Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

Kathleen Flaherty, JD, is a lawyer and currently serves as the Executive Director of Connecticut 

, a statewide non-profit agency that provides legal services to low-income individuals with mental health conditions on matters related to their treatment, recovery, and civil rights. She is a graduate of Wellesley College (’88) and Harvard Law School (’94) and has devoted her legal career to advocating for the rights of individuals with psychiatric disabilities. She is the recipient of many awards for her advocacy and legal work, including the 2021 Charles J. Parker Legal Services Award, recognizing excellence in career-long dedication to the delivery of legal services to the disadvantaged in Connecticut, and the 2017 Board of Directors Award by National Alliance on Mental Illness, CT.

Given her personal experience of receiving mental health services as a patient/service user and long career as a lawyer providing services to disadvantaged individuals with mental illness, Ms Flaherty is well-placed to recognize the deficiencies in our current psychiatric and legal systems, particularly when it comes to involuntary psychiatric care and treatment. Debates regarding social justice, disability and human rights, involuntary detention and treatment, expectations regarding safety and risk, and the carceral nature of inpatient psychiatric care are increasingly entering public consciousness. This exchange with Ms Flaherty delves into some of these intricate issues.

 Your experience in providing legal representation to low-income individuals with mental health conditions in matters concerning their civil rights, including involuntary commitment and involuntary treatments, offers you a unique perspective on the challenges facing individuals with mental illness that may not be readily apparent to psychiatrists. What sort of systemic difficulties and obstacles have you observed in this regard? What issues do you think are being overlooked by the current systems of mental health care, especially by psychiatrists?

 Thanks for inviting me to have this dialogue with you. As the Executive Director of Connecticut Legal Rights Project (CLRP), I lead a team that represents clients who are eligible for mental health services from the 

State of Connecticut Department of Mental Health and Addiction Services

. Many of the challenges faced by our clients are the same challenges faced by others in Connecticut and around the country: a lack of decent, safe, affordable, and accessible housing; insufficient voluntary services and supports because of chronic underfunding of the community-based system of care; and unequal opportunity when it comes to education and employment. You have asked about systemic issues I have observed in my legal work, and there is a long list.

The systemic difficulties and obstacles experienced by our clients subjected to the state actions of involuntary treatment and involuntary civil commitment are longstanding and pervasive. Systemic inequity and poverty are layered over discrimination that stems from disability.

Many police departments reflect the larger prejudices of their communities and use infractions and laws to criminalize disability, instead of providing accommodations and diversion into health care and meeting basic needs. Systemic problems within the state judicial action of involuntary commitment include ineffective assistance of counsel, lack of adequate due process, lack of access to independent expert witnesses, and treating judicial hearings like treatment team meetings in how they look at behavior and outcomes.

The judicial system does not have a realistic and accurate understanding of mental health conditions, which results in almost complete deference to proffered diagnosis and risk assessments, both of which lack a robust foundation in empirical science. The judicial system has limited awareness of the complicated efficacy (to the extent that it exists) of psychiatric treatment and medication, especially for the cohort of patients subjected to commitment. Once committed, the problems include unsafe conditions of confinement, police presence at hospitals, inadequate system response to allegations of patient abuse and neglect, and forced psychiatric treatment. The system often fails to provide adequate information about the risks and benefits of psychiatric medication so that patients can give truly informed consent. Finally, discharge planning is inadequate; patients’ rights to be discharged into the most integrated setting as soon as they are stable and ready for discharge is routinely violated.

Community supports and services necessary to discharge patients to the most integrated setting have not been measured, planned for, budgeted, and put in place. Tax cuts for the rich have been universally endorsed over adequate supports and services for individuals with mental health conditions to live in the community. Too often, NIMBY (“

”) responses to proposals to build low-income subsidized housing for individuals with disabilities means a lack of opportunities to live in the community of one’s choice.

I recognize this is a lot; these are the issues we at CLRP wrestle with every day. They are the systemic issues that affect our clients’ lives and place barriers in the way of their opportunities to build great lives in the community. I hope that once more individuals realize all these other things are going on, they will recognize some of what they label as hostility towards psychiatry is not necessarily that—it is a railing against these profound systemic inequities and a call for psychiatrists to stop playing into them.

 You also have personal experience of mental illness as well as psychiatric hospitalization, and it appears that those experiences, difficult as they were, have provided a fuel for your legal and advocacy work. Can you share with us what your own experience of being under psychiatric care was like?

 Sure, I would be happy to do so. First, it has been a while since I was in the system as a patient, but the last time I was, I remember having a 

 every 3 months. That is clearly nowhere near enough time to have any kind of in-depth conversation with a patient about all the things that may be contributing to their distress. I cannot help but wonder if we collectively have unrealistic expectations of psychiatrists. Are we expecting them to do something yet providing neither the time nor resources for that to happen?

As I relate my story, your readers must keep in mind that I am in my early 50s. Looking back on my childhood, I was depressed and anxious, but in the 1970s no one cared, especially if you performed well in school. I first went to a therapist my senior year of college when I was so depressed and anxious that I could not get out of bed and walk into the science center (which made it impossible to complete my senior thesis). That first counselor suggested to me that I could just drop the thesis, which was rather a mind-blowing concept to me at the time. Between college and law school, I started seeing a psychiatrist and was first prescribed antidepressants. My first year of law school, I experienced my first—and to date, only—full-blown episode of what was labeled as mania. I was civilly committed to 

 for up to 6 months, discharged after 60 days when my insurance ran out, took a medical leave from school, and returned the next year. The law school put conditions on my return to campus which included staying on medications. The medications kept me from being manic but locked me into a permanent depression.

With the help of my psychiatrist, I tapered off (but not incredibly slowly, to the best of my recollection) the medications after graduation. Although he did not agree with me on that course of action, he respected my choice and helped me do it. I moved overseas for a teaching position, but a confluence of factors led to my restarting medication in Ireland and returning home after a semester to a hospital admission for a medication change (it was a different world then).

That led to more than 15 years of trying every new medication that came out from the mid-1990s to early 2000s. Every single new drug. During my last hospitalization, the attending resident prepared a chart of all the medications I had been on. At the end of the day, it was 32 different prescriptions over the course of 20 years (not all at the same time, of course.) When I would do presentations for the 

National Alliance on Mental Illness’ In Our Voice Program

, I would always explain the highs and lows of bipolar disorder; in my case, where I got locked in was somewhere below whatever the line for “normal” is. I made several suicide attempts and lived with suicidal ideation for years. I got to a point where I was not going to throw myself in front of a bus but would not have been disappointed if the bus jumped the curb in a freak accident and took me out. Does that make sense or sound familiar? After an attempt, they suggested electroconvulsive therapy (ECT). I consented, mostly because I did not care anymore.

In terms of the deprivations of rights, I not only know the theory of the law but what it is like to have it happen. I know what it is like to be grabbed by cops and put in the back of an ambulance. I know what it is like to sign in as a supposedly “voluntary” patient and immediately revoke the voluntary but not be allowed to leave. I know what it is like to be restrained and secluded. I have experienced being forcibly injected with medication.

I am fortunate in that I never have seemed to experience some of the worst cognitive adverse effects of ECT or the multiple medications I was prescribed. However, I have been labeled “treatment-resistant,” including when I was doing everything the doctors told me to do, taking all the medications that were prescribed, and it was not helping. Ultimately, about 8 years ago, I decided I did not want to be on meds anymore. I talked to my clinician, and we did the slowest taper ever of the last medication I was on. It was not an easy decision.

 How has your understanding of your own psychiatric issues changed over the course of your life? This is an area where we see a lot of diverse ways in which individuals relate to their mental illness, whether this is understood as medical disorder, as psychological reaction to life circumstances, as disability within a social model, or even as a form of identity.

 When I first received a diagnosis of bipolar disorder, it explained a lot of things that were going on. It certainly made it easier for my parents to understand. When those first doses of lithium kicked in, they stopped the constant whirring in my brain that did not let me sit still, did not let me sleep, did not let me focus in class. When I was able to read the various brochures and information that were available when I was in the hospital, I realized I checked every box. And at that time (1990) the mainstream recommendation was medications for life, just like diabetes for insulin.

I had no reason to doubt the doctors. I grew up in the suburbs, went to prep school and college, and was in law school. I believed what authority figures told me, and I did what they recommended. I thought I had an illness, just like any other illness (I truly fell for everything hook, line, and sinker. There is proof of that in one of the first pieces I ever wrote—a guest column for the law school newspaper . . . I cringe when I read it now).

Time passed. I got connected to peer support groups. I saw individuals living their lives with the same diagnosis that I had been given, but not taking meds. That concept at first did not make sense to me, because I only knew what I had been told: The medications corrected some kind of “

” in my brain, so why would I give that up? Problem was, I was not happy with how I felt. So I started doing some of the things that my friends were doing: getting enough sleep, getting more exercise, eating better. I was not ready to let go of the medication yet, but I started realizing that maybe some of the things I had been told were not entirely accurate.

I started reading more. That made me a lot more skeptical of everything I had been told before, to be honest. However, I know friends who rely on medication, because it does for them what they need it to do, without significant adverse effects. I do not begrudge their choice, and in fact, I support them in exercising that choice. I figure that they weighed the pluses and minuses for themselves and made their choices accordingly. I do not think it is particularly helpful or persuasive for either side of the medication debate to operate from an absolutist position. I do think that the system response of placing diagnostic labels on all distress and thinking that writing a prescription will solve every problem, or using certain diagnostic labels to deny care, is misguided.

Once I got more involved in cross-disability advocacy work, I learned a lot more about the social model of disability and political theory. I identify as disabled, but no longer describe myself as having bipolar disorder. I will sometimes say I am living in recovery from a psychiatric label.

 Can you say a bit more about identifying as disabled, as experiencing a disability, yet not identifying as an individual with a psychiatric disorder? The reason I am asking is that for many readers the notion of disability without disorder would be rather counterintuitive. What does it mean to say, “I accept that I am disabled, but I do not describe my disability with a diagnostic label”?

 That is a good question; I can best answer it by explaining that I am a lawyer. 

 defines an individual with a disability as someone who has a physical or mental impairment that substantially limits 1 or more major life activity. This includes those who have a record of such an impairment, even if they do not currently have a disability. It also includes others who do not have a disability but are regarded as having a disability. I qualify under all these prongs: I certainly have a record of such an impairment, and others have regarded me as having an impairment.

I also happen to be experiencing long-haul COVID; at the time of this conversation, I have just crossed the 1-year anniversary of getting sick. I think it makes a difference when individuals who live with chronic illnesses (whether physical or mental, if they identify with the medical model) claim the identity of disabled, because there is nothing inherently negative about it. I am part of a fabulous community, so why would I not describe myself that way? There was a time in my life when I claimed the identity of being someone living with bipolar disorder. It was a big part of my life, and I found a community of others as a result. Over time, especially once I made the decision to continue my recovery without medications, the diagnostic label became a less useful descriptor.

Another way to conceptualize this is to make parallels to the conversations we have about other issues. There is not a significant biological distinction between individuals of different races; some say that race does not exist but is instead a social construct that has been used for the justification of heinous institutions such as the trans-Atlantic slave trade. But both individual and 

 continue to exist. Gender does not exist as gender qua gender. It too is a social construct. But individual and systemic 

; it was created by the patriarchal capitalists to perpetuate power and property.

Some argue that disability does not exist and is a social construct. I do not agree entirely with this perspective, because disabilities do exist and pretending that they are only a social construct means we will fail to provide the accommodations and the services and supports that some disabled individuals need to live in the world. However, I do think that this perspective does help to explain why I say that I am an individual labeled with a mental health condition. There is no blood test, genetic test, x-ray, or lab work for bipolar disorder. We all have moods and behaviors. Society, doctors, lawyers, police, and judges need mental health labels in order to keep normative-minded individuals safe and satisfied in their own perceptions of the world.

Therefore, I believe that “disability without disorder” is a bit of a false disjunction. I am human. Mood is human. Experiencing a full range of thoughts, perceptions and mood is human. I believe that disorder is a contestable judgment we impose on it. If there is a disorder, I would posit that the disorder exists in the so-called normal individual’s perception of their own normality and limiting their own conception of normality to their perceptions, relationships, experiences, and religion rather than recognizing the breadth of human experience.

 In our communication before this interview, you commented on the lack of spaces for meaningful conversations between the mainstream psychiatric community and critics such as yourself advocating for reform. I certainly share your impression, and this series is a part of an effort to enable such discussions to take place. In your opinion, why has this been so difficult?

 I wish I knew the answer to that. What has always bothered me is that individuals from all camps (this is not about sides—I can think of at least 3 or 4 different groups here) are not truly intellectually curious about the perspectives of others. I am frustrated most by professionals who (seemingly) refuse to listen to those who have had negative experiences within the psychiatric system.

Here is something I have always wondered about, both as a patient myself and as a lawyer representing clients who are psychiatric patients: Why does it seem that no one questions the capacity of an individual who consents to treatment when they are consenting to the treatment, but the second he or she demonstrates the least bit of unwillingness to go along with a psychiatrist’s recommendations, all of a sudden the individual has anosognosia (my least favorite word), lacks insight, and lacks capacity to refuse to consent to treatment? Am I imagining that? I can understand how frustrating it must be as a professional with years of training to make recommendations to patients about what they should do and then have them not do it.

 all the time. They talk about how much they hate their lawyers and the legal system. We do not go around labeling individuals “anti-lawyer.” We understand that clients are not coming to lawyers to seek legal help when everything is going right in their life. We also recognize our system is far from perfect and rarely results in justice. It is a problematic system with all of the biases inherent in any system that relies on precedent for how it moves forward.

So, I ask psychiatrists: Are patients coming to you when their lives are going well? My guess is no. If we accept as our starting premise that the system does not give you as much time as you need to attend to your patients, do you think it is possible that there are things going on in your patients’ lives that you do not understand? And that if patients are saying that the help you are offering is not all that helpful, that is not an attack on you, but simply a statement of fact? I am not saying that is easy, because believe me, it is still hard for me when people reject the legal advice I offer—but I do not have to live their lives and I do not know everything that goes into the choices they make. All I can do is say that the likely consequences of choice A is X, choice B is Y, and I will advocate for whatever you tell me your preference is.

 You are bringing up important issues and I am quite sympathetic to your arguments. Regarding the question of why psychiatric clinicians do not seem to question the decision-making capacity when an individual is consenting to treatment, I think you will get a variety of answers from medical professionals (eg, a possible answer would be that the threshold for incapacity is different for accepting treatment vs refusing treatment because the risks of accepting and refusing are different, but such answers are less relevant for us at the moment). My suspicion is that there are 2 major reasons. The first is pragmatic: the legal system is already so strained that there is little to no appetite among stakeholders—including physicians, hospital administrators, patients, families, lawyers, judges—to go to court when an individual is already complying with recommended treatment. The second is risk, and I mean that very broadly. Forced medications are often sought in situations when the behavior is socially disruptive, or the individual is impaired to a degree that they cannot control their behavior, or the families/caregivers are unable to care for them, and forced medications are less likely to be sought in situations where such considerations do not apply.

This is also relevant because forced medications are sought within the context of involuntary commitment, and the criteria for involuntary commitment are based on considerations of risk, so in practice these considerations are highly relevant to clinical decisions about forced medications. The formal argument is presented using the language of incapacity because that is the language the system has decided on, but the considerations behind such decisions typically extend beyond incapacity.

Society has tasked psychiatrists with managing various problematic behaviors that society is not willing to tolerate outside the walls of hospitals (or prisons). It has told psychiatrists that the pharmacological tools they need to use to manage such behaviors are available to them if an argument is made along the lines of incapacity. It has also told them if they do not use these tools and some adverse outcome happens, they can be held liable.

An example that comes to my mind from clinical experience is that of a man with persecutory delusions. He has ruined his business, has been increasingly agitated, has been threatening his family, and has destroyed his house looking for imaginary persecutors hidden in the walls and the vents. His family is scared to death, for his safety as well as their own. They initiate the process for civil commitment, and he ends up in the hospital. He has no insight into the delusional nature of his thinking; he believes he is really being persecuted and that his family is refusing to see the evidence. It is easy to say in the abstract that we should respect his preferences, and we can debate at what point his lack of insight into delusions constitutes incapacity, and we can debate the construct validity of the diagnostic label “delusional disorder.” The real-world reality is that there is no way to discharge him safely to his family (or anywhere else, for that matter) unless his persecutory delusions are at the very least attenuated.

How can we do that in the inpatient setting without the use of medications? Even if you discharge him in this paranoid state, he will end up in the hospital again in a few days, or worse, he will end up in jail. This is a rather extreme example, and I concede that there are many, many examples that are far more debatable, but it does highlight the sort of considerations that go into clinical decision-making in the inpatient setting. I do not think anyone will argue that there should not be robust checks and balances. All power is at risk of being abused, and the power of commitment and forced treatment is no different. In my experience, however, I have found the judges to often be just as conservative and risk averse as physicians, if not more so.

So, I guess, my question to you is how do you take these additional considerations related to risk, safety, ability to function in the community, and the responsibility placed onto psychiatrists by the society into account? How should we approach these situations differently in your view? Should society have different expectations regarding who should assume risk and liability? Who should families turn to if their loved one is paranoid and unraveling, and is unwilling to get help?

 These questions are difficult ones. I can appreciate the challenges faced by psychiatrists who have these responsibilities placed upon them by a society that limits the tools they have to use. Fundamentally, I think the system puts too much trust into psychiatrists and relies on them to control risk, which, as you say, they mostly do by keeping someone locked up and tranquilized with powerful drugs. I have had many conversations with concerned family members who feel like they are powerless to help someone they love. I tell them that psychiatry imposed by force may have some short-term results, but often leads to longer-term trauma and distrust. I have told them that, based on my experience as both a patient and a lawyer representing clients who are patients, seeking to superimpose the legal control of a conservatorship may complicate already fraught family relationships.

Neither the medical profession, the legal profession nor the judicial system can fix everything.Liberty, civil rights, due process, agency, and self-determination must be balanced with public safety, family safety, and professional risk. We agree that families, psychiatrists, and society have legitimate interests in their own professional security and family security. Our position is that the systems are all out of balance. First of all, society needs to stop looking to psychiatry, psychiatric medication, forced treatment, and the police to solve what they perceive as a problem individual and/or problem behavior. Society needs to invest in safe, affordable, accessible, readily available housing. Second, society needs to invest in an inviolable affirmative entitlement to a broad array of culturally competent, voluntary mental health treatment. Third, psychiatrists should not be liable for conduct of a patient. The duty to warn is a folly. No one knows what any other individual is ever going to do. I think a psychiatrist should be allowed to warn anyone thought to be at risk, but at the same time, should never be liable if they fail to warn.

The therapeutic alliance is the single most important factor to keeping patients in treatment and keeping them and others safe. Society should demand a much higher standard of care and improved conditions of physical facilities where individuals are confined for involuntary treatment. It is an outrage and inhumane to involuntarily commit someone to a 19th-century psychiatric ward with 20 strangers or more per unit locked up, most with preexisting trauma, sleeping 2 or more to a room, with institutional food, and a complete lack of autonomy over things like the room lights. I think the public is unaware of what the inside of an inpatient psychiatric ward looks like and would have a hard time contemplating the shocking lack of dignity and respect with which psychiatric patients are often treated. I think if more of the public understood the reality of these environments, they would be joining us in our efforts for system change.

 One of the biggest failures of American health care and legal systems has been, so to speak, the criminalization of mental illness, such that jails and prisons are now the largest institutions providing psychiatric care in the country. It is astounding to me that we have accepted this as the new normal. The conventional story we hear is about the closure of asylums and lack of resource for community mental health care, but we hear much less about the other side of the story, the manner in which law enforcement has criminalized homelessness and poverty, and how, instead of providing decent living conditions, the social response has been to either ship them to the jails or ship them to the hospitals using some form of civil or forensic commitment. What is your perspective on all this?

 This is not acceptable, and this is not anything that any of us want. I do not understand how we have not been able to figure out how to effectively align on this, because I think this is an area where mental health professionals and civil rights lawyers have identified the same fundamental problem. The difference may lie in what we think is the best solution to that problem. I think we agree that criminalizing disability-related behavior and poverty-survival behavior is wrong. No one should go to jail or prison for being homeless. We need to provide decent, safe, affordable, and accessible housing to all. I believe that housing (not just shelter) is a human right. I think we should have an adequately funded, community-based system of voluntary services and supports. I do not believe forced psychiatry leads to anything we would call “recovery.” It causes trauma and makes it really difficult for anyone to want to engage with the system. I do not think we can use the excuse of the closing of the asylums anymore. That was decades ago. It is the choices we have made in the decades since that have led us to where we are today.

Policymakers need to make better choices. Here in Connecticut, when they closed 2 of the large state hospitals in the 1990s, they promised to reinvest the savings in the community-based system of care. They have never done that. That is why the Keep The Promise Coalition was established in 1999, after the Supreme Court issued the decision in the case brought by Lois Curtis and Elaine Wilson to get their freedom from a Georgia psychiatric facility (you probably recognize the case by the name 

 We want everyone, including those with psychiatric labels, to be able to build great lives in the community. That means, we, collectively, may have to provide some individuals, including some with psychiatric disorders, additional services and supports to make that happen. I wish systems would listen more to the individuals who are most impacted by policy decisions when making those decisions. Those folks need to be at the table from the beginning, not consulted after the fact.

We have to come up with a better system than calling the police on individuals in crisis, and that is an issue I have been working on. Police should rarely, if ever, be involved in welfare checks or arrests of individuals in distress experiencing mental health conditions.

I do not think we can automatically say that having mental health professionals respond is the best solution, because that often results in a trip to the hospital, where one can be subject to forced psychiatric treatment, and to many of us who have been on that side of the locked door, it does not feel all that different from jail or prison. For those who are already trapped in the criminal legal system, we need to provide better medical care (both physical and mental health) to incarcerated individuals. We need to develop re-entry plans that allow for support for return to the community, since most who go to jail or prison do get out. We need to provide opportunities for individuals to succeed once they have served their time: They need access to housing, to income (whether through employment or benefits), to education, and to voting and participating in community life. We need to include forensic mental health in our discussions about criminal legal system reform. We need to talk about re-entry for folks who spend decades in a state psychiatric hospital under the jurisdiction of a group of political appointees (the psychiatric security review board) whose mission is solely to protect so-called “public safety.” We have joined others in proposing we change that mandate to replace it with a balancing test that requires the board to consider both the protection of society and whether or not a less restrictive placement is available along with respect for the rights of patients under the 

I have really enjoyed the opportunity to talk with you about these issues, and I hope we have demonstrated it is possible to talk with, rather than simply past, each other. You have raised thoughtful questions, and I hope I have provided thoughtful answers. Clearly, needed far more than 280 characters to do this!

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of 

is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of Psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the 

Dr Aftab and Ms Flaherty have no relevant financial disclosures or conflicts of interest.

Articles

A lawyer discusses how the legal system treats (and mistreats) those with mental illnesses. 

Reconsidering Care and Coercion in Psychiatry: Kathleen Flaherty, JD

Rearview: A Psychiatrist Reflects on Practice and Advocacy in a Time of Healthcare System Change

A natural pearl is formed when an irritant works its way into certain mollusks. The mollusk secretes a fluid to coat the invasive irritant, and layer upon layer of this coating produces a lustrous pearl. So, it seems, is the life and times of Barry B. Perlman, MD, as the irritants he encounters transform him into a pearl of a psychiatrist to his patients, colleagues, and society. Such irritants, big and small, include the stigma of psychiatry, the intrusion of for-profit managed care, political maneuvering, and his own medical illness. It is as if, after each irritant, obstacle, and/or trauma, he and psychiatry come back stronger and more resilient. If this play on words and spelling seems trite, his work is anything but that.

Reading about his journey in this memoir will reveal pearls that will enhance the lives of anyone interested in mental health and illness, including the public, patients, medical students, and other physicians, especially primary care physicians. How could a memoir by a psychiatrist have this sort of scope? First of all, Perlman always values and uses his medical skills and knowledge. Secondly, most of his career was at St Joseph’s Medical Center, a rather unique community system that included a small community hospital; nursing home; freestanding psychiatric hospital; and outpatient clinics in Yonkers, a suburb just outside of New York City. For many years, Perlman was a director of the department of psychiatry, then before retirement he was medical director of the entire system—a rare administrative and leadership position for a psychiatrist. In addition to those interested in the medical field, family and friends should enjoy this inside look at a psychiatrist’s working life too, especially given that the confidentiality of our field inhibits workday sharing of information.

The title and image on the front cover illustrates Perlman’s journey. There is a rearview mirror and car windshield that have some clear sight spaces among what seem to me to be like many cracks and blurriness. When I asked Perlman by email why he named the memoir 

, he answered: “Because I’m retired. The initial impetus for a book was as a legacy for my kids . . . Once it got going & took on its own life it began to transcend the legacy project idea.”

I was a fellow traveler at the start of his medical journey. We were both medical students at Yale University from 1967 to 1971, both of us surprised, if not shocked, that we were accepted. After graduation, we met occasionally at reunions or communicated when our paths overlapped, like now in retirement. Since we were friendly, though not close friends, I can offer both a real-life confirmation of some of his story, but also the perspective of someone who took a slightly different, albeit eerily overlapping, psychiatric road. Our 50th year class reunion is fast approaching, and like so much of medicine in this COVID-19 era, it will be held virtually. Perlman closes the book with comments on the pandemic’s devastation, much of it seemingly preventable.

Still, he ends on a happy note: “I do assuredly feel an enormous sense of gratitude for my life despite the pandemic that has radically disrupted its later years.” Hopefully, most everybody in our class, as well as readers of this review, has felt that gratitude in being able to help others.

The structure of this book is unique, and it reminds me of the free association process that Freud advised for his patients. Perlman describes them better than I can: “These are recollections of sound bites, actions taken, or visual images retained in my mind’s eye, each within a particular context. Serious or humorous, I have amplified upon each as a story or tale providing content and personal meaning, joined to a discerned lesson or distilled thought.”

As you may be able to tell already, he tells his story in easy-to-read, conversational language and a touching thoughtfulness, full of grace. It falls into the tradition of narrative medicine, and it can be thought of as a book of personal short personal reminiscences.

There are 41 of these fragments. Everyone will have their favorites, but here are a few of mine, as I try to follow the model of conveying his fragment, elaborating on it a bit, and providing some afterthoughts.

My recalled fragment: “S**t, s**t, s**t . . . s**t…” (stars for letters are mine)

In describing learning about aphasia during a summer placement as a teenager, he meets an elderly gentleman who had a stroke. An executive at the Tootsie Roll company, all he could communicate was different expressions of “s**t.” Later, as a psychiatric resident, a teacher raised the possibility of why the patient used that word, and only that word, as it could be a symbolic, possibly Freudian anal connection with the physical appearance of Tootsie Rolls, those small, dark brown, and linked chocolate candies.

My recalled fragment: “Tell me doc, wasn’t there any piss in it?”

Here, the “piss” in the joke refers to the colloquial language of the patient, compared with the clinical, informational language that a doctor used to convey the results of a urine lab test (a language the patient cannot understand). Perlman tries to teach family practice residents to appreciate the psychiatric patients’ point of view by both play acting and sharing firsthand accounts from the literature. It is hard to imagine reading these recommendations and not wanting to read everything he references, including a 

 series titled “Personal History”; Andrew Solomon’s book, 

The Noonday Demon: An Atlas of Depression

The Black Season: Falling Out of Love with Mental Hospitals

An Unquiet Mind: A Memoir of Moods and Madness

The Center Cannot Hold: My Journey Through Madness

My recalled fragment: “They are not art.”

Perlman was curious and humanistic enough to rescue about 600 drawings of a preceptor done by a patient. They were going to be thrown out, as the preceptor was moving, but Perlman asked if he could have them, and he got them. This chapter discusses what is outsider art or not, and it includes some of the patient’s evocative and informative pictures on the subject of her reaction to the analyst and the analysis. If he still kept the rest of the 600, that could make for a whole new book.

My recalled fragment: “I wondered, ‘is he, she?’”

Here, Perlman describes his growth in understanding transgender individuals and the associated terminology changes. This is a subject of great importance to me, as I was the medical director for Pathways, the sole clinic in the Midwest processing those with gender concerns in the 1990s, and there is a trans child in our extended family. Expanding his curiosity beyond gender identity to bodily integrity (when someone might want an amputation of a normal limb to feel that their body is correctly aligned), he wonders if these can be called “misalignment syndromes.” Good idea! He acknowledges that transgender care and terminology remain complicated issues. This fragment “has been among the most difficult to write.”

My recalled fragment: “I couldn’t pull the plug on my father.”

This chapter poignantly illustrates the difference between personal and professional medical decision making. During his beloved father’s dementia, Perlman was unable to decide not to place a pacemaker, even though he wondered if his father would have refused it.

Besides these chapter pearls, Perlman also writes many short, sentence-length pearls scattered throughout the memoir. Here are a few that particularly struck me:

“Deceptively, history makes the present seem foreordained; or so it may seem as we look back at our lives.”

“It did not take me long to become aware that better self-understanding meant more successful engagement in advocacy.”

“Asserting my position, I found, often made me into an acquired taste.”

When the reader finishes the book, the Introduction section becomes even more striking, as Perlman deservedly begins to find his retirement pearls on the day after he retired. He and his supportive and understanding wife drive to their country home.

“I quietly observed to myself how beautiful the scene was. For the first time in decades, I could relish the snow-covered landscape without the attendant worry about whether the “moonlighter,” the off-hours psychiatrists, would be able to get to the hospital, and if they could not what arrangements I could make to assure that the psychiatric service was covered.”

Then, if you happen to turn to the back cover, you see Barry with sunglasses on, smiling over the small lake near his country home, the sun shining on his world. Likely, that lake does not have pearl-bearing mollusks, but he has enough of them anyways.

With this book, he is giving some of those pearls back, back to his medical and family descendants. I am quite sure that any reader will be mentally enriched by reading this memoir.

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of being a Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He has recently been leading Tikkun Olam advocacy movements on climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

A psychiatrist shares the pearls of his life, clinical and otherwise. 

If you meant to tase me then I implore your weapon to transmit jolts of infinite mercy that invites tranquility.

If you meant to shoot me then I implore your weapon to discharge bullets that provide validation to a dehisced vexed wound.

If you meant to place your genu on my listless collum then I implore your weapon to release oxygenated synovial fluid that coats my cyanotic vasculature.

If you meant to pepper spray me then I implore your weapon to deliver capsaicin that has paradoxical effects on my traumatized orbits.

If you meant for me to silence my first amendment larynx then I implore your weapon of invalidation to be disarmed by the divine whose spirit weeps unapologetically.

If you meant to justify the carnage of my fellow Black brothers and sisters with explicit bias then I implore your weapon of septic optic nerves to be repaired with the balm of shared humanity.

is clinical assistant professor at the University of South Carolina School of Medicine-Greenville and medical director & division chief for Adult Inpatient and Consult-Liaison Services for the Department of Psychiatry and Behavioral Medicine at Prisma Health-Upstate. He currently serves on the APA Task Force to Address Structural Racism Throughout Psychiatry as well as the Diversity & Inclusion Section Editor and Advisory Board member for

Accoutered With Underutilized Ammunition

H. Steven Moffic, MD, reflects on the racial injustices faced by Black Americans.

Videos

H. Steven Moffic, MD, reflects on the guilty verdict against Derek Chauvin for the murder of George Floyd.

The Verdict Is in: A Corrective Emotional Antiracism Experience

Susan J. Noonan, MD, MPH, talks about the unique problems caregivers may face when trying to help a patient with a mood disorder. 

is a physician consultant and Certified Peer Specialist in the Department of Psychiatry at McLean Hospital and the Massachusetts General Hospital. She is the author of four books and a blog on managing depression, most recently 

Helping Others With Depression: Words to Say, Things to Do (December 2020)

. Dr Noonan offers peer counseling to fellow patients, including physicians and other professionals, and can be confidentially reached through her website at 

Caring for patients with mood disorders is different than caring for patients with any other medical issues. 

Special Challenges of Caring for a Patient With a Mood Disorder

COVID-19 shined light on the inequities caused by racism in the United States and has served as a wake-up call. Yet there are additional areas that are impacted by the insidious nature of racism. 

, the Racism & Psychiatry collection will highlight the ways communities of color have been uniquely impacted by climate disruption. 

While the specific stories may be idiosyncratic, the shared interconnections cannot be lost. As the articles are published online, we will be adding the links to:

◊ Facing Down a Crisis, by Robin Cooper, MD

◊ Recovering Ancient Knowledge for the Good of the Earth, by Mary H. Roessel, MD

◊ Rising From the Ashes of Oppression: The Black Experience, by Ulrick Vieux, DO, Eneida Miranda, DO, and S. Roger Maginley, MD

◊ Impact of Climate Change on US Hispanic and Latinx Communities, by Hector A. Colon-Rivera MD, CMRO, and Giselle Plata, DO, MPH

◊ Exploring the Asian and International Focus, Russell Lim, MD, and Barrington Hwang, MD

◊ Next Steps: Solutions and Recommendations For Healing, The Racism & Climate Change Authors

The Racism & Psychiatry collection highlights the ways communities of color have been uniquely impacted by climate disruption and what psychiatrists can do about it.

The Tangled Roots of Racism and Climate Change

When Amazon Prime decided to base a television series on selected stories from the “Modern Love” column of The New York Times, I was excited. I had been an avid reader of the column, in which individuals reflect on the intricate nature of human relationships. The episode that struck me most was “Take Me As I Am, Whoever I Am,” 

based on the essay written by Terri Cheney in 2008

 Then an entertainment lawyer, Terri wrote about her struggles with ultradian bipolar disorder, revealing how she hid her condition from her friends before ultimately going public.

In the series, Terri is played by Anne Hathaway. The Oscar-winning actress takes the viewer through the roller coaster of bipolar highs and lows. The episode begins with Lexi (Hathaway) during a manic high at a supermarket. She sports loud makeup, sequins, and bright clothes. She is instantly drawn to a man named Jeff and lands herself a date with him that week. The action segues into a flash-mob dance reminiscent of a scene in the movie 

As might be expected, the high does not last. As soon as Lexi reaches home, she abruptly sinks into depression and curls up in a fetal position, almost catatonic in her bed. While she does manage to wake herself up for the date, she appears slow, dysphoric, withdrawn, and unkempt, making Jeff wonder if she has a twin.

A few mornings later, Lexi wakes up—euphoric again—to the sound of birds chirping, and she calls Jeff for another date. However, by the time he arrives that night, she has flipped again, going from dancing around her apartment to sobbing uncontrollably on the bathroom floor. When Jeff walks away, she decides things need to change. She needs to give everyone a chance to know the real Lexi.

The episode illustrated how stigma often prevents individuals from getting the psychiatric help they need. Particularly unusual was the portrayal of a high-functioning lawyer with ultra-ultra rapid cycling (ultradian) bipolar disorder, an uncommon illness for even psychiatrists to see and diagnose. Lexi had almost no baseline or a euthymic phase.

As a portrayal of bipolar disorder, the episode has both strong and weak points. Hathaway’s portrayal of Lexi’s depression makes you feel empathetic. Crumpled on her bathroom floor in tears, hopeless and terrified, Lexi is a realistic portrayal of many patients’ experiences. Lexi’s mania, however, looks as glamorous as a Hollywood movie. She is super-productive and euphoric, with no impairment or mixed symptoms. Unfortunately, many patients will not be able to relate.

Pluses and minuses aside, it is heartening to think that viewers will see and empathize with Lexi’s struggles. Ultradian bipolar disorder can be difficult to recognize, even for psychiatrists, and it can be a controversial 

 While 12% to 24% of patients with bipolar disorder experience rapid cycling (defined as 4 or more mood episodes in a year), the ultradian form is characterized by multiple episodes in a day. Some psychiatrists would prefer to classify it as a mixed state. Ultradian might also be mistaken for borderline personality disorder (BPD), but there are ways to distinguish them. For instance, mood cycling in BPD is closely tied to events in patients’ emotional lives, so it may appear random. In contrast, the underlying chemical disturbance in ultradian bipolar disorder leads to more regular mood cycling.

Despite its rarity, ultradian has been on psychiatrists’ radar for decades, and good treatment options are available. Robert M. Post, MD, and colleagues first described 

 Anticonvulsants like valproic acid and carbamazepine may be more effective for treatment than lithium. It is also important to reduce triggering factors like antidepressants, drugs of abuse, thyroid abnormalities, and irregular sleep schedules. There have been promising results with calcium channel blockers like 

In the episode’s final scene, Lexi finally opens up about her condition to a coworker. It is a powerful moment in which she likens the cathartic experience to an elephant lifting its foot off her chest. After a trial of several medications and electroconvulsive therapy, Lexi finds a new stability. She is ready to begin a new chapter in her life.

Cheney’s column and the episode both end with 

: “I’ve finally accepted that there is no cure for the chemical imbalance in my brain, any more than there is a cure for love.”

An earlier version of this article was posted ahead of print on March 9, 2021 with the following title: 

Handling the Highs and Lows of Ultradian Bipolar Disorder—and Love

is chief resident physician of psychiatry at the University of Missouri–Columbia.

1. Jones D. Modern Love: coming out as bipolar in Modern Love and reliving it on TV. The New York Times. October 18, 2019. Accessed February 15, 2021. 

https://www.nytimes.com/2019/10/18/style/anne-hathaway-modern-love-terri-cheney.html

2. Bauer M, Beaulieu S, Dunner DL, Lafer B, Kupka R. Rapid cycling bipolar disorder—diagnostic concepts. Bipolar Disord. 2008;10(1 Pt 2):153-162. doi:10.1111/j.1399-5618.2007.00560.x

3. Kramlinger KG, Post RM. Ultra-rapid and ultradian cycling in bipolar affective illness. Br J Psychiatry. 1996;168(3):314-323. doi:10.1192/bjp.168.3.314

4. The Carlat Psychiatry Podcast. Word of the day: ultradian cycling. Carlat Publishing. July 4, 2020. Accessed February 15, 2021. 

https://www.thecarlatreport.com/blog/word-of-the-day-ultradian-cycling/

5. Cheney T. Modern Love: take me as I am, whoever I am. The New York Times. January 13, 2008. Accessed February 15, 2021. 

https://www.nytimes.com/2008/01/13/style/modern-love-take-me-as-i-am-whoever-i-am.html

“As soon as Lexi reaches home, she abruptly sinks into depression and curls up in a fetal position, almost catatonic in her bed.”

Finding Love Among the Highs and Lows of Ultradian Bipolar Disorder

is professor of psychiatry and the Former Von Tauber Chair,

Psychiatry & Behavioral Sciences at Nassau University Medical Center.

Nature is an integral part of religion. Religion serves as a bridge between humans and the environment by using rituals to mark the rhythm of the seasonal changes, to express gratitude for a bountiful harvest, and pray to keep away destructive natural forces. Many religions teach that humans are the caretakers of this planet earth. The beliefs about human-nature relationships, religious cosmologies, and climate change perceptions are a set of interrelated concepts, reinforced and shaped by one another. How might we approach climate change from the Hindu point of view?

It is critical to understand how various cultures function concerning nature. Hindu religion is a multifaceted faith with numerous perspectives on human-nature relationships.

 There is no central authority that prescribes and proscribes universally accepted human behavior to all Hindus. There is a description of unity in all diversity: “Vasudhaiva Kutumbakam,” meaning “the whole world is a family” in Sanskrit.

Hinduism teaches that the 5 significant elements (space, air, fire, water, and Earth) that constitute the environment are all derived from 

, the primal energy. Each of these elements has its own life and form; together, the elements are interconnected and interdependent. Hinduism recognizes that the human body is composed of and related to these 5 elements. Each element is connected to 1 of the 5 senses. The human nose is related to Earth, tongue to water, eyes to fire, skin to air, and ears to space. This bond between our senses and the elements is the foundation of our human relationship with the natural world. For Hinduism, nature and the environment are not outside us, not alien or hostile to us. They are an inseparable part of our existence, and they constitute our very bodies.

 explain the interdependence of these elements in relation to 

, the supreme reality, from which they arise: “From Brahman arises space, from space arises air, from air arises fire, from fire arises water, and from water arises earth.”

 is considered to be a universal organizing principle that governs all reality. Thus, protecting the environment has been considered by some as Hindu dharma. Another central concept of Hinduism is 

, which holds that every action has consequences and that there is a causal relationship between one’s actions and one’s future fate, even in subsequent lifetimes. Thus, 

 is also closely related to the concept of rebirth, or 

. Both concepts further illustrate the Hindu conception of the human-nature relationship in 2 ways: 1) there is a continuity and an intimate relationship among all forms of beings on Earth, and so it is essential that no harm is done to any of them; and 2) one’s behavior toward the environment will have karmic consequences, which means one can accumulate good 

—has mantras that remind Hindus of the need to behave respectfully toward Mother Earth by making sure that any personal activities do not hurt her vitals, body, or appearance. The Hindu Puranas are one such collection of Hindu myths and traditional lore. For example, some are related to the Ganges River, or Ma Ganga, which is depicted as a goddess who descended to Earth to save the world. The Ganges River is thus perceived to be a sacred place where believers can remove their sins by touching or consuming the water, and the river is an essential site for worshipping rites and rituals in India.

In 2009, at the Parliament of the World’s Religions, a convocation of Hindu Spiritual Leaders adopted the inaugural Hindu Declaration on Climate Change, which failed to gain full support from the members. This declaration was later reintroduced at the Paris Climate Conference in 2015, when it won the support from various Hindu organizations and activists worldwide. Within the Declaration, Hindu leaders made specific references to teachings from religious texts to highlight how Hindus have an inherent duty to protect the environment.

 Bhumi was established in 2009 by the Oxford Centre for Hindu Studies. The UK-based Bhumi Project recognizes that Hindu communities can become an important voice in addressing climate change, through the “unique contributions Hindu teachings can make.”

 One of their global initiatives includes the Green Temples Guide, an effort to make Hindu pilgrimage sites and worshipping practices around the world more environmentally sustainable.

 Local Hindu communities in India do not engage in environmentally friendly practices as part of a wider contemporary environmental movement; rather, their own practices have inherent environmental significance, as guided by their religious tradition to express 

. One such example is the famous Chipko movement, which first started as a local response against a deforestation project. The strategy was eventually adopted in various other locations, where villagers would hug the trees as a form of protest, risking their lives in front of contractors.

 In his research, Pankaj Jain quotes a Swadhyayi who is skeptical about the academic focus on ecological characteristics underlying their cultural practices, because such practices were never about environmental sustainability, and should instead be viewed as an expression of their devotion to the divine.

I would like to share a personal experience: when Hurricane Sandy ravaged the North Eastern United States on October 29, 2012, it inflicted massive damage to my life and property. Nothing could stop an 8-foot wave of ocean water from flooding my basement filled with memorabilia, a library, and a collection of music gathered over 35 years. In addition, 3 automobiles had to be condemned. By the time the event was over, there was nothing left, and I had to start afresh once again after living in the US for 32 years. This was a tragedy that brought me and my family face to face with death.

These experiences, more common these days, warn us to start paying serious attention to preserve and protect the environment. Only meditation helped me to survive.

To see more on Earth & Psychiatry, please see

The Power and Potential of Earth Week and Psychiatry

1. Tay P. Can religion teach us to protect our environment? Analyzing the case of Hinduism. 

https://www.ethicsandinternationalaffairs.org/2019/can-religion-teach-us-to-protect-our-environment-analyzing-the-case-of-hinduism/

2. Alliance of Religions and Conservation. The Bhumi Project: Hindu plans for generational change. October 2009. 

http://www.arcworld.org/downloads/Hindu-9YP.pdf

3. Rao NR, Mehra A. Hurricane Sandy: Shared trauma and therapist’s self-disclosure. 

Psychiatry: Interpersonal and Biological Processes

4. Rao NR. The influence of culture on learning of psychiatry: the case of Asian-Indian international medical graduates. 

International Journal of Applied Psychoanalytic Studies

Ancient religious texts from India explain the deep connections between human beings and their environment. 

Climate Change and Hinduism

John J. Miller, MD, talks about paying attention on purpose to the present moment to better understand oneself. 

is medical director, Brain Health, Exeter, NH; editor in chief,

; staff psychiatrist, Seacoast Mental Health Center, Exeter, NH; consulting psychiatrist, Exeter Hospital, Exeter, NH; consulting psychiatrist, Insight Meditation Society, Barre, MA.

Meditation: useful, helpful, and health-promoting for both psychiatrists and patients. 

Meditation: It's Not What You Think

Lyndra Therapeutics announced results from its phase 2 study of the extended-release (ER) risperidone capsule, LYN-005, in an oral presentation at the 

2021 Congress of Schizophrenia International Research Society

A new risperidone capsule for the treatment of schizophrenia sees positive phase 2 study results. 

Do Psychiatrists Treat Diseases?

The Bigger Picture: Across Neuronal Systems

Mayday! Mayday! Mayday! It’s Earth Day

A Call to Change in the Relationship Between Psychiatry and the Earth

How Can One Mental Illness Generate the Opposite Mood Experiences?