The NCCHC Foundation will award scholarships for students and correctional health professionals who have three or less years of experience in the field to attend the NCCHC 

Correctional Mental Health Care Conference

, taking place August 1-2 in Denver. Completed applications are due no later than 12 pm (CDT) on May 27, 2022. Awardees will be notified by July 5, 2022.

The Scholarships will cover the full price of conference registration, a value of $425, plus travel and hotel expenses. Gifts are made possible by Centurion Health, Corizon Health, and other generous donors to the NCCHC Foundation.

Articles

Apply for a scholarship for the NCCHC Correctional Mental Health Care Conference!

NCCHC Foundation Offers Scholarships for the NCCHC Correctional Mental Health Care Conference

Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of 

 (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on

The horrific mass school shooting in Uvalde, Texas, is the deadliest such shooting at an American school in nearly a decade.

 A mass shooting is frequently defined as a single attack in a public place, in which 4 or more victims were killed. Sadly, there are few reasons to believe that the frequency of such tragedies will decline anytime soon. On the contrary, unless a wide range of contributing factors change, there are compelling reasons to expect more mass shootings in the US, some of which will target schools.

The reasons for this rather gloomy prediction are detailed below. It is not my intent to dissect the specific details of the Uvalde shooting or to speculate on the psychology or motives of the shooter; but rather, to provide a framework for understanding why the US seems caught in an endless, repeating loop of gun-related carnage.

1. There is an almost inexhaustible supply of marginalized, emotionally disturbed, rage-filled young men in this country

Since 1982, at least 123 mass shootings have been carried out in the US by male shooters, versus 3 by females.

 I will say more about the gender issue and its cultural roots presently. According to psychology professor 

, most of the perpetrators of K-12 shootings are under the age of 18.

And while there is no single psychological or demographic profile that can proactively identify likely school shooters, there are some general features school shooters tend to share, such as profound feelings of rejection and a history of having been bullied. Many shooters also display a fascination with guns and/or a preoccupation with violence.

There is no credible, clinically-based evidence that mass shooters, as a group, are psychotic or delusional when carrying out their violence.

 Furthermore, blaming “mental illness” for school shootings stigmatizes those with clinically-diagnosed psychiatric disorders, who are rarely violent when adequately treated.

 That said, Kowalski and her colleagues found that more than half of K-12 shooters had a history of “psychological problems” of various sorts.

2. Handguns are easily obtainable in the US, and are often poorly-secured by family members. 

Though the Uvalde shooter apparently used a rifle,Kowalski found that handguns were used in over 91% of the K-12 shootings, and almost half of the shooters stole the gun from a family member.

 According to Daniel Flannery, a professor at Case Western Reserve University and the director of the Begun Center for Violence Prevention Research and Education, “It’s way easier to get a handgun than it is to do just about anything else in this country…our background check is woefully inadequate.”

 Furthermore, more than half of gun owners do not safely store all their guns, according to a survey of 1444 US gun owners conducted by researchers at the Johns Hopkins Bloomberg School of Public Health.

3. Violent acts, including mass shootings, are on the rise nationwide, possibly related to the pandemic and its attendant socioeconomic dislocations.

Recent data from cities across the US show a trend of increased violent crimes as the COVID-19 pandemic has lingered on, though the numbers vary from city to city.

 Moreover, a cross-sectional study showed large increases in mass shootings with the start of the COVID-19 pandemic, “…consistent with the notion that mass shootings, an extreme form of violence, may be influenced by social and economic factors.”

 While acknowledging that such correlations do not necessarily represent causation, the recurrent and largely unpredictable surges of COVID-19 infection, coupled with their adverse socioeconomic repercussions, probably represent a risk factor for more mass shootings.

4. Psychological distress is increasing among teens and adolescents, and there is a shortage of mental health support for this age group.

In December 2021, the United States surgeon general, Vivek Murthy, MD, warned that young people are facing devastating mental health effects as a result of generational challenges, including the coronavirus pandemic. Dr Murthy’s report noted significant increases in self-reported depression and anxiety in younger age groups, along with more emergency room visits for mental health issues.

 Murthy observed that, “Young people are bombarded with messages through the media and popular culture that erode their sense of self-worth—telling them they are not good-looking enough, popular enough, smart enough or rich enough [and]…that comes as progress on legitimate, and distressing, issues like climate change, income inequality, racial injustice, the opioid epidemic and gun violence feels too slow.”

 While it is not clear that these trends will have a direct effect on the likelihood of school shootings, we need to recall Dr Kowalski’s finding that most perpetrators of K-12 shootings are under the age of 18.

 Unfortunately, obtaining professional help for this troubled age group has become increasingly difficult in the US, and shortages of mental health workers have only been worsened by the pandemic.

5. Media attention may encourage the copycat effect.

After mass shootings, the general media are often fixated on the shooter’s motives, family background, signs of mental disturbance, social media postings, etc. Almost inevitably, this lurid coverage is linked to the shooter’s name and face. Unfortunately, there is reason to believe that this sort of sensational publicity may encourage copy-cat killers, bent on outdoing the previous shooter.

 To the tens of thousands of disaffected, rejected, and bullied young men who imbibe this sort of cultural glorification, the temptation to “make history” by violent and vengeful means may prove irresistible. Alas, I see no sign that the media are becoming more restrained in their publicity of these horrific events—and this does not bode well for the future.

Though it is easy to give in to despair, there are ways, as a society, that we can reduce the frequency and lethality of mass shootings. As my colleague, James L. Knoll IV, MD, and I argued in a previous article,

“While solid, evidence-based methods of preventing mass shootings are still lacking, we believe that progress will come through work on a number of fronts. First, better reporting of ominous behaviors and careful use of extreme risk protection orders may avert at least some mass shootings. Second, the use of Threat Assessment and Management (TAM) teams in our schools may also help preempt planned attacks. TAM teams are interdisciplinary groups of professionals that include law enforcement, mental health providers, and other security stakeholders, collaborating in a structured effort to accurately assess and mitigate the risk of violence.”

Beyond these remedies, I believe that we Americans, as a society, need to do some serious introspection. That begins by asking ourselves some serious questions, like: what must we do to reduce the likelihood that troubled adolescents with violent intentions will get hold of unsecured firearms? What resources are required to address the mental health needs of younger populations? And what must we do to counteract the allure and glamor of these unspeakably violent deeds?

1. Kornfeld M, Iati M, Knowles H, et al. Biden says Second Amendment ‘not absolute’ as more details of school shooting emerge. 

https://www.washingtonpost.com/nation/2022/05/25/texas-school-shooting-uvalde-victims-live-updates/

2. Statista Research Department. Mass shootings in the U.S.: shooters by gender, as of May 2022. May 25, 2022. Accessed May 26, 2022. 

https://www.statista.com/statistics/476445/mass-shootings-in-the-us-by-shooter-s-gender/

3. Kowalski RM. School shootings: What we know about them, and what we can do to prevent them. Brookings. January 26, 2022. May 26, 2022. 

https://www.brookings.edu/blog/brown-center-chalkboard/2022/01/26/school-shootings-what-we-know-about-them-and-what-we-can-do-to-prevent-them/

Mass murder: causes, classification, and prevention. 

6. Shapiro E, Andreano C. The type of gun used in most US homicides is not an AR-15. ABC News. October 26, 2021. Accessed May 26, 2022. 

https://abcnews.go.com/US/type-gun-us-homicides-ar-15/story?id=78689504

7. Survey: more than half of U.S. gun owners do not safely store their guns. Johns Hopkins Bloomberg School of Public Health. February 22, 2018. Accessed May 26, 2022. 

https://publichealth.jhu.edu/2018/survey-more-than-half-of-u-s-gun-owners-do-not-safely-store-their-guns

8. Beals M. How violent crime has gone up since the pandemic. 

. February 15, 2022.Accessed May 26, 2022. 

https://thehill.com/policy/national-security/594291-how-violent-crime-has-gone-up-since-the-pandemic/

Mass shootings in the US during the COVID-19 pandemic.

10. Richtel M. Surgeon General warns of youth mental health crisis. 

 December 7, 2021. Accessed May 26, 2022. 

https://www.nytimes.com/2021/12/07/science/pandemic-adolescents-depression-anxiety.html

11. Axelson D. Addressing the youth mental health crisis with coordinated systems of care. 

https://www.psychiatrictimes.com/view/addressing-the-youth-mental-health-crisis-with-coordinated-systems-of-care

Reducing media-induced mass killings: lessons from suicide prevention. 

13. Pies RW. After Las Vegas, the danger of copy-cat killers. 

http://www.psychiatrictimes.com/trauma-and-violence/after-las-vegas-danger-copy-cat-killers

14. Knoll JL IV, Pies RW. Moving beyond “motives” in mass shootings. 

. January 14, 2019. Accessed May 26, 2022. 

https://www.psychiatrictimes.com/view/moving-beyond-motives-mass-shootings

Kowalski RM, Leary M, Hendley T, et al. 

K-12, college/university, and mass shootings: similarities and differences

Unless there are substantive societal changes at many levels, the answer may be yes.

Is the Plague of Mass School Shootings in the US Here to Stay?

Special Report Chairperson: Tony P. George, MD, FRCPC

The majority of adults worldwide drink alcohol,

 and most individuals drink alcohol without developing problems related to alcohol use.

 Yet, epidemiological data in the United States suggest as many as 13.9% of individuals meet criteria for a current 

 (AUD) and approximately one-third (29.1%) meet lifetime criteria.

 Globally, alcohol use contributes to 5% of the total disease burden and is associated with tremendous social and economic costs.

AUD is defined by the DSM-5 as clinically significant impairment or distress, resulting from endorsing at least 2 of 11 symptoms in the past 12 months.

 The 11 symptoms are intended to fall into 4 symptom clusters (

The DSM-5 also provides a definition of remission from AUD based on the length of time that symptoms are no longer present. Early remission is defined as greater than 3 months and less than 12 months of endorsing no symptoms of AUD, apart from craving. Sustained remission is defined as 12 months or more of endorsing no symptoms of AUD, apart from craving. Craving is excluded from definitions of remission, given that craving could persist long after remission of other AUD symptoms is achieved.

Although AUD is often described as a chronic and relapsing condition, remission from AUD is achievable. In fact, most people with AUD enter remission even without treatment.

 This natural recovery process is the most common pathway to AUD resolution.

 As noted previously, it is important to highlight that many people drink alcohol without developing problems,

 and those who drink less have lower morbidity and mortality.

Recovery-Based Approaches and Forward-Thinking Policy: Implications for Addiction Care

Ashley E. Kivlichan; Darby J.E. Lowe, MSc; Tony P. George, MD, FRCPC

Cannabis Legalization: What Psychiatrists Need to Know

Samantha Johnstone, BA; Kevin P. Hill, MD, MHS; and Tony P. George, MD, FRCPC

Dual Diagnosis: Double the Stigma, Double the Trouble

Darby J.E. Lowe, MSc; Emily Simpkin, RN; Tony P. George, MD, FRCPC

As early as the 1700s, AUD recovery was defined by complete and total abstinence from alcohol use, and this view persisted until the 1900s.

 Although in some spaces, such as Alcoholics Anonymous, total abstinence is still considered a required aspect of recovery, current definitions have shifted toward a focus on the importance of overall functioning and general well-being with or without abstinence.

 Recovery from AUD includes broader domains of well-being, quality of life, social environment, and health functioning, with subdomains of cognitive and emotional functioning, purpose in life, engagement in valued activities, social network support, cultural connections, reductions in harmful use, and ecological and contextual features that support health (

Domains and Subdomains in Definitions of Recovery from AUD

The Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute on Drug Abuse both define recovery as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”

 SAMHSA noted the importance of abstinence as 1 example of achieving improvements in health.

In 2017, a meeting was convened by recovery researchers with a specific focus on examining the concept of recovery based on a literature review and ideas generated by group members.

 Their final definition was: “Recovery is an individualized, intentional, dynamic, and relational process involving sustained efforts to improve wellness.”

 This definition acknowledges the presence and importance of individual differences in the recovery process, focuses on the recovery process as being both intentional and dynamic, and is one that requires sustained efforts to improve wellness. Improving wellness includes not only the physical benefits associated with reducing alcohol use,

 but also benefits related to psychosocial and functional dimensions of wellness (eg, social, emotional, and financial).

The shift away from abstinence-based definitions of recovery and toward nonabstinent definitions of recovery that consider quality of life and well-being is also supported by preliminary quantitative and qualitative research in this area. Witkiewitz and colleagues

 social functioning, employment followed individuals enrolled in AUD clinical trials for 3 years and identified 4 profiles of individuals based on intensity and frequency of alcohol consumption, as well as other indicators of health and well-being: (1) low-functioning frequent heavy drinkers, (2) low-functioning infrequent heavy drinkers, (3) high-functioning occasional heavy drinkers, and (4) high-functioning infrequent nonheavy drinkers. Relative to high-functioning infrequent nonheavy drinkers, individuals who were high-functioning occasional heavy drinkers did not differ on measures of functioning. High-functioning occasional heavy drinkers had significantly higher purpose in life when compared with poor-functioning profiles and greater satisfaction with life when compared with abstainers, which suggests that overall functioning and well-being do not require abstinence.

Mixed methods research with people seeking to resolve AUD supports the importance of incorporating indicators of recovery outside those related to consumption. For example, Kaskutas and colleagues

 surveyed 9341 individuals who self-identified as being in recovery to describe specific aspects of recovery from their perspective. Participants identified several aspects of recovery that were unrelated to the amount of alcohol consumed, including spirituality, dealing with challenging negative feelings, realistic self-appraisal, and an individual’s ability to look inward (eg, inner peace) and outward (eg, living a life that contributes to others and society) and to engage in self-care.

 developed a new patient-reported outcome measure of recovery from drug and alcohol dependence, named the Substance Use Recovery Evaluator, which was developed alongside addiction psychiatrists as well as staff and individuals in recovery (eg, former/current drug and alcohol service users). A 5-factor solution emerged: (1) substance use, (2) material resources, (3) outlook on life, (4) self-care, and (5) relationships. Similar to the findings of Kaskutas and colleagues,

 few items pertained specifically to substance use–related recovery outcomes. This research provides further support for the importance of nonabstinence-based factors, such as quality of life, social connection, and personal meaning, in recovery.

Nonabstinent Recovery and Social Determinants of Health

By expanding definitions of recovery to include nonabstinent recovery, researchers and clinicians can contribute to reductions in harmful use of alcohol and potentially improve whole-person health outcomes by acknowledging and addressing the multilevel, social ecologies that shape individuals’ lives.

 When recovery requires abstinence, it reinforces empirically unsubstantiated understandings of AUD that may enhance the stigma associated with AUD. Specifically, abstinence-only recovery can reinforce the notion that alcohol use is problematic only for those with AUD, and those with AUD will not ever be able to drink again.

 Requiring abstinence as the major focus of treatment can also lead to neglect of other areas that are important to health and well-being, including treatment for comorbid mental health disorders and building environments that support life functioning (eg, housing, access to medical care).

The corresponding author previously conducted research at a community-funded residential treatment program that focused exclusively on abstinence. Unfortunately, many individuals who achieved abstinence were “successfully” discharged without housing in a major metropolitan city. Failure to address broader determinants of health precipitated a quick return to substance use, which would often result in individuals returning to treatment or prison shortly after discharge. Focusing on whole-person recovery and not just abstinence would have likely encouraged the same treatment program to consider the influence of housing status on individual well-being, quality of life, and health functioning. More importantly, it is likely the people served by such a program with a broadened focus would have far better chances of recovery.

Abstinence-based approaches to helping individuals who receive a diagnosis of AUD have been shaped by the disease-based understanding of AUD and the clinical setting, in which problem recognition and help seeking occur. Instead of focusing on negative self-definitions that arise from a disease-based understanding of AUD, incorporation of nonabstinence in recovery allows individuals to instead envision and actualize a life that would be of the greatest value to them. Expanding recovery to include nonabstinent understandings of recovery reduces stigma not only by deemphasizing a disease or pathology-based understanding of AUD, but also by shifting emphasis toward an approach that highlights individual strengths, improves intra- and interpersonal resilience, and engages social and community support systems.

Importantly, when AUD is conceptualized as existing on a continuum of severity, rather than using a dichotomous disease-based model, more nontreatment-seeking heavy drinkers recognize their own alcohol use as problematic.

 As a result, defining both AUD and AUD recovery on a continuum could promote treatment seeking and motivate behavior change among a greater proportion of drinkers. From the perspective of improving public health and reducing population-level risky alcohol consumption, greater population health is achieved by promoting reductions in alcohol use among the whole population.

 As such, broader definitions of AUD recovery that incorporate nonabstinence as a pathway of recovery could enable improved alcohol use outcomes at the population level through reduced stigma, greater problem recognition, and increases in help seeking.

Recent work in the AUD field that relies on a framework of AUD focused on functioning and well-being as key determinants of recovery has theorized the importance of capturing the multilevel, socioecological context in which both drinking behavior and AUD recovery exist.

 Expansion of notions of recovery to include this constellation of influences on an individual’s life stands in stark contrast to most current clinical treatment models that focus on amelioration of disease and intraindividual mechanisms of change. Most treatment programs in the United States are primarily concerned with the initiation and maintenance of abstinence. A clinical treatment model that incorporates a broad understanding of recovery to focus on whole-person health might prioritize facilitating the building of social and community ties, promoting healthy diet and exercise, and identifying activities that do not involve using alcohol.

Research has also shown that financial stability as well as housing and food security are also particularly important in maintaining high levels of functioning and well-being in recovery.

 At the community level, Swan and colleagues

 found that individuals in communities with low rates of insurance and high rates of income inequality were least likely to achieve recovery, whereas those with high rates of insurance and low rates of income inequality were more likely to achieve a nonabstinent recovery. Limiting definitions of recovery to abstinence and the absence of AUD symptoms fails to capture the multidimensional and heterogeneous pathways to recovery that research has shown to exist among both treatment-seeking and population samples.

is a research assistant professor at the University of New Mexico. 

 is a postdoctoral fellow at the University of New Mexico. 

 is a Regents’ professor of psychology at the University of New Mexico.

Global Status Report on Alcohol and Health 2018

2. Grant BF, Goldstein RB, Saha TD, et al. 

Epidemiology of DSM-5 alcohol use disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions III

3. American Psychiatric Association, DSM-5 Task Force. 

Diagnostic and Statistical Manual of Mental Disorders, 5th ed

. American Psychiatric Association Publishing Inc; 2013.

4. Hasin DS, O’Brien CP, Auriacombe M, et al. 

DSM-5 criteria for substance use disorders: recommendations and rationale

5. Tucker JA, Chandler SD, Witkiewitz K. 

Epidemiology of recovery from alcohol use disorder

Recovery from alcohol problems with and without treatment: prevalence in two population surveys

Alcohol use and burden for 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

8. Witkiewitz K, Montes KS, Schwebel FJ, Tucker JA. 

Abstinence not required: expanding the definition of recovery from alcohol use disorder

10. SAMHSA’s working definition of recovery: 10 guiding principles of recovery. Substance Abuse and Mental Health Services Administration. 2012. Accessed April 1, 2022. 

https://store.samhsa.gov/sites/default/files/d7/priv/pep12-recdef.pdf

11. Recovery. National Institute on Drug Abuse. Accessed April 1, 2022. 

https://nida.nih.gov/drug-topics/recovery

12. Ashford RD, Brown A, Brown T, et al. 

Defining and operationalizing the phenomena of recovery: a working definition from the recovery science research collaborative

The risks associated with alcohol use and alcoholism

14. Witkiewitz K, Wilson AD, Pearson MR, et al. 

Profiles of recovery from alcohol use disorder at three years following treatment: can the definition of recovery be extended to include high functioning heavy drinkers?

15. Kaskutas LA, Borkman TJ, Laudet A, et al. 

Elements that define recovery: the experiential perspective

16. Neale J, Vitoratou S, Finch E, et al. 

Development and validation of ‘SURE’: a patient reported outcome measure (PROM) for recovery from drug and alcohol dependence

Dynamic Pathways to Recovery from Alcohol Use Disorder: Meaning and Methods

18. Morris J, Albery IP, Heather N, Moss AC. 

Continuum beliefs are associated with higher problem recognition than binary beliefs among harmful drinkers without addiction experience

19. Swan JE, Aldridge A, Joseph V, et al. 

Individual and community social determinants of health and recovery from alcohol use disorder three years following treatment

Conceptualizing recovery capital: expansion of a theoretical construct

"Limiting definitions of recovery to abstinence and the absence of AUD symptoms fail to capture the multidimensional and heterogeneous pathways to recovery that research has shown to exist among both treatment-seeking and population samples."

Nonabstinent Recovery From Alcohol Use Disorder

The following is “Simple Tasks,” second-prize winner of the 2022 Gerald F. Berlin Creative Writing Award, introduced by a brief note from the author. The Gerald F. Berlin award recognizes exceptional prose and poetry written by medical, nursing, and doctoral students; residents; and fellows. To learn more about the award, see “

I wrote this piece on a whim one Saturday morning, partially to procrastinate my studying for a few more hours, but mostly to articulate the complex range of emotions I had been experiencing over the course of a year. It flowed out of me in less than 45 minutes. I have come to see the practice of writing as a way of processing and healing from the many challenges that arise in medical school (and outside of medical school), while also honoring the celebrations. I was motivated to submit this essay for the Berlin prize after the piece was published on a UMass community blog, and I received an incredible outpouring of praise and support from my peers with whom it resonated. This award honors not only the piece, but the authenticity of the experiences detailed therein, and I am deeply grateful to the Berlin family for this recognition.

“I would open it,” he snaps, staring intently at me. I’ve already grasped the door handle, but I suppose I hesitated a moment too long. The resident doesn’t take his eyes off me as I yank the door open and flatten myself behind it, making as much space as possible for him and the rest of the team to leave the room. The patient, a kind but chatty man, has been talking for 15 minutes, and we were only here to ask him a brief question. It’s well past noon, rounds have gone late, and it’s Friday: we’re all ready to leave.

As we walk back to the elevator, the resident educates me on “one of the best skills to develop as a med student”: the ability to sense when everyone wants to leave and open the door so that they can. “It’s because you guys are always in the back by the door. You need to relieve the obstruction.” He hurries past me to board the elevator, and I follow him in, taking my position in the back.

This is the second-to-last rotation of my third year of medical school. The curtain was pulled back for me long ago, revealing the extent of the illusion I was promised. That year of bold entry into the world of clinical medicine—filled with life-changing patient encounters, vibrant with educational opportunity—has turned out to be mostly moments like this: being made to do menial tasks, and being told I’m not doing them well enough. I’ve held doors, filed papers, cut suture strings, and printed lists for eight months. I’ve been referred to as “kid” or “the student” far more often than my name. I’ve been ignored, infantilized, and demeaned. Month after month, rotation after rotation, this year has often felt like death by a thousand cuts.

And yet, this year has also been transformative. I have delivered babies. I have stood through 6-hour surgeries, sidelining all my bodily needs for longer than I ever have. I have watched as a neurosurgeon pulled fourteen nails out of the head of a man my own age, a man who shot those nails himself in a desperate attempt to silence the voices he couldn’t stop hearing. I have sat for hours with a patient deep in the throes of psychosis, as he pleaded with me to believe him that he was indeed reading the minds of everyone in the building and we were all in grave danger. I have made friends, lost friends, laughed, cried. I got engaged to my partner of four years, and I have felt love deepen in ways that still surprise me every day. I have learned and grown and changed, and yet some days I feel as though I am still where I was at the outset of this year: at the back of the room, at the bottom of the hierarchy, being told that the one thing I did was not done well.

I think it would surprise no one to hear that medicine, with all its selflessness and service, is a field plagued by cynicism and misdirected passive aggression. Healthcare worker burnout is at an all-time high. Now rounding into its third year, the COVID pandemic has left the medical world downtrodden. And I think it would surprise no one to also hear that in an environment where tensions run high and fuses are short, these frustrations are often let out on the most junior person in the room. Part of me understands it. Two years in the classroom (especially a virtual one) is ill preparation for navigating the hospital ecosystem, and so often it takes twenty minutes to teach us how to do something that an experienced intern could do themselves in five. And I’ve met and worked with so many incredible teachers and colleagues this year. But, for all the good there is in this year, it doesn’t make the bad any easier to endure.

How do we approach a problem so pervasive? A permanent solution seems unlikely to appear, at least while I am still in medical school. Our current grading system—one that places great emphasis on our seniors’ subjective evaluations of our skill and professionalism—keeps us firmly held in the lower end of the power dynamic. Should we swear to ourselves that we will never treat our students this way? Should we let ourselves grow jaded and cynical? Should we continue to go into the hospital, putting on a brave front day after day, and save our feelings of inadequacy and frustration for our loved ones, in tearful conversations and inconsolable moments? I’ve tried all of the above, but none seem to work quite as well as I’d like.

While no permanent solution may exist, I do offer one that I have found most sustainable—one for which the simple tasks of the third-year med student have prepared me well. It is a solution that I am reminded of that same day, in the next patient’s room. We step off the elevator into the emergency department, and fan around a small bed currently occupied by a man in his nineties. It is impossible to look at him and not notice the length of his ears. When he recounts his story of the fall that brought him here, he has an undeniably spry wit that makes me smile beneath my mask. Though he wears the same johnny and yellow socks with fall-proof rubbered bottoms as every patient in the hospital, he still has his own slippers on, a glimmer of the identity that he has mostly been stripped of here. I recognize these slippers. They’re LL Bean moccasins. I have a pair that looks almost exactly the same, given to me by my fiancé last Christmas. When the attending removes them to test the man’s Achilles reflexes, she leaves them at the foot of his bed. I know these slippers; I love how comfortable they are, how warm they keep my feet, how they help me get out of bed on the coldest of mornings. If I were in this place, this unfamiliar territory of beeping machines and crowded hallways and the constant shouting of another patient down the hall, I would cling to these slippers and the small comfort they provide as much as I could.

I think of another kind of moment I have witnessed over and over again this year. I remember the resident who held the hand of an elderly woman as she began to cry, filled with the mortal terror of the cancer diagnosis she’d received just yesterday. I remember the scrub tech who followed me out of the hospital on my last day of surgery, after I’d left before he had the opportunity to say goodbye, just so he could shake my hand and wish me all the best. I remember my classmate kneeling in front of her co-student, who has nearly fainted from exhaustion, as she peels the lid off a cup of apple juice for her. If death comes by a thousand cuts, resilience is made in a thousand acts of kindness. 

It is in these little moments that we are reminded of the humanity we all share, of the reason we all answered the call of medicine in the first place. I twist the engagement ring on my finger. It’s like falling in love: it doesn’t take the pain of the world away, but rather gives you the strength to go on despite it. Kindness is a pair of slippers for the soul.

As the team files out of the room, I stop at the foot of the bed. “Would you like me to put your slippers back on?” I ask the man.

“Yes, please,” he smiles, “if you don’t mind.”

I pick up each moccasin, gently sliding them on one foot at a time, and wish him a good day before I run after my team down the hall.

 is an MD candidate, class of 2023, at the University of Massachusetts Medical School.

Presenting the second-prize winner of the 2022 Gerald F. Berlin Creative Writing Award.

Simple Tasks

 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 Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. To create a better world, he is an advocate for treating mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism. He serves on the Editorial Board of

H. Steven Moffic, MD, shares that Milwaukee is attempting to form an alliance between Jewish and Asian American citizens to work on mutual problems and celebrate sucesses. 

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 Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

Videos

In honor of Jewish American & Asian American and Pacific Islander Heritage months, it might be time to form a coalition. 

Honoring Heritage Months: Jewish American & Asian American and Pacific Islander  

is an outpatient psychiatrist at Prisma Health-Upstate and clinical associate professor at the University of South Carolina School of Medicine, Greenville. He served on the American Psychiatric Association’s Task Force to Address Structural Racism Throughout Psychiatry, and he currently serves as the Diversity and Inclusion section editor and advisory board member for

A psychiatrist reflects on yesterday's tragedy in Texas. 

Enough

Recent research shows that faculty and staff have reported significant increases in stress, burnout, and workload since the start of the pandemic. In this 

, Michelle B. Riba, MD, MS, discusses some ways we can better support the mental health of faculty and staff on college campuses so that they can be better able to support the mental health of their students.

 is a professor in the University of Michigan Department of Psychiatry, and codirector of Workplace Mental Health Solutions at the University of Michigan Eisenberg Family Depression Center.

Mental Health on College Campuses: Supporting Faculty and Staff

,” by Dr Riba and colleagues Preeti N. Malani, MD, MSJ; Robert D. Ernst, MD; and Sagar V. Parikh, MD, FRCPC.

How can better supporting the mental health of faculty and staff on college campuses help improve the mental health of college students—and educational institutions themselves?

Supporting Faculty and Staff Mental Health

is a senior undergraduate student at Queen’s University in Kingston, Ontario, Canada, and a research practicum student at the Centre for Addiction and Mental Health (CAMH), Toronto, Ontario.

is a recent graduate of the Institute of Medical Science of the University of Toronto and a consultant to the Centre for Complex Interventions (CCI) at CAMH.

Substance misuse has become increasingly common in the 21st century, especially among students enrolled in colleges and universities. It has social, economic, psychological, and physiological consequences among adolescents, especially with the emergence of the COVID-19 pandemic and its societal complications. The most used substances on college campuses include alcohol, 

, cocaine, prescription opioids, recreational drugs (eg, MDMA), and nicotine, and, more recently, 

 (vaping). Behavioral addictions (eg, internet gambling) are also very common.

Not only have substance use trends increased in the past 2 decades among university students, but negative perceptions and societal attitudes toward the use of illicit substances have also lessened. The adolescent brain is in a unique period of development at this age, leaving students at a heightened susceptibility to abnormalities on measures of brain functioning, including neurocognition

 which are risk factors for the initiation and maintenance of 

Substance misuse is a strong predictor of student well-being, as it is associated with worsened mental health outcomes, poorer grades, and chronic health problems. According to the National Survey on Drug Use and Health (NSDUH), of the students aged 18 to 22 years, 5.9 million young adults smoked cigarettes in the past month (26.7%), 12.0 million drank alcohol (54.8%), almost 7.8 million engaged in 

 more than 4.5 million young adults used cannabis (20.7%) and 299,000 used cocaine (1.4%).

Cassandra L. Boness, PhD; Alena Kuhlemeier, PhD; Katie Witkiewitz, PhD

Substance use trends for alcohol use, binge drinking, and cocaine use in the past month were higher in full-time college students aged 18 to 22 years compared with their counterparts who were not enrolled in college.

 Between 2007 and 2014, the percentage of students who used 

The prevalence of annual alcohol consumption is highest in full-time college students 1 to 4 years after high school.