 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

We have heard all this way too many times before in America: “This has to end.” And the like. This time a young white male, who had posted an anti-Semitic and racist manifesto beforehand, came to a Buffalo supermarket on Saturday. He shot 13, among them 11 Black and 2 white Americans, killing 10. In my Milwaukee, 21 were shot, then 3 killed over the weekend.

Is COVID-19 the Quintessential Neuropsychiatric Disorder?

Already the grieving, labelling, and promising has begun, as it did in so many similar recent tragedies. However, as psychologically and religiously important as such processes are, they clearly have not been nearly sufficient enough. Human tendencies to scapegoat and hate the “other” have rippled out in small to tsunamic waves, some of which also have dangerous undertows.

Some are saying once again that this is “evil.” Maybe it is, but I would also say it is psychiatric. Some responsibility for addressing racism and hate crimes lies within psychiatry because it inevitably involves how people think and act, sometimes counterintuitively. For instance, calling out the hate can pull in the sympathetic, but also actually boomerang back to the haters and intensify their hateful beliefs. This expertise goes beyond any usual involvement for diagnosable mental disorders, and yes, the suspect seems to have been in a hospital for a mental health evaluation too briefly last year after threatening a mass shooting.

Here are a few preliminary out-of-the box recommendations beyond the usual of more weapon control of guns and social media:

Racism of some degree or another has been turned down as an individual formal diagnosis time and time again, but why not a social psychopathology classification of it and related social psychological problems like anti-Semitism, Islamophobia, sexism, and burnout in order to develop new insights and interventions?

The old strategy of those in desired power is to divide and conquer other groups, so why not develop more new alliances between discriminated groups, such as we are doing in Milwaukee by forming a Jewish and Asian American/Pacific Islander Alliance?

Besides publicizing the tragedies, why not more of the antiracism success stories like I covered in my column on International Jazz Day, for jazz has successfully had Black leadership with allies for over 100 years, becoming beloved around the world?

Cultures do not want to be erased in a melting pot, so why not recognize the nourishment of all cultures as reflected in a potluck?

Remember this definition of insanity attributed to Einstein: “Doing the same thing over and over again, and expecting different results.”

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 relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

Articles

Insanity: doing the same thing over and over again, and expecting different results. 

Possible Psychiatric Solutions to Reduce Harmful Hate After the Buffalo Killings

In this episode of The Big Q, Gaurava Agarwal, MD; Manuel Astruc, MD; and Richard M. Berlin, MD, discuss the importance of understanding a patient's ethnicity and cultural norms when working with them to develop a treatment plan.

serves as director of physician well-being for Northwestern Medicine and as an associate professor of psychiatry and behavioral sciences (general psychiatry) and medical education in Northwestern Medicine’s Feinberg School of Medicine. 

is a psychiatrist with more than 20 years of experience based in New York. He is also the founder of Your Next Act, a coaching program in which he gives people the tools they need to transform stress into success. 

is an instructor in psychiatry at the University of Massachusetts Medical School in Worcester, Massachusetts. He has also been writing a poem about his experience of being a doctor every month for the past 24 years in 

™ in a column called “Poetry of the Times.”

How important is it to understand a person’s ethnicity and cultural norms when developing a treatment plan?

The Importance of Cultural Understanding

“I’ve been feeling bad since I had COVID. My chest pain is unbearable. It hurts so much. I wish I could have come earlier but I do not have health insurance. Please, tell me I’ll be okay. Please.”* I spoke these words in a sad tone, in pain, and with a hint of desperation. That is the job of an interpreter: to relay everything that is said by a patient. I embodied the patient’s feelings so that the team would understand her pain.

Interpreting is its own work of art—a theater where the interpreter is receiving the lines in live action and expected to act these lines immediately. Before you are able to process this, you begin to receive more lines and continue the play. Except the lines you are receiving are real words spoken by real patients who experience profound disease processes. Sometimes you interpret illness, pain, and grief, while other times you interpret happiness.

As you channel the grief and worry, you also unknowingly shoulder vicarious or secondary trauma. Secondary trauma is heightened by the interpretation practice of speaking in first-person.

 Vicarious trauma—interchangeably known as secondary trauma—happens to clinicians, interpreters, and medical students who absorb their patient’s traumatic experiences, words, and feelings.

 Vicarious trauma can be painful and transformative. The symptoms of secondary trauma include reimagining the traumatic event, intrusive thoughts, irritability, and generalized anxiety, among other posttraumatic stress disorder (PTSD)-like symptoms.

 The lack of experience and the increased exposure to patients’ stories make medical students more vulnerable to secondary traumatic stress.

As a medical student without professional interpreter training, I act as an ad-hoc interpreter. Many times, in the health care setting, this can be for a family member, a medical assistant, nursing staff, and medical students. I started interpreting for my mother when I was about 9 years old. This was when she injured her shoulder and had several doctor appointments and a surgery. Being an ad-hoc interpreter and a language broker is a very common phenomenon for Latino immigrant children.

 For most of us, interpreting for our loved ones was what exposed us to the medical field. Some of us had great experiences, and others were fueled by injustice. We hoped our culture, language, and narratives would lead to better health care outcomes for our Latinx community.


However, many of us found ourselves regressing to ad-hoc interpreters during our clinical rotations. Several studies have shown that medical students also experience vicarious trauma on the wards.

 We may experience grief, anger, shock, or sadness during rotations, especially when we lose a patient. What happens to the medical students who serve in both roles? And why is this so important? From what I have seen, the majority of my colleagues who are bilingual medical students and serve as ad-hoc interpreters come from communities that are underrepresented in medicine (URiM). We already know that URiM students experience structural barriers and racism. Many are the first in their family to go to medical school. What if URiM medical students also bear emotional vicarious trauma as interpreters?

Personally, it is through my own therapy that I have gained insight and have been able to process the emotional vicarious trauma I experienced in the wards. It is through my own therapy that I was able to recognize that my role as an ad-hoc interpreter was also triggering my previous trauma as a child ad-hoc interpreter for my mother during her doctor appointments.

It is imperative that physicians, health care workers, and other professionals acknowledge the vicarious trauma that medical students may experience while ad-hoc interpreting and therefore opt to use professional interpreters instead.

 Health care teams may allow medical students to talk to their patients in their native language. However, medical schools and institutions should have clear guidelines, language assessments, and support for students who choose to interpret for LEP patients.

 It is also important that medical students who act as ad-hoc interpreters receive therapy services and workshops on vicarious trauma, and become informed on how to set boundaries with their teams. The work, most importantly, should be on institutions to provide these resources and emphasize their importance for the well-being of doctors in training.

*Patient quote has been altered to protect patient privacy.

is a medical student in the Program in Medical Education for the Latino Community (PRIME-LC) at the University of California, Irvine (UCI) School of Medicine. She is the co-founder and co-chair of the Child and Adolescent Psychiatry Interest Group at UCI and an. advocate for diversity in mental health. She is currently working on a qualitative research project with Violeta Osegueda PGY-1 at UCLA/VA Psychiatry on this very important topic.

Secondary traumatic stress in medical students

Vicarious traumatization: a framework for understanding the psychological effects of working with victims

The stressful (and not so stressful) nature of language brokering: identifying when brokering functions as a cultural stressor for Latino immigrant children in early adolescence

4. Paradise RK, Hatch M, Quessa A, et al. 

Reducing the use of ad hoc interpreters at a safety-net health care system

5. Vela MB, Fritz C, Press VG, Girotti J. 

Medical students' experiences and perspectives on interpreting for LEP patients at two US medical schools

We must educate and provide resources for medical students and institutions.

Interpret at Your Own Risk: Medical Students as Ad-Hoc Interpreters and Vicarious Trauma

This is how one of my patients advocated for his peer who ended up in the seclusion room due to agitation: “Dr Reda, please try to get her out of there as soon as it is safe to do so. Seclusion is a very lonely experience.”

Due to multiple and complicated systemic issues, it is not uncommon to have a staff shortage in the acute inpatient psychiatric unit. Frontline mental health professionals—who are usually stretched too thin to start with—are expected to multitask; to carry a heavy caseload; and to navigate the culture of acute psychiatry that can, even under normal circumstances, pose an imminent threat to their safety and the safety of their patients.

Staff are humans, not machines, and they cannot be everything for everyone at all times. As a result of short staffing and burnout, when a patient’s anxiety goes unnoticed, the situation can quickly escalate into restlessness, agitation, and even full-blown violence. When things go beyond the point of verbal de-escalation, staff might see no other option than to restrain and seclude the patient to protect them from inflicting harm on themselves or on others.

A seclusion episode is commonly viewed as a bad outcome, and staff for the most part feel guilty and debrief the incident, trying to find out what went wrong and how to prevent it from happening again in the future.

It is true that most patients with mental illness are not violent, and it is true that most violence is committed by individuals who are not mentally ill. However, patients in the acute psychiatric unit could resort to violence when they have acute psychosis or substance-related intoxication or withdrawal; when they feel unheard or dismissed; or when they are wrestling with intense thoughts to harm themselves and/or others.

The approach to violence is a comprehensive one. There are many tools that can be used before resorting to restrictive measures. Seclusion and restraints, however, are sometimes unavoidable or even lifesaving. The approach to this dilemma is collaborative. Staff can use tools like LUDA (listen to understand and deeply appreciate) and LATTE (listen, agree or agree to disagree, talk about the unmet need leading to the behavior, thank them for working with you through it, and empower them by equipping them with the skills needed to navigate future episodes). Some systems implement programs like “soft show of force,” “show of concern,” and “therapeutic takedown.”

The truth is your patient might end up in the seclusion room no matter how hard you try to avoid that, and seclusion could be the most appropriate action and the most therapeutic intervention. It is not always “patient first,” and it does not have to be “staff first”—we should all prioritize safety.

Safety means that we build a culture of care, so our healers stop to walk wounded, design a healing environment that focuses on early prevention rather than late intervention, fix systemic issues that place everyone at risk, and not forget the patient in the seclusion room who deserves to be debriefed and who usually shows remorse and makes amends.

We are all humans. We all make mistakes. Mistakes are opportunities to improve; they are teachable moments. And that is okay as long as we follow every rupture with a repair.

 is a practicing psychiatrist with Providence Healthcare System in Portland, Oregon. He is the author of 

The Wounded Healer: The Pain and Joy of Caregiving

Overview of Project BETA: best practices in evaluation and treatment of agitation

What is the role of seclusion in creating a culture of care within acute inpatient psychiatric units?

In the Seclusion Room

is a psychiatry resident at Baylor College of Medicine.

is a PGY 3 general psychiatry resident at Menninger Department of Psychiatry & Behavioral Sciences at the Baylor College of Medicine. She plans to pursue a fellowship in forensic psychiatry after graduation.

is an addiction psychiatrist at Baylor College of Medicine and the Director of the Consult Liaison Psychiatry service at the Ben Taub General Hospital- Harris Health System- Houston, Texas.

Tales From the Clinic: The Art of Psychiatry

Tales From The Clinic: The Art of Psychiatry,

 we follow the story of a young man who turned his life around for the sake of his spouse and child, but nevertheless struggled with the tribulations of normal upheaval. Recovery from 

 does not protect against normal life events, but our patients are more sensitive to stress than their nonsubstance user counterparts, increasing the potential for stigmatization. We visit the moral versus brain disease model of addictive processes through the case, and hope to help readers appreciate their own biases and open themselves to understanding the neurobiology of addiction. The aim of proper diagnosis and treatment is to have an objective conception of addiction rather than a morally framed conversation, when behaviors related to addiction are viewed through a negative prism.

“Mr Wallace” is a young man with opioid use disorder and major depressive disorder. He lost contact with his wife and young child as a consequence of his 

. His wife moved to another country, prompting him to get treatment “like I really mean it this time.” He gained sobriety on medication-assisted treatment (buprenorphine/naloxone) and did well, earning advanced certification in his field and increasing his earnings significantly. He also took up the hobby of synthetic music. His wife returned with their child, with subsequent stabilization of the relationship, the purchase of a house, and other life milestones.

The National Institute on Drug Abuse (NIDA) defines addiction as “a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain—they change its structure and how it works. These brain changes can be long lasting, and can lead to the harmful behaviors seen in people who abuse drugs.”

 Although NIDA adheres to the brain disease model of addiction (

), there continues to be controversy surrounding whether addiction is a disease or a matter of choice. If addiction is viewed as a moral failing, as posited by the moral model of addiction, then there is the belief that the patient is responsible for their substance use and at fault for having a character defect or a weakness of will.

Advancements in neuroscience have made it possible to identify strong genetic, neurodevelopmental, and sociocultural components of addiction. Evidence pointing to the activation of reinforcement circuits (

) by drugs through the neurotransmitter dopamine in brain areas, such as the nucleus accumbens and ventral tegmental area, further supports irreversible changes in the brain’s structure and function resulting from substance use.

 Because of these permanent changes, it is postulated that individuals cannot exercise self-control over their behavior pertaining to addiction.

This biological approach, supported by animal models of addiction,

 has made room for pharmaceutical treatments of 

. This approach also supports liberation from the belief that addiction is a moral lapse in individuals who have deep character flaws. The disease model of addiction has often been assumed to diminish the attribution of free will to those with drug addictions, which could possibly have significant implications in the attribution of responsibility and stigma as well as the acceptance of treatment.

Critics of the purely brain disease model of addiction believe that categorizing substance use as a disease may further stigmatize individuals with addiction and prevent them from developing self-control, all while damaging their self-esteem.

 and simply diseasing addiction will only further stigmatize those who suffer from addictions. While proponents of the brain disease model of addiction believe adherence to this model will encourage treatment-seeking behaviors, critics believe it will erode the confidence of addicted individuals in their ability to overcome addiction if it is inherently viewed as permanent structural and functional changes in the brain. Research on addictions such as smoking finds that attribution of addiction to unchangeable intrinsic factors leads to lower levels of quitting intentions and quitting self-efficacy.

 Naysayers of the brain disease model of addiction also point out that a clear majority of addicted individuals recover naturally without requiring medical interventions.

Opponents of the brain disease model of addiction believe it: is insufficiently supported by animal-model and neuroimaging data; has only a modest impact on public policies toward drugs and addiction; and has not majorly contributed to the development of more effective treatments despite the decades of research.

 Evidence to support environmental approaches to reducing substance use cautions strongly against the possibility of policy makers and government officials being enticed by the allure of 

. There is some concern that an overly biological emphasis on addiction could take attention away from the necessary social and environmental interventions and divert resources to the production of expensive and perhaps risky medical interventions that can realistically only be accessed by a certain population. 

Proponents of the brain disease model of addiction postulate that adherence will encourage seeking of evidence-based medical assistance to overcome a brain disease. They believe this model lends itself to a collaborative approach between patients and physicians against addiction. However, critics believe the brain disease model of addiction lends itself to addicted individuals absolving themselves of personal responsibility. This results in infantilizing individuals with addictions while shifting the responsibility of overcoming addiction to medical professionals.

 This stark difference in how each model contributes to the physician-patient relationship sheds light on the topic of countertransference (

 The Brain Disease Model of Addiction and Countertransference

Mr Wallace later found out—after buying the house, buying a car, and moving back in with his wife and child—that his wife had not been faithful. This led to significant use of Adderall by Mr Wallace and ongoing relationship issues. He continues to have interpersonal issues in the relationship and struggles with maintaining the relationship for the sake of keeping access to his daughter.

, not only does the relationship between the clinician and the patient play a role, but so do the thoughts, beliefs, and experiences of the physician. Besides the brain disease model of addiction, there are several other models that seek to explain the development of substance use. The moral model describes addiction as resulting from a character flaw or moral failing; the choice model sees drug use as a voluntary but harmful behavior; and the psychosocial model regards substance use as related to economic, cultural, and other social factors.

These lead to beliefs about who claims responsibility for beginning and overcoming 

, including the medical model, which regards patients as requiring medical treatment and having low responsibility for the presence and resolution of use; the moral model, which places all responsibility on the patient; the enlightenment model, which states that the individual is responsible for the problem but not the solution; and the compensatory model, which states that the individual is not responsible for the problem but is responsible for the solution.

From studies on treatment providers’ views on the brain disease model of addiction, there seems to be overall support for this concept, although with variations noted among different professions of providers. The strongest support was generally seen in psychiatrists, especially those who were older.

 Interestingly, there was significant evidence of an amalgamation of beliefs, with providers expressing support for multiple models and levels of patient responsibility. These findings extended from treatment providers to treatment settings as well, with examples provided of substance as a “self-induced disease,” bringing together the requirement for medical treatment with responsibility for the initiation and resolution of use belonging to the individual.

 This appears to reflect the complexity of 

 and its treatment, and suggests that the conceptualization of substance use may be tailored to the needs of a particular patient or to the needs of the patient population seeking treatment in a specific setting.

How a physician conceptualizes substance use plays a role in the countertransference experienced. Thinking a patient is willfully making bad choices will obviously decrease positive feelings or wanting to help them, or to go the extra mile in treatment planning. On the other hand, approaching substance use from the brain disease model of addiction helps patients overcome stigma and reduce guilt, as use is not conceptualized as a moral failure of the patient. This may help reduce negative countertransference toward patients with substance use by assisting in understanding frustrating, demanding, or confrontational behavior as not intentional or specifically directed at the provider. Negative countertransference could result in direct consequences, such as avoidance of the patient, difficulty with empathetic responses, and sessions cut short.

This could also increase protective or parental feelings toward patients, especially if they are viewed as helpless against the structural and chemical factors that contribute to their use.

 Such a “positive” countertransference can also lead to difficulty in the therapeutic relationship, as the clinician may take on the role of a parent, becoming overly engaged, protective, and permissive. If the patient then regresses and begins to act out or relapses, the clinician may feel betrayed and subsequently have difficulty in future encounters with the patient. A parental countertransference may also result in the clinician infantilizing the patient and minimizing their strengths and abilities.

 As with all forms of countertransference, the ability to identify and label the ensuing emotion is as critical as the adjustments the clinician must accordingly make.

Although there are many frequently underutilized medications for substance use disorder, a mainstay of treatment relies on naturalistic options such as Alcoholics Anonymous, Narcotics Anonymous, inpatient and outpatient rehabilitation programs, and similar offerings. The Anonymous groups generally involve a 12-step approach that includes concepts of acknowledging addiction as well as the difficulty in overcoming it, recognizing wrongs, making amends for those shortcomings, committing to a life with continued focus on sustained abstinence, and working to help others, especially those experiencing similar struggles with substance use (

Historically, and continuing in the present day, these programs tend to have a strong spiritual component to them, which can be off-putting for some individuals and make it harder to engage. Of the limited data available, there is evidence for the beneficial effect of involvement in 12-step programs for maintaining sobriety, both with and without attending a rehabilitation program. The impact seems to be strongest for those who started attending 12-step groups prior to entering a rehabilitation program and who continued to be involved after completion of rehabilitation. Most of the available evidence is in regard to alcohol use, with less data focused on other substances.

Medicine is far from the conceptualization of addiction as a sin, yet the belief in biological models still lags considerably, as evidenced by suboptimal prescribing of anti-craving medications. In general, evidence-based practices for addiction treatment are still not fully implemented at the scale they could be, and this is likely reflective of how addictive diseases are conceptualized in everyday practice.

is a psychiatry resident at Baylor College of Medicine. 

 is a PGY 3 general psychiatry resident at Menninger Department of Psychiatry and Behavioral Sciences at the Baylor College of Medicine in Houston, Texas. She plans to pursue a fellowship in forensic psychiatry after graduation.

is an addiction psychiatrist at Baylor College of Medicine and the director of the Consult Liaison Psychiatry service at the Ben Taub General Hospital- Harris Health System in Houston, Texas.

1. National Institute on Drug Abuse; National Institutes of Health. Drugs, brains, and behavior: the science of addiction. 2007. Accessed March 15, 2022. 

https://nida.nih.gov/sites/default/files/soa.pdf

Brain disease or biopsychosocial model in addiction? Remembering the Vietnam Veteran Study.

The science of making drug-addicted animals.

Free will and the brain disease model of addiction: the not so seductive allure of neuroscience and its modest impact on the attribution of free will to people with an addiction.

Addiction and moralization: the role of the underlying model of addiction.

6. Harackiewicz JM, Sansone C, Blair LW, et al. 

Attributional processes in behavior change and maintenance: smoking cessation and continued abstinence.

The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises?

Drug and alcohol treatment providers’ views about the disease model of addiction and its impact on clinical practice: a systematic review.

Countertransferential and attitudinal considerations in the treatment of drug abuse and addiction.

11. Thomas S, Monico N. The 12 steps of Alcoholics Anonymous. American Addiction Centers. Updated December 20, 2021. Accessed March 15, 2022. 

https://www.alcohol.org/alcoholics-anonymous/

Recovery from addiction does not protect against normal life events...

Normal Life Stress, They Say…

has been writing a poem about his experience of being a doctor every month for the past 24 years in

He is instructor in psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts. His latest book is

Videos

"All in green went my love riding on a great horse of gold into the silver dawn..."


All in Green Went My Love Riding

 develop their own jargons and theories, but the stages of treatment tend to be remarkably similar regardless of orientation and duration.

The patient knows things are not going well and that help is needed. The specific presenting problems are varied and very individual, but usually include some combination of symptoms, troubling behaviors, interpersonal friction, work problems, disappointment, 

, demoralization, increased stress, and/or a loss of support. The patient often has little awareness of underlying contributing factors and no idea what to do next.

As a result of the therapy—either in sessions, with 

between sessions, or ideally both—patients become increasingly aware of the emotions, thoughts, and behaviors that have created their problems, and also their reduced competence in dealing with them. They may be misinterpreting other people's motives, not recognizing their behaviors that have a negative impact on others, avoiding things that cannot be avoided, becoming too easily frustrated and demoralized, pushing people away, or any of the hundreds of ways people get stuck in vicious cycles of self-perpetuating, self-destructive behavior.

Stage 3: Corrective Emotional Experiences

Insight alone never cured anything except ignorance but becoming intellectually aware of what is causing the problem sets the stage for trying new ways of thinking, feeling, and behaving—both inside and outside the sessions. Chain reactions of corrective emotional experiences replace the downward spiraling caused by previous vicious cycles with virtuous cycles of recovery. Some corrective emotional experiences occur naturally within the context of 

, but most must come from deliberate efforts made by the patient to think in new ways, feel suppressed emotions, try new things, and stop avoiding feared situations.

If the therapy is successful, the new and healthier ways of thinking about, feeling, and acting competently in the world are internalized and become automatic.

Schools of therapy differ markedly in their theories of change, but they are very similar in their stages of change.

Crucial contextual factors in promoting change are also similar across therapies. There must be a strong therapeutic alliance. Patients must come with—or be induced to develop—at least some motivation for change and a positive expectation that therapy can help. The most effective therapies and therapists will not get very far in the process if the patient has fixed negative expectations and a fixed unwillingness to try new thoughts, feelings, and behaviors.

The stages of therapy interact with its duration in complex ways. Going from Stage 1 to Stage 2 is usually the maximal goal for patients seen only for evaluation, but some patients seen only once are able to carry forward the insight gained and achieve Stages 3 and 4 on their own through life experience or with additional later therapy. When they work well, brief treatments of 6 to 20 sessions can encompass all 4 stages. Stalemated long-term treatments may never get beyond the first or second stage. And this model of change does not apply to supportive treatments in which stability, not change, is the goal.


The best way to understand the different therapy schools is to study what they do in practice, not what they say in theory. All therapies, however seemingly different their specific techniques, succeed by facilitating corrective emotional experiences. The paths to achieve this may vary greatly, but their destination is the same.

Tune in to the full podcast to learn more. 

, we discuss the issues covered in this blog in more depth. You can view the episode 

is professor and chair emeritus in the department of psychiatry at Duke University.

Despite their differences, all psychotherapies have these things in common—and are important to consider.

Stages of Change Common to All Psychotherapies

A quintessential neuropsychiatric disorder might be one that reflects the variety of ways that the brain and mind can be adversely affected. Neuropsychiatry would consist both of the direct neurological impact of some pathogen on the brain, which is what we used to call “organic,” as well as the psychological reactions to the impact, or what we used to call the “functional.”

Neurodiversity as a Strength-Based Psychiatry

At various times, there have been failed attempts to connect neurology and psychiatry into 1 specialty. Certification testing has always overlapped the fields to some degree. Some given examples of neuropsychiatric disorders are traumatic head injury, migraine headaches, menopause, and medication side effects.

Although the major pathology of COVID-19 is respiratory damage, over time it has become clearer that there also are neuropsychiatric ones. I apparently had an acute respiratory episode, but did not notice any neuropsychiatric aspects—that is, until recently, when I experienced more anxiety and uncertainly about how much risk to take outside of the home. I reluctantly decided that coming to the 2022 APA annual meeting next week was too risky.

Around this same time, I ran across a new COVID-19 study out of England.

 The results indicated that new and increased rates of anxiety disorder, dementia, psychosis, and bipolar disorder were occurring. It is unclear how much is the result of the viral pathogen, the psychological response, or both. Some also seem to be associated with long COVID including unexplained mood changes, brain fog, and language difficulties. When the illness is more severe or a loved one dies, posttraumatic stress disorders and prolonged grief disorders are likely to increase. Then there is the conscious and unconscious defense mechanism of denial of the risk we have encountered over the last 2 years.

All of this complexity and uncertainly suggests that COVID-19 would benefit from being studied at academic neuropsychiatric centers, if only more of them existed. In the meanwhile, I would suggest leaning to the safe side for now as the infections, and now even hospitalizations, are increasing.

1. Clift AK, Ranger TA, Patone M, et al. 

Neuropsychiatric ramifications of severe COVID-19 and other server acute respiratory infections.

What are the neuropsychiatric effects of COVID-19, and how can we study them further? 

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

Inalienable rights shackled by arrogance.

A psychiatrist reflects on recent events.

Personified Uterus

Cases involving false allegations of abuse and parental alienation call for detailed documentation by the targeted or rejected parent. The purpose of a timeline is to list (1) major events, (2) court filings, (3) verbal and behavioral actions, and (4) external investigations. By plotting out a timeline, one can visualize a sequence of events and behaviors over time—even years. This timeline method is especially useful for parents, mental health experts, and attorneys.

Parental alienation during and after divorce is an all-too-frequent phenomenon. It is where one parent intentionally coerces and manipulates a child to reject his or her other parent.

 Parental alienation is usually a secretive and insidious process that is denied by the offending parent. To be sure, the parent almost never admits to their disruptive and damaging behavior.

False allegations of abuse are often lodged by an alienating parent to sabotage the targeted parent’s relationship with their child. False allegations are a ramping up of the alienating mission of the offending parent. Sometimes, there are multiple allegations of abuse in attempt to throw the other parent under the bus. Offending parents frequently believe that multiple allegations are the best way to sink the targeted parent once and for all.

Compelling evidence of false allegations of abuse and parental alienation can be detected when examining a timeline of events and actions. The sequence of events and actions usually tells the story. For example, we know there are certain major events that are likely to trigger the onset of the process of alienation by 1 parent, such as filing for divorce, filing for full custody, having a close relationship with the child, starting a new romantic relationship, getting remarried, and many others. Alienating behaviors often appear in response to these triggers.

As we know, alienating behavior can take many forms, ranging from bad-mouthing and interfering with parenting time to children calling a parent by his or her first name. Seventeen different behaviors have been described in the literature.

 All alienating behaviors, when detected, can be placed on a timeline and a pattern can be seen.

As Stephen Miller has described, mental health clinicians, attorneys, and judges are prone to make faulty attribution decisions in cases of false allegations and parental alienation.

 This is because the offending parent is often cool, composed, and convincing in demeanor during the divorce proceeding. In contrast, the rejected parent is often anxious, agitated, and angry because they are being rejected by the child. On the surface, then, the offending parent is often successful at convincing attorneys, judges, and others that his or her narrative is correct. This results in a fundamental attribution error—a major mistake that can have catastrophic consequences in the decision-making in a case. This makes a detailed timeline of events and behaviors even more crucial for the targeted parent.

Timelines can be introduced in testimony in court. They can be displayed on a big-screen TV so that all parties and the judge can view them. Mental health experts and others can testify about the timelines and their implications. Timelines are an excellent way to present documentation in a child custody matter. Displaying them in court usually captures the judge’s or jury’s attention. It is the perfect method for combining visual and auditory modalities in a presentation.

Mental health experts play a vital role in cases of false allegations of abuse and parental alienation. Compelling evidence and opinions need to be presented in an understandable yet forceful manner. Timelines fit that bill.

is a clinical and forensic psychologist in private practice in Birmingham, Alabama. He can be reached at alanblotcky@att.net.

1. Blotcky AD. False allegations of abuse during divorce: the role of alienating beliefs. 

https://www.psychiatrictimes.com/view/false-allegations-of-abuse-during-divorce-the-role-of-alienating-beliefs

2. Blotcky AD. False allegations of abuse can be a strategy in child custody litigation. 

https://www.psychiatrictimes.com/view/false-allegations-of-abuse-can-be-a-strategy-in-child-custody-litigation

Surviving Parental Alienation: A Journey of Hope and Healing

4. Miller SG. Clinical reasoning and decision making in cases of child alignment: diagnostic and therapeutic issues. In: Baker AJL, Sauber SR, eds. 

Working With Alienated Children and Families: A Clinical Guidebook.

Timelines can assist mental health experts in cases of false allegations of abuse. 