The definitive history of Hitler is found in the superlative two volumes by Kershaw I. 

The best books on Hitler’s medical history are by Redlich F. 

Hitler: Diagnosis of a Destructive Prophet

. Oxford University Press; 1998; and, Eberle H, Neumann H. 

Two books describing Hitler’s encounter with Ott are Ross P. 

. Little, Brown and Company; 2016; and Simms B. 

Adolf Hitler, the genocidal monster of the twentieth century, would not seem to be someone likely to seek psychological counseling, let alone respond. Since his death at the end of the war, there has been a vast outpouring of literature on the Nazi Fuhrer. Until recently, he was not known to have had psychological treatment—with 

 This encounter was rumored to have occurred at Pasewalk Hospital at the end of World War 1 when he was hypnotized by psychiatrist Dr Edmund Forster. However, it has been firmly discounted by historians.

In 1990, however, there came a surprising revelation: Hitler had been treated by a psychologist at Landsberg Prison in 1924, with a positive response to treatment.

 Alois Maria Ott, the prison “teacher,” was responsible for the rehabilitation. Ott first disclosed his involvement with Hitler at the hearty age of 98, with reports that he was going to write a book on his experiences, which has not occurred. A devout Catholic, Ott was a firm believer in the power of goodwill, having a nonjudgemental approach to his patients.

In 1924, Hitler was just another Bavarian right-wing rabble-rouser spawned by the loss of the war and the chaos of the 

. Inspired by the 1920 Kapp putsch, he decided to mount a coup against the Bavarian government. What is known as the Munich Beer Hall Putsch culminated in a march on the Bavarian Defense Ministry on November 9, 1923.

 In the exchange of fire, 16 Nazis and four policemen were killed. Hitler was pulled down, dislocating his shoulder; Ludendorff, undeterred, marched on; Goering was shot in the thigh (which started his morphine addiction).

Hitler was devastated. He could be jailed, deported to Austria, or shot for treason. He managed to escape to the home of Ernst “Putzi” Hanfstaengl, his press spokesman. Overwrought, if not hysterical, he threatened to kill himself and Helene Hanfstaengl had to take the gun from him.

 This behavior was not unusual: Hitler frequently threatened suicide when events did not go his way.

On 11th November, Hitler was arrested and taken to Landsburg Prison, 38 miles west of Munich, arriving at night. Fearing a rescue attempt, the Reichswehr was brought in to guard the special prisoner. Hitler was put in Cell Seven in die Festung, a special wing reserved for prisoners of conscience, the nobility, and duellists (a very German arrangement). He was to stay there until December 20, 1924.

The records on arrival state that the prisoner was “of moderate strength,” 5 feet 9 inches tall, and weighed 12 stone one pound (measurements converted from metric). Medical officer Dr Josef Steiner Brin declared Hitler “healthy and strong,” fit for imprisonment. An interesting find at the examination was only learned in 2015: Hitler had “right-side cryptorchidism” or an undescended right testicle, thereby confirming the longstanding rumor.

,” was unshaven, miserable, and distracted. Rudolf Hess found him in a very low emotional state, expecting to be shot as a revolutionary (and which, of course, he was to do to so many who opposed him). When the investigators arrived, he demonstrated the histrionic behavior that was such a feature of his personality. He would either remain silent, “acted fresh, or broke out into crying fits.”

 His shouts and screams could be heard all over the building.

Leybold, the prison warden, had to deal with his rages. Hitler “howled like a madman” before raving about “liars and traitors.” His response was to go on a hunger strike; at least he would die like a martyr. As the hunger took hold, he became apathetic and looked “like a heap of misery, crestfallen, poorly shaved, and listening to my simple words with a tired little smile and no interest.” Moved to the hospital wing, he got steadily weaker and the staff decided that force-feeding was the only option. Before this came about, he was visited by Ott.

The prisoner made a disappointing impression. Hitler was a “scowl-eyed stocky man,” a “middle-class man with mannered black hair combed into his forehead and the well-known trimmed beard fly,” “a wide, ordinary mouth and a broadly protruding, somewhat indented nose.” Ott’s emphasis on physiognomy was derived from the focus on physical characteristics promoted by Lombroso and Kretchmer.

) with a report from a colleague accusing him of “falling victim to the devil of his own vanity and a prima donna complex.” Ott said, “Herr Hitler, I give you my word that I’ve told nobody in the prison that I was coming to see you, and nobody will learn anything of this conversation. You and I are about the same age and have both lived through war and misery. I’m coming to you man to man, to be of assistance, the same way I do with every inmate.” In this way he levelled out the differences between the two, despite the obvious inequities in a prison situation.

Hitler ignored the invitation. Convinced that he was going to be shot, he became more hysterical. “The people are a pack,” he cried. With “whitish-yellow flakes of foam on his mouth,” he intended to “wipe out his life on a hunger strike.” Distraught at the death of his comrades in the march, Hitler announced that “I have had enough, I am done, if I had a revolver I would take it.”

 Ott made his assessment of the prisoner: a hysteric and pathological psychopath. This is unique: the only psychiatric diagnosis of Hitler by anyone who examined him.

Not intimidated by his ranting patient, Ott was determined to take control of the encounter. First, he lectured Hitler on the need to be patient about establishing his political program, only to receive another melodramatic tirade that Germany could not wait for this before he would be crucified and burned at the stake. Ott found another way to engage his volatile subject, asking whether he had chosen the wrong role model in view of Austria’s recent history with the Hohenzollerns. This did the trick; the impasse was broken. Hitler, back on familiar territory, gave Ott a lengthy discourse on his interpretation of history and the two now had a basis for conversation. From this point, they would debate current and past issues.

“Then you must know,” said Ott, “how long it took the Prussian general staff to prepare for the last war, and that revolutionaries like Garibaldi and Mussolini need the will of the people behind them. Slogans, especially ideological ones like anti-Semitism and anti-clericalism, won’t bring starving people to the barricades. . . . Why do you and your followers spread hatred toward Jews and toward papal authority? We can be political opponents, but if you want to lead a whole nation into a better future, we need one another.”

This must be one of the very rare (if not unique) occasions when someone challenged Hitler’s fanatic and hate-filled views to his face. Despite contradicting Ott (as would be expected), Hitler stayed engaged, stating that only two institutions in the world required his respect “the old Prussian General Staff and the Roman College of Cardinals.”

Ott concluded by recommending a “pious recipe” to his patient: “Find back to the old order of God!” This must have registered with Hitler, who had been raised a Catholic—although he was deeply skeptical of the church as an adult. The intervention worked. The next day, Hitler stopped his 10-day hunger strike—the planned force feeding abandoned—and returned to his comfortable room in the fortress.

On this note ended the only known treatment of Hitler by a psychologist who used an approach that had allowed his difficult patient to engage with him, followed by contradiction of his fervid opinions. Ott was not deterred by his difficult patient, but used a combination of confrontation and empathy, providing opportunities to vent. The results were excellent; his patient settled, stopped the hunger strike and gave up suicidal ideation. He prepared for his trial and wrote 

The trial for high treason was held from February 26 to April 1, 1924 in the Bavarian People’s Court. Hitler, confident again, effectively took over the trial proceedings, addressing not only the judges, but the German public. This changed the hearing from a criminal prosecution to a stage to put his ideas before the German public, turning him into a national figure. That the judges were right-wingers helped—the two pro-Nazi lay judges wanted him acquitted. In the end he got a five-year sentence to be served under the least severe conditions, the sentence likely to be heavily curtailed. As it was, he would only serve 13 months.

Ott concluded that his patient had a “penchant for magical-mysterious thinking,” an opinion that is difficult to disagree with. Hitler was filled with “vanity and brutal dogmatism.” His hatred for “those who think differently” could not be attenuated: “I could feel his demonic obsession with an ideology that unleashed the psychopath in him.”

From the time of his assent to power, psychiatrists offered their views on Hitler’s mental state.

 Ott, however, was the only mental health professional to examine and treat the future German dictator; this encounter deserves to be known. In addition, he was able to challenge Hitler’s anti-Semitic views, which did not make any difference, but it is one of the few occasions (if ever) this occurred.

The news that Hitler was treated by a psychologist is intriguing. Many would consider him to be the least likely person to respond to psychotherapy. A number of reasons can be considered for the success of Ott’s intervention. Hitler was at an early stage of his political career, just one among many right-wing politicians in Bavaria, with no guarantee that he would succeed in his political goals. Second, the penalty he faced in the forthcoming trial could include lengthy imprisonment or deportation. Third, the rampant megalomania he displayed once he came to power was in its early stages—he was the drummer, not the leader of the forthcoming revolution. Fourth, the presentation was characterized by his suicidal threats, a persistent response when facing adversity until his end in the bunker.

Ott did the right thing for his patient; what it meant for the world is another thing. We can look back and wonder whether if there had been someone like Ott at other critical points in Hitler’s life history would have been different. If only . . . .

 is Clinical Associate Professor at the Graduate School of Medicine, Wollongong University and Research Fellow, History Department, Stellenbosch University, South Africa. He writes about political leaders in his book 

Dark Tales of Illness, Medicine and Madness: The King Who Strangled His Psychiatrist.

. Cambridge: Polity Press; 2012.
2. Armbruster J, Theiss-Abendroth P. Deconstructing the myth of Pasewalk: Why Adolf Hitler’s psychiatric treatment at the end of World War I bears no relevance. 

Bewährungsfrist für den Terroristen Adolf H. Der Hitler-Putsch und die bayerische Justiz

 (Munich, 1990; p 35); quoted in Simms B. 

. Penguin Books Ltd. Kindle Edition, September 2019; see also: Ross P. 

. New York, NY: Little, Brown and Company; 2016: 717-795.
4. Bavaria’s governor Eugen von Knilling to the envoy of neighboring Baden-Württemberg, in Plöckinger, Geschichte, 21. Quoted in Ross P. 

 (p717-95).
6. Jordans F. Newly published documents reveal that Hitler received special treatment in prison. 

. December 22, 2015.
7. Hitler really did have only one testicle, German researcher claims. 

. December 19, 2015.
8. Bavaria’s governor Eugen von Knilling to the envoy of neighboring Baden-Württemberg, in Plöckinger, Geschichte, 21. Quoted in Ross P. 

 (p304).
9. Gritschneder, Bewährungsfrist, citing comments made in 1988 by Ott, former Anstalts-Psychologe. Quoted in Kershaw I. 

. New York, NY: Penguin Books; 2001: 669.
10. Kaplan RM. Norwegian psychiatry and the trial of Vidkun Quisling. 

Articles

Adolf Hitler, the genocidal monster of the twentieth century, would not seem to be someone likely to seek psychological counseling, let alone respond. 

Alois Maria Ott: I Was Hitler's Psychologist

Recently, a family of owls nested behind my house. An unfamiliar neighbor approached me and pointed them out. This simple interaction scared me; it had been around a month since I had talked to anyone in person other than my family because of COVID-19. From the first, I did not enjoy the owls’ presence; they reminded me of the uncomfortable interaction with my neighbor. However, I realized the local owls had come to symbolize hope in our community.

Even though the owls were smaller than I expected, they seemed to loom over our alley. They would perch for hours in the trees, then suddenly disappear. I had never seen them up close until I saw one fly past my window. I noticed how large the owl actually was. I saw the intricate pattern of its feathers and its pointy, commanding ears.

The owls started to attract crowds of admirers in the alley. Seeing so many people congregated together was strange after weeks of isolation. I wanted to see the owls up close myself, but I chose to avoid the alley. The observers were not distancing themselves from each other. Seeing the birds from my window reminded me of the confinement I felt, and my own isolation.

I had often met my neighbors outside; that changed with the pandemic. My next-door neighbor, entranced by the owls, reached out to talk. We initially reunited online and soon started talking outside again. Without the owls, I would not have reconnected with my friend. Having someone to talk to during a stressful time helps relieve the anxiety of the pandemic. I miss many things in quarantine: my friends, sports, extended family, and especially, socializing outside with my neighbors. Although the owls kept their distance, they brought me closer to my friend.

. At first, they reminded me of my withdrawal from the community. I now realize that they strengthened the ties within our neighborhood. They attracted residents from all over my town. Sharing a love of these winged visitors brought optimism to a community facing the pandemic. Instead of dwelling on our distress, we shared a common interest we may have overlooked if not in quarantine. The owls sparked a community-wide fascination with the inconspicuous joys of nature.

Sharing a love of these winged visitors brought optimism to a community.

The Owls: A Reminder There is Hope

Suicide risk screening is especially challenging in the time of a pandemic. Data are not yet available to ascertain how COVID-19 will affect the suicide rate. However, the 3-tiered clinical pathway needed to be revised to accommodate mostly telehealth screening. Maryland Pao, MD, Annabelle M. Mournet, and Lisa M. Horowitz, PhD, MPH, revised the suicide risk screening clinical pathways published by Brahmbhatt and colleagues to reflect the need for phone screening and assessments. 

Learn more in the article "Implementation Challenges of Universal Suicide Risk Screening in Adult Patients in General Medical and Surgical Settings," to appear in the July 2020 issue of

Courtesy: National Institute of Mental Health

Suicide risk screening is especially challenging. Although data are not yet available to ascertain how COVID-19 will affect the suicide rate, the 3-tiered clinical pathway has been revised to accommodate mostly telehealth screening.

Youth Suicide Screening Pathway

Public endorsement for potential benefits of the marijuana plant is at an all-time high. To date, 33 states and the District of Columbia have responded by legalizing medical marijuana, with 10 states also having legalized recreational use of marijuana. The current practice is said to be ahead of science, as robust research has been hindered by strict regulations and most epidemiological studies point toward harmful associations. Yet the general population turns to this botanical while seeking self-remedies for various ailments and conditions for which other, evidence-based, treatment modalities exist. As physicians, we have seen some of the outcomes associated with use, particularly in vulnerable populations with underlying mental health and addictive disorders, as well as adolescents and—for the purpose of this article—pregnant individuals.

estimates that 16.2% of pregnant women between the ages of 18 and 44 are daily users and, of all illicit drugs, cannabis is the most commonly abused by this population.

 Estimates also indicate that between 2009 and 2016 cannabis use among pregnant females has nearly doubled, with young age being positively correlated with use.

 Given the decreased perception of harm by the general public, women are certainly compelled to seek what they perceive as more natural self-management remedies.

Aside from continuation of use if already smoking at the time of pregnancy, some initiate cannabis to manage morning sickness, overall nausea, and vomiting. A study was recently conducted in Colorado in which researchers identified themselves as pregnant women and contacted dispensaries for guidance in managing pregnancy-related symptoms.

 Close to 70% of dispensaries recommended products to treat symptoms particularly in the vulnerable first trimester, while 36% of them also provided reassurance of the safety profile. Very few encouraged a discussion with the physician.

Consumption of cannabis during pregnancy results in cannabinoid placental crossing and accumulation in the fetal brain as well as other organs, where it interferes with neurodevelopment and the endocannabinoid system.

 Use during the postnatal period can also lead to secretion in breast milk for extended periods (up to a week) after use. From retrospective studies, we know prenatal cannabis ingestion has been associated with anemia in the mothers as well as low birth weights, greater risk of preterm and stillbirths, and increased need for neonatal intensive care unit admissions.

Although there is no phenotypic syndrome and no overt birth defects, a review of 2 longitudinal studies indicates that the majority of the teratogenicity translates later in life, beyond the infant developmental stage. Children born to mothers who used cannabis during pregnancy have higher rates of impulsivity, delinquency, learning and memory impairment as well as executive function deficits.

 There is also an increased association with proneness to psychosis during middle childhood.

Given that most human studies are observational and retrospective, we turn to animal studies in attempts to go beyond associations. Studies using rodent models hint at a variety of long-term neurobiological changes in a multitude of systems, particularly the neuroendocrine system as well as the dopaminergic and glutamate neurotransmitter systems, resulting in behavioral impact later in life.

 Such behavioral consequences affect mnemonic processing and drug sensitivity but also emotional behavior and the development of locomotor activity.

It is important to be mindful of the increasing cannabis potency and the different formulations and administration routes (ie, vaping), especially due to the declining perceived risk among patients. In 2018, the American College of Obstetricians and Gynecologists released guidelines for screening for cannabis use in pregnant and breastfeeding women and to disuade its use. This is a recommendation extended to all fields of medicine.

We also shall not overlook the impact of cannabis on mothers during pregnancy. Cannabis has been associated with increased: anxiety incidence; risk for depressive disorders; incidence of suicidal ideations and behavior; and symptoms of mania and psychosis in those with bipolar and schizophrenia spectrum conditions.

 Use of cannabis has also been linked to co-ingestion of other substances as well as alcohol. Hence, best practices would hint at screening for all substances in pregnancy when cannabis is being used.

is Assistant Professor of Psychiatry at Dartmouth’s Geisel School of Medicine and Director of Addiction Services at New Hampshire Hospital, Concord, NH. He reports no conflicts of interest concerning the subject matter of this article.

The author would like to acknowledge the contribution made by Karen Goodman, MSLIS, MA, medical librarian at the Dorothy M. Breene Memorial Library at New Hampshire Hospital, as she assisted with the literature search and procuration of the articles needed for this article.

1. Azofeifa A, Mattson ME, Schauer G, et al. National Estimates of Marijuana Use and Related Indicators - National Survey on Drug Use and Health, United States, 2002-2014. MMWR Surveill Summ. 2016;65:1-28. 

www.cdc.gov/mmwr/volumes/65/ss/ss6511a1.htm

2. Young-Wolff KC, Tucker LY, Alexeeff S, et al. Trends in Self-reported and Biochemically Tested Marijuana Use Among Pregnant Females in California From 2009-2016. 

3. Dickson B1, Mansfield C, Guiahi M, et al. Recommendations From Cannabis Dispensaries About First-Trimester Cannabis Use. 

4. Harkany T, Guzmán M, Galve-Roperh I, et al. The emerging functions of endocannabinoid signaling during CNS development. 

5. Gunn JK, Rosales CB, Center KE, et al. Prenatal exposure to cannabis and maternal and child health outcomes: a systematic review and meta-analysis. 

6. Huizink AC, Mulder EJ. Maternal smoking, drinking or cannabis use during pregnancy and neurobehavioral and cognitive functioning in human offspring. 

7. Fine JD, Moreau AL, Karcher NR, et al. Association of Prenatal Cannabis Exposure With Psychosis Proneness Among Children in the Adolescent Brain Cognitive Development (ABCD) Study. 

8. Schneider M. Cannabis use in pregnancy and early life and its consequences: animal models. Eur Arch Psychiatry 

9. The Health Effects of Cannabis and Cannabinoids. Washington, DC: National Academies Press; 2017. ❒

Consumption of cannabis during pregnancy results in a host of problems, including cannabinoid placental crossing and accumulation in the fetal brain as well as other organs.

Talking to Pregnant Patients About Cannabis Use 

Mood and anxiety disorders are the most frequently reported psychiatric comorbidities with epilepsy, with a prevalence of 20% to 22%; however, in select populations, the prevalence can reach 50%.

Reasons for the association are both biological and psychosocial.

 that brings about a number of social limitations and discriminations that lead to demoralization and poor self-esteem. Moreover, epilepsy and mood disorders seem to share a common neurobiology, with involvement of the limbic structures and the modulation of major neurotransmitter pathways by anticonvulsant medications.

Epilepsy and Seizures: Neuropsychiatric Implications

,” by Marco Mula, MD, on which this quiz was based.


1. Tellez-Zenteno JF, Patten SB, Jetté N, et al. Psychiatric comorbidity in epilepsy: a population-based analysis. 

This quiz was originally posted on October 16, 2014, and has since been updated. -Ed

Poll

What medical condition is most frequently reported with comorbid mood and anxiety disorders? Take the quiz and learn more.

Mini Quiz: Comorbid Mood and Anxiety Disorders

 asked integrative psychiatrist James Lake, MD, for insights and advice for patients to reduce stress and take care of their mental health on a day to day basis, especially important now when life seems to be in upheaval for so many. It is of utmost importance to focus on improving lifestyle factors, which may then translate into improved general mental health, and more resilience in the face of stress. 

Dr Lake talks about 4 pillars of mental health and health: getting enough sleep, regular physical activity, healthy nutrition, and a practice addressed at stress management.

In order to optimize your mental well being, a healthy diet with the essential nutrients are vital to healthy brain function. Individuals who have healthy diets tend to function better, feel better, and manage better in the face of stress, whether that is day-to-day work stress, or in this case, the extraordinary unprecedented stress that we are all experiencing. Because of the COVID-19 pandemic a healthy diet that includes fresh fish, vegetables, and grains is essential. 

People who engage in regular physical activity tend to feel better and function better. This does not necessarily mean vigorous workouts every day today, but staying active is key. Moderate level of activity might include regular walks (up to 30 minutes or more per day); strength training; using weights; and hiking on the weekends. Nature is always a wonderful way to be active and refreshed, especially during these times of confinement. There is an enormous body of research showing the relationship between regular physical activity and good mental health. In fact, many studies show that individuals who have moderate depression or anxiety or who engage in regular physical activity, including patients who take antidepressants, derive benefit.

A consistent pattern of rest means a patient has enough time to get into deep sleep. This enables one to wake up the next day refreshed, ready go to work or school. Good sleep hygiene entails the things you do from the beginning of your day until the time you go to sleep that night. They will predispose you sleeping better. Try to turn off the television or any other electronics. Students should stop studying at least an hour before going to bed. Don't drink alcohol right before bed and try to avoid it the last few hours of the day. For patients with anxiety disorders, go into a very quiet, peaceful space using gentle yoga or simple mindfulness practice to take their minds off their worries before trying to fall asleep.

People who sleep tend to be more emotionally resilient. In the context of what we are dealing with now, sleep is fundamental to those who are struggling with depression

This can be simple or it can be elaborate, depending on your preferences, or religious or spiritual bearings. Listening to music with earbuds, while also engaged in very relaxing breathing practice can be very calming and can significantly lower your baseline anxiety.

Tools for reducing stress include mindfulness, such as meditation, simple yoga styles that are calming and relaxing, and breathing. Some yoga postures can promote improved sleep, and those should be done at night, an hour or so before bed.

During this time of extreme stress, spiritual practices can help relieve anxiety. Because we don't know what the future will bring, it is particularly important and valuable for people to engage in their spiritual work or to get closer to their religious community, whichever is more personally useful. It can provide enormous peace at to delve into, spiritual practice, which might be meditation and even Buddhist prayer, Christianity or Judaism.

There can be enormous power from thinking more deeply in one's spiritual life. and through affiliation with religious community or fellowship for support and for sharing faith with others. 

A Mental Health Pandemic: The Second Wave of COVID-19

 is a Psychiatrist in private practice in California. His most recent book is 

An Integrative Paradigm for Mental Health Care: Ideas and Methods Shaping the Future

Videos

Psychiatric Times asked integrative psychiatrist James Lake, MD, for insights and advice for patients to reduce stress and take care of their mental health on a day to day basis.

4 Pillars of Good Mental Health

The first forms of telepsychiatry were initiated as videoconferencing in the 1950s. Its use has steadily increased in recent decades. Due to the 

 pandemic, the majority of outpatient psychiatric encounters in the last couple of months have been switched to virtual in a rushed, desperate bid to keep care going. These virtual encounters have become a necessity to maintain mental health care, but the abrupt change has forced many adjustments for patients and clinicians alike. In this article, we focus on potential reasons why virtual encounters feel different, incomplete, or simply unsatisfying. We hypothesize that the “flavor” of a virtual encounter, just like a traditional one, is a conglomerate of physical/environmental factors, clinician-specific factors, patient factors, and the interactive process that includes both verbal and non-verbal elements. Drawing on 

, we discuss the importance of the frame in interactions, and the impact of a rushed frame shift without preparation or training

 was developed carefully, where patients and supervisees where made aware of the method of treatment in which they would be engaging. In that capacity, telepsychiatry has allowed for treatment and supervision to occur across long distances. This has ranged from a variety of underserved areas—as varied as rural communities not serviced easily by roads, to providing services to crew members of cruise ships. Telehealth now provides a way to maintain connection and treatment while reducing the chance of spreading COVID-19. In order to protect the population quickly, this change was made rapidly and unexpectedly, for patients and clinicians alike.

One way to consider the move from seeing patients in offices, to seeing them from home through computers, is a shift in the frame. 

, an analyst and painter, coined the term “the frame” to represent the different kind of special reality in a therapeutic session (this was inspired by the concept that a different physical frame could change the experience of a painting). Variations in the frame that are introduced by either the patient or the clinician, relate to the work together. Often, changes in the frame are introduced by the patient and explored by the clinician. For example, the two might work to understand why a patient is chronically late or skips sessions. This could indicate, for example, a patient’s fear of discussing painful feelings around the clinician and trying to shift the frame to avoid those feelings.

There are many benefits to this shift in frame with virtual encounters: the main one, of course, is that many are continuing to receive mental health treatment, because clinicians were able to make this change quickly. Telehealth can provide international training, supervision, and treatment, and allows for continuing relationships with patients who relocated, or who are working or training remotely.

Virtual platforms provide HIPAA-compliant chat functions and allow informal discussion of patients between colleagues; providing much needed connection and interaction. Research supports the efficacy of virtual care in maintaining therapeutic rapport and fulfilling patients’ needs. It also demonstrates that remote supervision was experienced as equally effective to in-person supervision. However, the way clinicians conduct their visits is a finely honed technique that takes years to develop. You might change the way you ask questions, the way you sit, or focus on certain mannerisms during a session. These details are all but lost in virtual encounters and most programs lack specific training on connecting through virtual platforms (

In the past, it was felt by many that virtual mental health care was impossible. Treatment outside the office was deemed insufficient; even with video, nonverbal and subtle sensory experiences that the clinician and the patient take in about one another would be missed. Even now, clinicians feel they may miss subtle extrapyramidal findings or environmental cues when looking at a screen. The calm of the clinician or the simmering agitation of a psychotic patient may not be communicated the same way through video. It is easier to immerse oneself in the experience in the room with a patient and have a greater sensory awareness of the interaction.

 depends on the ability for the patient to maintain a connection with and a positive representation of the clinician in their mind. With the clinician not in the room, patients may revert to their default sense of relating to others and themselves, which is likely to be a very negative one.

Much of psychoanalytic literature discusses treatment in the room with the patient. Kernberg spoke to the use of structure and a frame to help patients struggling with a fragmented sense of self and difficulties with emotion regulation.

 The physical presence of the clinician is a part of that structure. The clinician’s presence can demonstrate a commitment to be in the life of a patient. Over time, a patient can develop and internalize consistency and structure into his or her sense of self by utilizing the experience in the room.

McWilliams discusses the need for both stimulating and comforting elements when working with patients.

 Comfort provides a sense of safety and stimulation is used to introduce challenge and complexity so that the patient can grow. The flexibility of providing a variety of comforting and stimulation interventions is shifted in telepsychiatry. As such, the interventions that the clinician provides may have to be amplified in other ways—just as an un-amplified actor on the stage emotes louder than a Hollywood actor.

Elements of the work in the room that convey meaning, such as silence, may be experienced quite differently in a virtual encounter. In the room, a silence can represent a shared moment of understanding, or an acceptance of patients as they are. During a tele-session, silence can be experienced as abandonment, an absence, distraction by the clinician, or even connection issues.

In the office, patients and clinicians have the privilege of a great deal of privacy. The clinician provides a private, neutral space uninhabited by family members or significant others. This level of privacy is now something patients need to create on their own, by finding their own space to meet. Also, most clinicians have a waiting room, a transitional space patients can use as a bridge between their personal lives and their relationship with their clinician. This transitional space is no longer present and can be jarring to patients. Furthermore, literal privacy is also at risk—tele-sessions introduce vectors for security breaches in a way that is different from the safety experienced in clinicians’ offices.

Just as the distance may affect patients in different ways, it can also affect clinicians in various ways. The distance of the treatment may provide a separateness to help contain their own anxiety. It can help the clinician maintain boundaries of feeling undue pressure to do more than they are able, in the session. The distance may also intensify the loneliness and separation the clinician is experiencing in the work (

Setting up a telepsychiatry environment in the current COVID-19 situation involves the basics of a private space with a desk, communication device, reliable internet, and a comfortable chair. Challenges include eliminating background noise and distractions such as interruptions from pets and family members. The goal is to create an environment that feels safe, inviting, and personal, but also allows privacy for both the psychiatrist and the patient. A safe, private, and quiet environment is essential for the patient to benefit fully from the interaction.

Once these elements are met, another struggle is the ability to maintain eye contact and proper attention while completing other necessary tasks such as note-taking or writing prescriptions. Unlike an on-site session with a patient who fully maintains his attention, there are many more distractions available to clinicians that may make it harder to focus. Emails can pop on-screen, messages ding, and cats slink by the camera. It is important for clinicians to establish with the patient, that they may need to type while talking, or that they may shift their gaze to view the patients’ records. Each eye movement made can be more closely scrutinized by the patient. Keeping patients aware of what might be going on allows clinicians to collaborate more and prevents patients from feeling ignored.

Clinicians may also experience fatigue after a long day of seeing patients through telepsychiatry. This fatigue can stem from energy expended to focus on, and be more active with, patients. Clinicians might feel limited in their ability to move in their lives and communities. These constrictions, as well as the effort of simultaneously providing containment of their own anxiety (and that of their patients) can lead to a sense of burden and weight. The clinician may be pressured to provide certainty during such an uncertain time. This can be a weighty burden for the clinician to bear and contribute to fatigue.

Telepsychiatry has highlighted existing health care and socioeconomic disparities. Tele-visits are far more utilized among patients in urban settings rather than those in rural communities, due partly to less reliable technologies such as fast internet access. The lack of an emotionally safe and private space for a tele-psychiatric visit is a major issue for the underserved. When patients cannot access mental health care on a regular basis, they are more likely to wait until symptoms are more severe and present to emergent care.

Tele-visits can be a great relief to those who do have difficulty accessing transportation. Those with financial and mobility issues may have an easier time initiating a session from home. Clinicians may learn more about the conditions and relationships in the home, recognize more of what the sanctity of the office provides to the patient. The socio-economic disparity may add a layer to the frame, by forcing into clearer view the economic hardship patients experience.

From a diagnostic perspective, certain patients may derive greater therapeutic benefit from telepsychiatry, and this area needs to be investigated further in a rigorously scientific manner. For instance, those who have social anxiety disorder or agoraphobia may initially feel more comfortable avoiding direct interaction by using telepsychiatry. However, it may impair their functioning long-term by reinforcing avoidant patterns.

A patient who is aggressive, psychotic, or one who is experiencing significant cognitive decline may be too inattentive or agitated to focus on the camera for a sustained period. It might be hard to get a full clinical picture of someone with schizophrenia if he or she is responding to internal stimuli. However, it might be easier to have a tele-session with paranoid patients if they do not want to come into the office. Patients with borderline personality disorder may feel abandoned by the switch to tele-visits. Conversely, some patients with histories of trauma, feeling unsafe, or feeling criticized by others may find it easier to speak with the distance of tele-visits.

From a physical perspective, both parties will break a barrier that existed before, between personal and professional. For example, the patient sees the clinician’s home in the video feed, or the clinician sees family members or pets whose existence was formerly abstract. This is not new, however; Freud, for example, frequently saw patients in his home in London. The new information gathered may intensify the treatment in new ways and provide different insights and understanding. Perhaps this is simply establishing a different level of intimacy (desired or otherwise) between the patient and clinician.

The are many elements to consider during this massive migration to telepsychiatry. Nonverbal, physical, and socioeconomic factors are all significant considerations of the shift in frame. These factors, combined with the clinical applications of telepsychiatry, affect the experience of the interaction between the patient and the clinician and bring up a range of feelings in both the clinician and patient. For clinicians, being able to address these changes and experience the related feelings fully, can allow them to apply telepsychiatry better. As many more clinicians are becoming more comfortable with this method, more relationships with patients can be forged, maintained, and renewed.

 is Assistant Professor of Psychiatry at the Menninger Clinic, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX; 

 is PGY-1 Resident, Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine; 

 is Associate Professor, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine and Ben Taub Adult Outpatient Services Director, Medical Director, Stabilization, Treatment & Rehabilitation (STAR) Program for Psychosis.

Convergences and divergences in contemporary psychoanalytic techniques

The are many elements to consider during this massive migration to telepsychiatry. Nonverbal, physical, and socioeconomic factors are all significant considerations of the shift in frame.

Tumbling Into Telepsychiatry in the COVID-19 Era: Challenges and Hope

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..

Ronald W. Pies, MD, is Professor Emeritus of Psychiatry and Lecturer on Bioethics & Humanities at SUNY Upstate Medical Center, and Clinical Professor of Psychiatry at Tufts University School of Medicine. He is also Editor-in-Chief Emeritus (2007-2010) of 

. Dr Pies is the author or co-author of several psychiatric textbooks, including 

Clinical Manual of Psychiatric Diagnosis and Treatment: A Biopsychosocial Approach

 (2005). He is also the author of several books on comparative religion, philosophy, poetry and fiction

 need little introduction to Dr Pies. His articles and commentaries have been a staple feature of this publication for a long time, and he is well-known for his articulate defense of psychiatry in the face of various criticisms. I first became acquainted with his writings during my 

 into making sense of Thomas Szasz. This interview series naturally has been of great interest to him and has been the source of much mutual discussion. I have found him to be gracious, thoughtful, and warm in my interactions. I have great respect for him and consider him to be a wise friend. These interviews, for obvious reasons, tend to gravitate toward more contentious issues, and from certain perspectives we might be seen as being on opposite sides of the aisle but there are lot more commonalities than might be apparent.

For much of your career you have been a vocal critic of Thomas Szasz and his ideas. I am sure there were others, too, but I am aware of at least one exchange between you and Dr Szasz which happened in the 2004 book, 

. Dr Szasz’s response seemed dismissive; I don’t think he made a good faith effort to engage with what you or other critics were saying. Szasz never changed his mind. Does that tell us something about him as an individual or does it, more pessimistically, tell us something about humans in general . . . about our inability to change our minds when confronted with arguments to the contrary?

 I should say at the outset that it is difficult for me to be “objective” about Dr Szasz, who was one of my teachers during residency. It is fair to say that, over the course of more than 30 years, he and I had a “complicated” relationship! Tom (as most of us knew him) was a brilliant polemicist, and, on a one-to-one level, a charming and cordial man. I will always remember how, when I was still a medical student, he once poured tea for me in his office—an “old world” kindness I have never forgotten!

And, I would also credit Dr Szasz with forcing all of us in the profession to reexamine our most basic and cherished assumptions, regarding mental illness; the civil liberties of our patients; and the language we use to express and defend our positions. That said, I believe that Szasz’s deeply misguided views on psychiatric illness and the nature of “disease”; his personalized attacks on psychiatry; and his inflexible adherence to his own positions all did considerable damage to our profession and our patients. And, yes: I was deeply disappointed with his rejoinder to my chapter in 

My more recent critique of Szasz is found in the book, 

Science is a self-correcting enterprise. Progress relies on diversity of opinion, dissent, and criticism of the status quo from within the scientific discipline itself. Psychiatry has been under attack for so long now that many psychiatrists are quite weary of any critique. An abundance of popular criticism against psychiatry is hostile, ill-conceived, rhetorical, sentimental, and divorced from any meaningful science. Unfortunately that tends to drown out the legitimate, sincere, and well-intentioned criticisms that do need to be taken seriously. Part of my task through this series has been to invigorate that self-correcting function of scientific inquiry, and to separate the wheat from the chaff when it comes to meaningful discourse. I am certainly not alone in this. You have been more active in defending psychiatry against criticism and have developed a reputation for that role, but I don’t believe our motivations are that dissimilar. How do you see your own relationship with psychiatric critics?

I would distinguish between two quite different groups of “critics.” There are, on the one hand, sincere and well-intentioned critics of psychiatry—many of whom are psychiatrists—whose aim is to improve the profession’s concepts, methods, ethics, and treatments. Indeed, Dr Aftab, you have interviewed a number of such constructive critics in your ongoing series. On the other hand, there are “critics” whose hostile and vituperative rhetoric is clearly aimed at discrediting psychiatry as a medical discipline. These critics, in my view, fall under the rubric of “anti-psychiatry,” which I would define as,

“. . . that movement which denies the fundamental legitimacy of psychiatry as a medical specialty; consistently imputes malign or mendacious motives to the profession; and which denies the efficacy and legitimacy of psychiatric treatment, particularly its somatic treatments.” Dr Nassir Ghaemi, Sairah Thommi, and I described the dual nature and origin of the anti-psychiatry movement in an article that appeared in 

I have had fairly cordial relations with several representatives of the “critical psychiatry” school of thought, even though I often disagree with their claims. On the other hand, there are simply no excuses for the bogus arguments and hateful attacks leveled by the most extreme voices of anti-psychiatry. What strikes me about most of the latter critics is how little they understand of general medical nosology and praxis, or of the history of medicine—which leads them fallaciously to marginalize psychiatry from the other medical disciplines.

 I quite enjoyed your 2016 exchange with Professor Hannah Decker

 in which you defend the Alexandrian-Jasperian-Engelian (AJE) integrative tradition as the underappreciated “solid center” of psychiatry in contrast with the schism between biological and psychosocial approaches to mental illness. I think a more cynical view would be that the AJE tradition in psychiatry has been a long-standing but unrealized 

. I think you are right that the 1970s and 1980s—the period when psychiatrists of your generation were trained—were probably the “golden” years of AJE tradition, but I think the agenda was hijacked pretty quickly afterwards. The explosion of pharmaceutical development in the 1990s and early 2000s with the development of SSRIs and atypical antipsychotics resulted in the reductionistic, caricaturish portrayal of psychiatric disorders as “chemical imbalance” in the public imagination; there was a large influx of money into neuroscience research with an undelivered faith that neuroscience will soon revolutionize the field, and then managed care knocked out whatever wind was left in clinical practice. When I see bio-psycho-social thinking described as the “solid center,” I cannot help but think of the famous phrase from W.B. Yeats, “The center cannot hold.” Do you also share this sense that the solid center has somehow fallen apart?

: I agree with much of what you are arguing here, but I would suggest that a more nuanced analysis is in order. First, let’s distinguish between two related but distinct claims: first, that psychiatry has become predominantly, if not exclusively, “biological;” and second; that psychiatry endorses some form of a “chemical imbalance theory.”

Taking the second claim first: it is quite clear that the “chemical imbalance” trope has become deeply engrained among many in the general public. As you know, I have argued repeatedly that the so-called “chemical imbalance theory” was never a bona fide “theory” in the strict, scientific sense.

 Nor was it a model embraced by most academic psychiatrists or, importantly, by the pioneers of the biogenic amine hypothesis.

 Yes, our critics tirelessly quote this or that notable psychiatrist who used the phrase, “chemical imbalance,” but this doesn’t mean the psychiatric profession as a whole ever embraced the chemical imbalance theory. Nor was it ever a model espoused by academic psychiatrists, or the official position of our professional organizations.

Now, circling back to the first claim: I think it is incontestable that, since the heyday of psychoanalysis (ca. late 1950s-1960s), the field of psychiatry took a fairly sharp turn toward the “biological” in the period from roughly 1978 to 1998, which, to a considerable degree, persists to this day.

 But we were far from alone in taking this turn, as witnessed by U.S. President George H.W. Bush’s proclaiming the decade from 1990-1999, “The Decade of the Brain.” And there is no question that the movement toward the biological/biochemical has been heavily influenced by the pharmaceutical industry. Nonetheless, what I have called the “Alexandrian-Jasperian-Engelian (AJE) integrative tradition” has remained central to academic psychiatry, alongside Engel’s Biopsychosocial Model (BPSM). You and I and Dr Ghaemi have had a fruitful debate on the merits, demerits, and validity of the BPSM, and I won’t rehash that discussion.6-8 I will simply say that, while the AJE/BPSM framework has struggled to remain a central part of psychiatric practice—pushing back against powerful market forces that favor brief “med checks” and provision of psychotherapy by non-physicians—the “integrative impulse” is alive and well in our profession.

Indeed, since Engel’s 1977 paper on the BPSM first appeared, “. . . the flow of citations [of Engel’s model] did not appear to fade over the years and, indeed, it has increased in the last decade.”

department at SUNY Upstate Medical University

 emphasizes the integration of psychopharmacology and psychotherapy and explicitly endorses “the biopsychosocial approach.” This is also the case at the 

, where Engel taught and practiced. In short, I believe the AJE/BPSM center is still “holding,” but it is surrounded by powerful forces that threaten its integrity.

 I have followed the controversy surrounding “chemical imbalance” with some interest over the years, including the multiple articles you have written on this issue. Generally, I agree with you that the chemical imbalance was never accepted as the “truth” by academic psychiatry or by our professional organizations. It was likely an advertisement strategy by pharmaceutical companies that took on a life of its own. However, I am not sure I am ready to exonerate our profession. At best, it seems like we were silent spectators, watching as this misleading idea spread like wildfire in the society (including among our patients and patient advocacy groups), doing little to nothing to correct these public misperceptions. At worst, it seems like at least some of us were participants. Ken Kendler writes in a 2019 

 commentary, “I would commonly see patients who would say some version of ‘my psychiatrist said I have a chemical imbalance in my brain.’”

 I have had a very similar experience myself. Either way, surely as a profession, we could have done a better job of educating our patients and the public?

Yes, I agree that we—all of us—could have done a better job of counteracting the so-called “chemical imbalance” trope, which, as your comments imply, was more a creature of “Mad Men” than of men and women who study madness! I wish I had tackled the issue earlier than my 2011 article.

And, yes—we often hear anecdotes concerning patients who tell their current clinician some version of, “My psychiatrist said I have a chemical imbalance . . .” But where is the evidence that this is what patients were 

 told? Who has contacted the patient’s psychiatrist, or reviewed his/her case notes, to see if that was really what the patient was told? To my knowledge, there has never been a study examining the “other side of the story”—and, to be clear: patients are not infallible recorders of what their doctors tell them. So, we are really left to speculate, and with the knowledge that about 80% of antidepressant prescriptions are written not by psychiatrists, but by primary care physicians and family practitioners. Who knows what these doctors told their patients? So, I consider this really a fruitless debate, unless and until I see contemporaneous documentation of what patients were actually told by their psychiatrists; or, failing that, a large “N” of psychiatrists confirm that they regularly used the “chemical imbalance” trope to explain the nature of their patients’ problem. I will add that, in my own practice over 25 years or more, I did 

 a discussion of neurotransmitters in my explanations to patients, 

but always in the context of “bio-psycho-social” causes and risk factors.

 I understand that there is no conclusive evidence, but this is not a court of law or a Cochrane committee appraising research evidence. Philosophers talk of “epistemic injustice,” which occurs when someone is not believed because of who they are. The victims of epistemic injustice are typically underprivileged and marginalized members of the community such as women, racial and ethnic minorities, and pertinent to us, persons with mental illness. The latter group has historically been silenced and robbed of a voice. Foucault famously described psychiatry as a “

 of reason about madness” (my emphasis). So, my tendency is to take seriously what my patients tell me, unless I have good reason to think otherwise. You have already stated that you would need a high level of evidence to change your mind, so I'm not trying to convince you here. My fear is that many patients who will read what you have said will feel ignored and invalidated, and their trust in psychiatrists may be further eroded. I don't believe that is what you intend, so I want to give you an opportunity to reassure such readers who may find your words alarming.

 Thank you for letting me clarify my comments, Dr Aftab. First, you are wise to take your patients’ reports and recollections seriously—and to treat such reports respectfully. Without mutual respect, the therapeutic alliance is doomed. My somewhat testy comments regarding, “Where is the evidence that this is what patients were 

 told?” were offered in the context of rebutting dubious claims by various antipsychiatry blogs, websites, and organizations. In the 

 context—sitting with my patients—I would 

challenge a report like, “My psychiatrist [family practitioner, general physician, etc.] said I have a chemical imbalance . . .” Rather, I would likely reply by asking the patient, “Can you tell me more about that meeting with your doctor, and how you felt when you heard what he/she said?” I would draw the patient out on what “message” he or she took from the encounter; eg, did apparent mention of a “chemical imbalance” leave the patient feeling relieved or anxious? More worried or less? etc. (Some patients react badly when given a purely “biochemical explanation” of their problem). Note that an interaction of this type 

does not prejudge the patient’s recollection

 or reach a final conclusion regarding what the patient was actually told by the psychiatrist or other physician. Remember: listening seriously and respectfully is not the same as listening 

As for Monsieur Foucault, that is a topic for another time! And keep in mind that while people with mental illness have indeed been marginalized and stigmatized, so have those of us who care for them. Among other factors, derogatory portrayals of psychiatry and psychiatrists in the media have contributed to stigma against psychiatrists and mental health professionals.

 When it comes to the AJE tradition, the biopsychosocial approach is surely the dominant player. There are many prominent psychiatrists—including Paul McHugh, Nassir Ghaemi, and Ken Kendler—who firmly remain embedded within the AJE tradition but have moved away from the BPS approach and have instead espoused other variants of pluralistic thinking. Are you heartened to see this flourishing of philosophical interest in pluralistic approaches?

 Yes, I am heartened, and I would add that I am not wedded to only one formulation of “pluralism,” such as the biopsychosocial model (or, as I prefer, 

), Kendler and Campbell,13 and our colleague, Dr Ghaemi,

 have all proffered pluralistic formulations of psychiatric diagnosis and treatment, some of which may well be improvements on Engel and Romano’s BPS model. We are all seeking comprehensive, holistic ways of understanding our patients and their afflictions, while hewing closely to evidence-based medicine.

In your discussions of the meaning of “disease” or “disorder,” you have focused on notions of suffering, impairment, and distress. When it comes to mental disorder, however, historically speaking its precursor concepts of “insanity” and “madness” have also included notions of social deviancy, irrationality, breakdown in meaningful connections, and harm to others. Do you think these notions still play an implicit role in our contemporary diagnostic manuals, and if so, is there a legitimate role for these notions in modern psychiatry?

 My short answer is, these features (social deviancy, irrationality, etc.) should not figure into our concept of disease, 

In this interview, Dr Aftab and Dr Pies revisit several debates concerning various criticisms of psychiatry that Dr Pies has been involved in over the course of his career, and they discuss how to make sense of the profession’s relationship with its critics. 