, because often they are bullies themselves.
In fact, Dr. Kowalski found that – because these young people are able to use all kinds of electronic devices – they are both cyberbullied and cyberbullies. Of course, all kinds of bullying involve an imbalance of power. The failure of some people with Asperger’s to read social cues is critical. "Children with Asperger’s ... often fail to pick up on social cues that would allow for fluent social interactions, often lack verbal fluency, are frequently overly sensitive to particular auditory or tactile sensations, and are unyielding in their need for a routine, characteristics that make them likely candidates for bullying by others who see them as odd and different," she wrote. These patients "frequently behave in aggressive ways, which increases the probability that they might perpetrate bullying behaviors."
Asperger’s is difficult to treat, but some strategies have been identified that address some of the problematic behaviors these patients exhibit. For example, according to researchers in Virginia, a mindfulness-based strategy can help adolescents with Asperger’s shift their focus from the negative emotion triggered by the aggressive behavior to a neutral stimulus: the soles of their feet (Res. Autism Spectr. Disord. 2011;5:1103-9).
The study was very small – just three adolescent boys with Asperger’s participated. All had been on new-generation antipsychotics at least one time before enrolling in the study. All three showed minimal aggressive behaviors at school, but their parents found that they were unable to manage their aggressive behaviors at home or during community outings.
The boys’ mothers were trained to use the technique, called Soles of the Feet (SoF), 1 month before the beginning of baseline. For the first 5 days of the intervention, the researchers reported, each mother taught her son to use the procedure in daily 15-minute sessions. In some cases, the patients remained aggression free for 4 years.
In the SoF meditation, which is very concrete, the participant with severe mental limitations follows a series of steps that essentially wipe out his feelings of aggression. The person meditating is asked to divert attention from an emotionally arousing thought, event, or situation to a neutral part of the body. The individual is able to stop, focus his mind on his body, calm down, be in the present moment, and then make an informed choice about how to react to the thought, event, or situation that has triggered an arousal response.
I found the description of the SoF meditation interesting therapeutically, because the strategy builds on the idea that the Asperger’s syndrome patient has the ability to make choices. This technique also seems like a refinement of ideas advanced by my good friend Aaron (Tim) Beck, developer of cognitive-behavioral therapy (CBT).
These studies raise numerous questions for those of us in psychiatry. We are seeing a remarkable growth in the number of children diagnosed with Asperger’s syndrome, and it is now estimated that 10,000 children have autism and/or Asperger’s. This is a significant number. We know that there has been an expediential growth in the number of children diagnosed with autism, and I suspect we will see more Asperger’s syndrome as time goes by. We also should expect to find a great many adults with Asperger’s syndrome who have suffered with it their entire lives. That means that we can no longer make an assessment of mental retardation in every patient who lacks social skills. Asperger’s syndrome patients have the capacity to reason, learn, and think. However, we are woefully ignorant of their cognitive capabilities and skills. Finally, psychiatrists and other physicians have to learn more about autism and Asperger’s syndrome in order to keep up with the times.
The Virginia case raises several questions for us about the criminal justice system and how it responds to people with behaviors that are not understood. We’ll never know what exactly happened that day in Stafford County. But we do know that one of the problems with illnesses related to autism is that "even innocent behaviors can come off as malicious" ("Is Sitting While Autistic a Crime?" Newsweek, July 8, 2010). Cynics like to say that the largest mental hospital in America is the Los Angeles County Jail, where the cost of incarceration is close to $40,000 per patient. We have to get those in need of mental health care who are housed in our jails into treatment settings, where they can get the attention and medication that they need.
As humanists and caring physicians, we in psychiatry must educate the public about how mental illness works. This tragic case is a good example of our failure to do so in the law-enforcement community. We have to protect those whose conditions make it either tough or impossible for them to protect themselves.
A Virginia case involving an adolescent with Asperger’s who faces a 10-year prison sentence for assault raises questions about whether society can protect the impaired. What strategies can psychiatrists give patients to help them control their aggression?
It is difficult to grasp the complexities of this case. A statement from the Stafford County, Va., sheriff’s office says that the adolescent was charged with several counts, including one count of "knowingly disarming a police officer in performance of his official duties," after assaulting the officer last year in the parking lot of a high school.
According to the statement, a call came into the county’s sheriff’s office one morning last May saying that a "suspicious male," possibly in possession of a gun, was sitting on the grass outside a library, which was directly across from an elementary school. When police units arrived on the scene, they were unable to find the young man. At 20 minutes into the search, the statement says, a school resource officer saw the young man coming out of the woods behind the high school. When the officer asked for identification, the teenager reportedly "proceeded to attack and assault the deputy for no apparent reason."
After other officers arrived on the scene, the teenager was taken into custody, and the officer was transported to a hospital with a head laceration, cuts, abrasions, and a broken ankle. The officer reportedly had to retire because of his injuries. A gun was never found.
The young man, who is black and had been diagnosed with Asperger’s disorder and "pervasive developmental disorder – not otherwise specified," according to his mother’s blog, eventually was found guilty of assaulting a law enforcement officer. A jury recommended that he serve a 10.5-year sentence; as of this writing, he is scheduled to be sentenced on May 19.
This is one of those heart-wrenching cases that make us wish that the general public had a better understanding of mental illness, particularly disorders such as Asperger’s. Why would a person with a disability receive such a harsh sentence? Why did the officer fail to recognize that the young man was disturbed? What role did race play in the way the incident unfolded?
Press reports say that the young man’s mother is distraught and that she has received a great deal of support from the community to try to get her son freed. But the symbols of man’s inhumanity to man are emblazoned all over this case.
Asperger’s syndrome is characterized by occasional aggressive outbursts; poor social skills; failure to develop peer relationships; abnormal, nonverbal communication; and numerous other nuances. The failure to develop social skills would make a child in school an easy person to victimize. Children and adolescents with special needs are among the groups that are at great risk of being bullied, according to a paper published recently by Robin M. Kowalski, Ph.D., (Res. Autism Spectr. Disord. 2011 [doi:10.1016/jrasd.2011.01.007]). However, sorting through these issues is particularly challenging when it comes to young people with autism spectrum disorders, because often they are bullies themselves.
In fact, Dr. Kowalski found that – because these young people are able to use all kinds of electronic devices – they are both cyberbullied and cyberbullies. Of course, all kinds of bullying involve an imbalance of power. The failure of some people with Asperger’s to read social cues is critical. "Children with Asperger’s ... often fail to pick up on social cues that would allow for fluent social interactions, often lack verbal fluency, are frequently overly sensitive to particular auditory or tactile sensations, and are unyielding in their need for a routine, characteristics that make them likely candidates for bullying by others who see them as odd and different," she wrote. These patients "frequently behave in aggressive ways, which increases the probability that they might perpetrate bullying behaviors."
Asperger’s is difficult to treat, but some strategies have been identified that address some of the problematic behaviors these patients exhibit. For example, according to researchers in Virginia, a mindfulness-based strategy can help adolescents with Asperger’s shift their focus from the negative emotion triggered by the aggressive behavior to a neutral stimulus: the soles of their feet (Res. Autism Spectr. Disord. 2011;5:1103-9).
The study was very small – just three adolescent boys with Asperger’s participated. All had been on new-generation antipsychotics at least one time before enrolling in the study. All three showed minimal aggressive behaviors at school, but their parents found that they were unable to manage their aggressive behaviors at home or during community outings.
The boys’ mothers were trained to use the technique, called Soles of the Feet (SoF), 1 month before the beginning of baseline. For the first 5 days of the intervention, the researchers reported, each mother taught her son to use the procedure in daily 15-minute sessions. In some cases, the patients remained aggression free for 4 years.
In the SoF meditation, which is very concrete, the participant with severe mental limitations follows a series of steps that essentially wipe out his feelings of aggression. The person meditating is asked to divert attention from an emotionally arousing thought, event, or situation to a neutral part of the body. The individual is able to stop, focus his mind on his body, calm down, be in the present moment, and then make an informed choice about how to react to the thought, event, or situation that has triggered an arousal response.
I found the description of the SoF meditation interesting therapeutically, because the strategy builds on the idea that the Asperger’s syndrome patient has the ability to make choices. This technique also seems like a refinement of ideas advanced by my good friend Aaron (Tim) Beck, developer of cognitive-behavioral therapy (CBT).
These studies raise numerous questions for those of us in psychiatry. We are seeing a remarkable growth in the number of children diagnosed with Asperger’s syndrome, and it is now estimated that 10,000 children have autism and/or Asperger’s. This is a significant number. We know that there has been an expediential growth in the number of children diagnosed with autism, and I suspect we will see more Asperger’s syndrome as time goes by. We also should expect to find a great many adults with Asperger’s syndrome who have suffered with it their entire lives. That means that we can no longer make an assessment of mental retardation in every patient who lacks social skills. Asperger’s syndrome patients have the capacity to reason, learn, and think. However, we are woefully ignorant of their cognitive capabilities and skills. Finally, psychiatrists and other physicians have to learn more about autism and Asperger’s syndrome in order to keep up with the times.
The Virginia case raises several questions for us about the criminal justice system and how it responds to people with behaviors that are not understood. We’ll never know what exactly happened that day in Stafford County. But we do know that one of the problems with illnesses related to autism is that "even innocent behaviors can come off as malicious" ("Is Sitting While Autistic a Crime?" Newsweek, July 8, 2010). Cynics like to say that the largest mental hospital in America is the Los Angeles County Jail, where the cost of incarceration is close to $40,000 per patient. We have to get those in need of mental health care who are housed in our jails into treatment settings, where they can get the attention and medication that they need.
As humanists and caring physicians, we in psychiatry must educate the public about how mental illness works. This tragic case is a good example of our failure to do so in the law-enforcement community. We have to protect those whose conditions make it either tough or impossible for them to protect themselves.
Many Stay-at-Home Dads Face Stigma of Nontraditional Role
Those of us who have lived a long time can look back at social change and how it affected the family, the community, and, subsequently, our practices. The impact of these changes on our society can be mind-boggling.
The recent recession has led to an increase in the number of stay-at-home fathers, many of whom experience stigma because of their nontraditional roles. How can we help fathers who find themselves in these roles because of a work-related transition?
The question was inspired by a paper by Aaron B. Rochlen, Ph.D., and his colleagues, "Stay-at-Home Fathers’ Reasons for Entering the Role and Stigma Experiences: A Preliminary Report."
Dr. Rochlen and his colleagues recruited 207 men from stay-at-home father blogs, support/play groups, and forums. Most of the men were white and heterosexual, and had middle to high incomes. The participants were evaluated based on their completion of several scales, including the 12-item Multidimensional Scale of Perceived Social Support and the 5-item Satisfaction With Life Scale. They also were asked several questions, including whether they had experienced an incident they consider to be stigma-related because of their role as stay-at-home fathers.
The findings were sobering: Thirty-six percent of the stay-at-home fathers surveyed got reactions from other adults reflecting "a general prejudice toward men in traditionally female roles." Furthermore, men who reported experiences that were stigmatizing also experienced weak social support – which predicts negative physical and psychological adjustment for stigmatized groups such as people who are HIV positive, single mothers living in poverty, and people with mental illness (Psychol. Men Masc. 2010;11:279-85).
This stigmatization has been occurring while more and more fathers are opting to make this choice ("Current population survey, 2006 Annual Social and Economic Supplement," Washington: U.S. Department of Commerce, Bureau of the Census. The recession of 2008-2009 (and the current economic aftershocks) have exacerbated these trends, so that we now have 158,000 stay-at-home fathers.
The Male Ego
The issue of what it means to be a "man" is one that we deal with regularly in psychotherapy. A male measures his manhood and is instantly concerned that he not do anything that undermines his power. Any insult or disrespect must be responded to, and he must be competitive with all men (and sometimes women) in his sphere.
If a man feels put down, he must retaliate to regain his status, that is, his feeling of being "man enough." Men in marriage want to feel in control – and given the large number of domestic violence cases in America, between 3 and 10 million per year – we know that some men lose control if they feel that the woman in the house is becoming too controlling or too powerful.
In short, it takes a certain kind of man to agree to stay home and take care of the children – in other words, to go against traditional cultural and gender norms. Such circumstances often prove so humiliating to the man, who feels he has lost his manhood, that they might cause a psychiatric disorder. I have never seen a couple in therapy in which the issue of control was not an essential part of the reason they had sought treatment.
Another issue that is a manifestation of these inner conflicts is erectile dysfunction. Men suffer a great deal if their penises do not work right. We know that there are many more men with erectile dysfunction than we thought just by noting the large number of prescriptions for Viagra and Cialis sold in this country. In the 50 years that I have been doing therapy, I have had a great many men worrying about the size of their penises. This is another way of expressing feelings of inadequacy.
I have digressed from the issues of stay-at-home fathers explored in the paper, because it does not raise any of these issues and remains very superficial in terms of trying to understand what is going on in these men. The authors do get close to the underlying issues as they examine the problem of stigma that stay-at-home fathers experience. Most of the stigma is expressed by stay-at-home moms, which can be quite humiliating for the man who is trying to be a good dad to his children and to take care of the house, the meals, the laundry, and so on.
Fifty percent of this perceived stigma fell into two major categories. The first is subsumed under ignorance of, or unfamiliarity with, the stay-at-home father role. The stigmatizer appears to have no familiarity or experience with a male serving as the primary caretaker of the children.
The second set of stigmatizing remarks saw the stay-at-home father as violating traditional gender roles/norms or value systems. These responses reflect a general prejudice toward men who were in traditionally female roles.
Reluctant Pioneers
The reported number of stay-at-home fathers is not particularly large in a country the size of ours. Nonetheless, these men are very courageous. Not only have they lost their jobs and have wives who earn more than they. They now find themselves in the position of "usurping" the woman’s traditional role.
Many of the men in the study truly wanted to take on the caretaking role. They sought to have an influence on their children’s values and watch them grow. Others wanted to nurture their children in a way that was different from the way they were nurtured while growing up.
Another factor that pushed some men toward their decision was the high cost of day care. These fathers wanted to spend more time with their children during their formative years and apparently had the ego strength to do it.
These men have good egos. They know who they are, and are able to shrug off wisecracks about homosexuality and other insensitive remarks and innuendos that would undermine most men.
I have a patient who has a very bad case of post-traumatic stress disorder that is the result of burns he received while working for a gas company. The explosion happened more than 10 years ago. Still, my patient is unable to overcome his sense that he wasn’t man enough at the beginning when his partner, the man who caused the explosion, approached him in the hospital and implied that he should lie to the company about what happened. "I should have gotten out of bed and kicked his ass" is a sentence I’ve heard many times from this patient.
This is a man who could never be a stay-at-home father. His persona is too wrapped up in his being a man and doing the manly thing. On the other hand, the men in this study were able to say, "I saw this as an opportunity I couldn’t pass up," or "Past experiments suggested that I would be better than my wife at staying home," or, "My partner is less nurturing that I am when it comes to children." These are men who are able to put the children ahead of themselves while making a life-transforming decision – and feel good about it.
Assumptions of Outsiders
The assumption by outside onlookers that there must be something wrong with this man is one of the most difficult hurdles that the stay-at-home father will have to confront. Other men and women who are traditional in their thinking about male and female roles not only think something is wrong, but express their doubts to the stay-at-home father. This is why I feel that it takes a man with a strong ego to undertake this role.
Another factor that undermines stay-at-home fathers is institutionalized homophobia, which pervades much of America. Again, this issue is not raised in the report, but I suspect that given the extent to which heterosexual stay-at-home fathers challenge gender roles, many of them face hostility comparable to that experienced by their homosexual counterparts.
I know of a homosexual couple who decided to adopt two children from a foreign country. One of them quit his job and was the stay-at-home parent. The amount of love this couple showered on these children should have been the envy of most parents in the community. This was a no-brainer for them. They experienced all of the problems of any parents with 2- or 3-year-olds. I haven’t spoken to them in several years, but I’m curious about how they will handle the issues of adolescence with their children.
Being a nurturer is learned and an attribute that can be difficult to find in our society. In this age of reality shows, video games, and 24-hour news cycles, far too many adults – and children – want to hurt or undermine others. This is all the more reason to cherish these men, who are willing to submerge their own ambition and change their futures to provide their children with the nurturing they need to grow and mature. (Of course, women have been making these kinds of sacrifices for years, but that’s a topic for another time).
One of the sad findings of this study was the feelings of lack of support that the stay-at-home fathers experienced, exacerbated by the stigma. When a stigma-related event took place in a playground, for example, the stay-at-home father found himself isolated and alone. The participants’ responses regarding stigma highlight the importance of helping stay-at-home fathers, addressing stigmatizing responses from others, and coping with isolation or rejection in settings that might have been considered the domain of stay-at-home mothers. Here is a place where the strength of the marriage might be tested. It is essential for the working wife to support the stay-at-home father and help him deal with the ignorant prejudices that lead to these remarks. If you are a psychiatrist consulted to help a couple in the throes of making such a decision, this is a kind of advice that would prove to be powerful and useful.
This column, "Fink! Still at Large," appears regularly in Clinical Psychiatry News, a publication of Elsevier. Dr. Fink is a psychiatrist and consultant in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia.
Those of us who have lived a long time can look back at social change and how it affected the family, the community, and, subsequently, our practices. The impact of these changes on our society can be mind-boggling.
The recent recession has led to an increase in the number of stay-at-home fathers, many of whom experience stigma because of their nontraditional roles. How can we help fathers who find themselves in these roles because of a work-related transition?
The question was inspired by a paper by Aaron B. Rochlen, Ph.D., and his colleagues, "Stay-at-Home Fathers’ Reasons for Entering the Role and Stigma Experiences: A Preliminary Report."
Dr. Rochlen and his colleagues recruited 207 men from stay-at-home father blogs, support/play groups, and forums. Most of the men were white and heterosexual, and had middle to high incomes. The participants were evaluated based on their completion of several scales, including the 12-item Multidimensional Scale of Perceived Social Support and the 5-item Satisfaction With Life Scale. They also were asked several questions, including whether they had experienced an incident they consider to be stigma-related because of their role as stay-at-home fathers.
The findings were sobering: Thirty-six percent of the stay-at-home fathers surveyed got reactions from other adults reflecting "a general prejudice toward men in traditionally female roles." Furthermore, men who reported experiences that were stigmatizing also experienced weak social support – which predicts negative physical and psychological adjustment for stigmatized groups such as people who are HIV positive, single mothers living in poverty, and people with mental illness (Psychol. Men Masc. 2010;11:279-85).
This stigmatization has been occurring while more and more fathers are opting to make this choice ("Current population survey, 2006 Annual Social and Economic Supplement," Washington: U.S. Department of Commerce, Bureau of the Census. The recession of 2008-2009 (and the current economic aftershocks) have exacerbated these trends, so that we now have 158,000 stay-at-home fathers.
The Male Ego
The issue of what it means to be a "man" is one that we deal with regularly in psychotherapy. A male measures his manhood and is instantly concerned that he not do anything that undermines his power. Any insult or disrespect must be responded to, and he must be competitive with all men (and sometimes women) in his sphere.
If a man feels put down, he must retaliate to regain his status, that is, his feeling of being "man enough." Men in marriage want to feel in control – and given the large number of domestic violence cases in America, between 3 and 10 million per year – we know that some men lose control if they feel that the woman in the house is becoming too controlling or too powerful.
In short, it takes a certain kind of man to agree to stay home and take care of the children – in other words, to go against traditional cultural and gender norms. Such circumstances often prove so humiliating to the man, who feels he has lost his manhood, that they might cause a psychiatric disorder. I have never seen a couple in therapy in which the issue of control was not an essential part of the reason they had sought treatment.
Another issue that is a manifestation of these inner conflicts is erectile dysfunction. Men suffer a great deal if their penises do not work right. We know that there are many more men with erectile dysfunction than we thought just by noting the large number of prescriptions for Viagra and Cialis sold in this country. In the 50 years that I have been doing therapy, I have had a great many men worrying about the size of their penises. This is another way of expressing feelings of inadequacy.
I have digressed from the issues of stay-at-home fathers explored in the paper, because it does not raise any of these issues and remains very superficial in terms of trying to understand what is going on in these men. The authors do get close to the underlying issues as they examine the problem of stigma that stay-at-home fathers experience. Most of the stigma is expressed by stay-at-home moms, which can be quite humiliating for the man who is trying to be a good dad to his children and to take care of the house, the meals, the laundry, and so on.
Fifty percent of this perceived stigma fell into two major categories. The first is subsumed under ignorance of, or unfamiliarity with, the stay-at-home father role. The stigmatizer appears to have no familiarity or experience with a male serving as the primary caretaker of the children.
The second set of stigmatizing remarks saw the stay-at-home father as violating traditional gender roles/norms or value systems. These responses reflect a general prejudice toward men who were in traditionally female roles.
Reluctant Pioneers
The reported number of stay-at-home fathers is not particularly large in a country the size of ours. Nonetheless, these men are very courageous. Not only have they lost their jobs and have wives who earn more than they. They now find themselves in the position of "usurping" the woman’s traditional role.
Many of the men in the study truly wanted to take on the caretaking role. They sought to have an influence on their children’s values and watch them grow. Others wanted to nurture their children in a way that was different from the way they were nurtured while growing up.
Another factor that pushed some men toward their decision was the high cost of day care. These fathers wanted to spend more time with their children during their formative years and apparently had the ego strength to do it.
These men have good egos. They know who they are, and are able to shrug off wisecracks about homosexuality and other insensitive remarks and innuendos that would undermine most men.
I have a patient who has a very bad case of post-traumatic stress disorder that is the result of burns he received while working for a gas company. The explosion happened more than 10 years ago. Still, my patient is unable to overcome his sense that he wasn’t man enough at the beginning when his partner, the man who caused the explosion, approached him in the hospital and implied that he should lie to the company about what happened. "I should have gotten out of bed and kicked his ass" is a sentence I’ve heard many times from this patient.
This is a man who could never be a stay-at-home father. His persona is too wrapped up in his being a man and doing the manly thing. On the other hand, the men in this study were able to say, "I saw this as an opportunity I couldn’t pass up," or "Past experiments suggested that I would be better than my wife at staying home," or, "My partner is less nurturing that I am when it comes to children." These are men who are able to put the children ahead of themselves while making a life-transforming decision – and feel good about it.
Assumptions of Outsiders
The assumption by outside onlookers that there must be something wrong with this man is one of the most difficult hurdles that the stay-at-home father will have to confront. Other men and women who are traditional in their thinking about male and female roles not only think something is wrong, but express their doubts to the stay-at-home father. This is why I feel that it takes a man with a strong ego to undertake this role.
Another factor that undermines stay-at-home fathers is institutionalized homophobia, which pervades much of America. Again, this issue is not raised in the report, but I suspect that given the extent to which heterosexual stay-at-home fathers challenge gender roles, many of them face hostility comparable to that experienced by their homosexual counterparts.
I know of a homosexual couple who decided to adopt two children from a foreign country. One of them quit his job and was the stay-at-home parent. The amount of love this couple showered on these children should have been the envy of most parents in the community. This was a no-brainer for them. They experienced all of the problems of any parents with 2- or 3-year-olds. I haven’t spoken to them in several years, but I’m curious about how they will handle the issues of adolescence with their children.
Being a nurturer is learned and an attribute that can be difficult to find in our society. In this age of reality shows, video games, and 24-hour news cycles, far too many adults – and children – want to hurt or undermine others. This is all the more reason to cherish these men, who are willing to submerge their own ambition and change their futures to provide their children with the nurturing they need to grow and mature. (Of course, women have been making these kinds of sacrifices for years, but that’s a topic for another time).
One of the sad findings of this study was the feelings of lack of support that the stay-at-home fathers experienced, exacerbated by the stigma. When a stigma-related event took place in a playground, for example, the stay-at-home father found himself isolated and alone. The participants’ responses regarding stigma highlight the importance of helping stay-at-home fathers, addressing stigmatizing responses from others, and coping with isolation or rejection in settings that might have been considered the domain of stay-at-home mothers. Here is a place where the strength of the marriage might be tested. It is essential for the working wife to support the stay-at-home father and help him deal with the ignorant prejudices that lead to these remarks. If you are a psychiatrist consulted to help a couple in the throes of making such a decision, this is a kind of advice that would prove to be powerful and useful.
This column, "Fink! Still at Large," appears regularly in Clinical Psychiatry News, a publication of Elsevier. Dr. Fink is a psychiatrist and consultant in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia.
Those of us who have lived a long time can look back at social change and how it affected the family, the community, and, subsequently, our practices. The impact of these changes on our society can be mind-boggling.
The recent recession has led to an increase in the number of stay-at-home fathers, many of whom experience stigma because of their nontraditional roles. How can we help fathers who find themselves in these roles because of a work-related transition?
The question was inspired by a paper by Aaron B. Rochlen, Ph.D., and his colleagues, "Stay-at-Home Fathers’ Reasons for Entering the Role and Stigma Experiences: A Preliminary Report."
Dr. Rochlen and his colleagues recruited 207 men from stay-at-home father blogs, support/play groups, and forums. Most of the men were white and heterosexual, and had middle to high incomes. The participants were evaluated based on their completion of several scales, including the 12-item Multidimensional Scale of Perceived Social Support and the 5-item Satisfaction With Life Scale. They also were asked several questions, including whether they had experienced an incident they consider to be stigma-related because of their role as stay-at-home fathers.
The findings were sobering: Thirty-six percent of the stay-at-home fathers surveyed got reactions from other adults reflecting "a general prejudice toward men in traditionally female roles." Furthermore, men who reported experiences that were stigmatizing also experienced weak social support – which predicts negative physical and psychological adjustment for stigmatized groups such as people who are HIV positive, single mothers living in poverty, and people with mental illness (Psychol. Men Masc. 2010;11:279-85).
This stigmatization has been occurring while more and more fathers are opting to make this choice ("Current population survey, 2006 Annual Social and Economic Supplement," Washington: U.S. Department of Commerce, Bureau of the Census. The recession of 2008-2009 (and the current economic aftershocks) have exacerbated these trends, so that we now have 158,000 stay-at-home fathers.
The Male Ego
The issue of what it means to be a "man" is one that we deal with regularly in psychotherapy. A male measures his manhood and is instantly concerned that he not do anything that undermines his power. Any insult or disrespect must be responded to, and he must be competitive with all men (and sometimes women) in his sphere.
If a man feels put down, he must retaliate to regain his status, that is, his feeling of being "man enough." Men in marriage want to feel in control – and given the large number of domestic violence cases in America, between 3 and 10 million per year – we know that some men lose control if they feel that the woman in the house is becoming too controlling or too powerful.
In short, it takes a certain kind of man to agree to stay home and take care of the children – in other words, to go against traditional cultural and gender norms. Such circumstances often prove so humiliating to the man, who feels he has lost his manhood, that they might cause a psychiatric disorder. I have never seen a couple in therapy in which the issue of control was not an essential part of the reason they had sought treatment.
Another issue that is a manifestation of these inner conflicts is erectile dysfunction. Men suffer a great deal if their penises do not work right. We know that there are many more men with erectile dysfunction than we thought just by noting the large number of prescriptions for Viagra and Cialis sold in this country. In the 50 years that I have been doing therapy, I have had a great many men worrying about the size of their penises. This is another way of expressing feelings of inadequacy.
I have digressed from the issues of stay-at-home fathers explored in the paper, because it does not raise any of these issues and remains very superficial in terms of trying to understand what is going on in these men. The authors do get close to the underlying issues as they examine the problem of stigma that stay-at-home fathers experience. Most of the stigma is expressed by stay-at-home moms, which can be quite humiliating for the man who is trying to be a good dad to his children and to take care of the house, the meals, the laundry, and so on.
Fifty percent of this perceived stigma fell into two major categories. The first is subsumed under ignorance of, or unfamiliarity with, the stay-at-home father role. The stigmatizer appears to have no familiarity or experience with a male serving as the primary caretaker of the children.
The second set of stigmatizing remarks saw the stay-at-home father as violating traditional gender roles/norms or value systems. These responses reflect a general prejudice toward men who were in traditionally female roles.
Reluctant Pioneers
The reported number of stay-at-home fathers is not particularly large in a country the size of ours. Nonetheless, these men are very courageous. Not only have they lost their jobs and have wives who earn more than they. They now find themselves in the position of "usurping" the woman’s traditional role.
Many of the men in the study truly wanted to take on the caretaking role. They sought to have an influence on their children’s values and watch them grow. Others wanted to nurture their children in a way that was different from the way they were nurtured while growing up.
Another factor that pushed some men toward their decision was the high cost of day care. These fathers wanted to spend more time with their children during their formative years and apparently had the ego strength to do it.
These men have good egos. They know who they are, and are able to shrug off wisecracks about homosexuality and other insensitive remarks and innuendos that would undermine most men.
I have a patient who has a very bad case of post-traumatic stress disorder that is the result of burns he received while working for a gas company. The explosion happened more than 10 years ago. Still, my patient is unable to overcome his sense that he wasn’t man enough at the beginning when his partner, the man who caused the explosion, approached him in the hospital and implied that he should lie to the company about what happened. "I should have gotten out of bed and kicked his ass" is a sentence I’ve heard many times from this patient.
This is a man who could never be a stay-at-home father. His persona is too wrapped up in his being a man and doing the manly thing. On the other hand, the men in this study were able to say, "I saw this as an opportunity I couldn’t pass up," or "Past experiments suggested that I would be better than my wife at staying home," or, "My partner is less nurturing that I am when it comes to children." These are men who are able to put the children ahead of themselves while making a life-transforming decision – and feel good about it.
Assumptions of Outsiders
The assumption by outside onlookers that there must be something wrong with this man is one of the most difficult hurdles that the stay-at-home father will have to confront. Other men and women who are traditional in their thinking about male and female roles not only think something is wrong, but express their doubts to the stay-at-home father. This is why I feel that it takes a man with a strong ego to undertake this role.
Another factor that undermines stay-at-home fathers is institutionalized homophobia, which pervades much of America. Again, this issue is not raised in the report, but I suspect that given the extent to which heterosexual stay-at-home fathers challenge gender roles, many of them face hostility comparable to that experienced by their homosexual counterparts.
I know of a homosexual couple who decided to adopt two children from a foreign country. One of them quit his job and was the stay-at-home parent. The amount of love this couple showered on these children should have been the envy of most parents in the community. This was a no-brainer for them. They experienced all of the problems of any parents with 2- or 3-year-olds. I haven’t spoken to them in several years, but I’m curious about how they will handle the issues of adolescence with their children.
Being a nurturer is learned and an attribute that can be difficult to find in our society. In this age of reality shows, video games, and 24-hour news cycles, far too many adults – and children – want to hurt or undermine others. This is all the more reason to cherish these men, who are willing to submerge their own ambition and change their futures to provide their children with the nurturing they need to grow and mature. (Of course, women have been making these kinds of sacrifices for years, but that’s a topic for another time).
One of the sad findings of this study was the feelings of lack of support that the stay-at-home fathers experienced, exacerbated by the stigma. When a stigma-related event took place in a playground, for example, the stay-at-home father found himself isolated and alone. The participants’ responses regarding stigma highlight the importance of helping stay-at-home fathers, addressing stigmatizing responses from others, and coping with isolation or rejection in settings that might have been considered the domain of stay-at-home mothers. Here is a place where the strength of the marriage might be tested. It is essential for the working wife to support the stay-at-home father and help him deal with the ignorant prejudices that lead to these remarks. If you are a psychiatrist consulted to help a couple in the throes of making such a decision, this is a kind of advice that would prove to be powerful and useful.
This column, "Fink! Still at Large," appears regularly in Clinical Psychiatry News, a publication of Elsevier. Dr. Fink is a psychiatrist and consultant in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia.