is a double-boarded psychiatrist with nearly 20 years’ experience and is currently the Medical Director of Outpatient Services at Iris Telehealth.

The United States has been experiencing a critical shortage in access to mental health for years now. According to a 2018 study from the National Council for Mental Wellbeing, 38% of Americans seeking care had to wait longer than a week for necessary mental health treatments, and 46% either knew someone who had to drive an hour round trip to seek treatment or had experienced that challenge themselves.

These challenges go hand in hand with our ongoing national psychiatrist shortage. According to the National Council for Mental Wellbeing’s exhaustive 2017 report, by 2025, between 6090 and 15,600 additional psychiatrists would need to be added to the workforce to meet projected demand.

 Those statistics could paint an even more drastic picture when taking into account the national mental health crisis brought on by the COVID-19 pandemic—particularly its 

Current Inequities in High-Quality Care Access

The current state of behavioral health boils down to this: we are in a crisis of access to care. However, while demand for care exceeds workforce supply nationwide, there are communities and specific demographics that are disproportionately impacted by access issues. The National Council report on the shortage found that 55% of counties across the US had no current practicing psychiatrists, and 43 of 50 states experienced a severe shortage in psychiatrists specializing in child and adolescent care.

Currently, the system is so overwhelmed that patients have to wait months to access a clinician. While rural areas are still especially underserved, areas with an abundance of mental health practitioners have also been overwhelmed during the pandemic. This situation can be discouraging for families because when they do reach out for care, they do not get called back—or they do not know who to call.

COVID-19’s Impact on Children’s Mental Health

According to the American Academy of Pediatrics, 1 in 5 children or adolescents in the US have a diagnosable mental illness that requires some form of intervention or treatment. This situation has been highlighted and exacerbated during the pandemic, which introduced new, long-term stressors into the lives of many children and families. Whether due to socioeconomic losses during the pandemic, stressors of in-home schooling, or added stressors on caretakers trying to adjust to a new normal, 

COVID-19 magnified existing mental health vulnerabilities

Children have been particularly vulnerable in this environment because they 

. Suddenly, they did not have school counselors, teachers, or coaches available to them as a support system. The isolation resulting from this shift drastically increases the risk of depression and anxiety—even up to 9 years after the fact.

 Additionally, studies have found the duration of loneliness has a larger impact on children than the intensity, making the 14+ months of school closures a significant mental health challenge for children.

During 2020, we also experienced an increase in acuity of need among children. Many children and families are in crisis and are overwhelming pediatrician’s offices, or they are taking to emergency departments (EDs) as a last resort for treatment. According to the Centers for Disease Control and Prevention, mental health-related ED visits for children aged 5 to 11 and 12 to 17 increased by 24% and 31%, respectively.

Weekly Number of Emergency Department (ED) Mental Health-Related Visits (A) and Proportion of (B) Children’s Mental Health-Related ED Visits per Total ED Visits* Among Children Aged < 

It is also important to note that, even before the COVID-19 pandemic, 

depression and anxiety diagnoses for children

 have been on the rise—with the percentage of children aged 6 to 17 diagnosed with anxiety or depression growing from 5.4% in 2003 to 8.4% in 2012.

Telehealth is directly helping the access issue by reaching many of those underserved areas that do not have behavioral health providers available to support their demand. There are many areas that would be forced to go without providers if it were not for telehealth.

Now, as we move forward, more Americans not only have had direct experience with telehealth—but in many cases, they prefer it to in-person care. The American Psychiatric Association recently released a poll demonstrating that nearly 60% of Americans would use telehealth for mental health services.

 As a result of patients adapting to a more virtual world during COVID, telehealth (specifically for mental health) is more mainstream and comfortable for patients than ever before.

 for so many during the pandemic that providers now understand they can deliver high-quality care through this methodology. The opportunity is there for organizations to continue to recruit providers who can reach some of the underserved in this manner.

What Patients Can Expect From Telehealth Visits

Although more patients and families are familiar with telehealth now than ever before, it is important for providers to set parameters with the families first in terms of expectations for telehealth visits. In practice, telehealth appointments should operate as close to a standard in-person visit as possible. However, these are some best practices to ensure the visit is successful: 1) the appointment should be confidential and in a secure location, 2) providers should confirm the patient’s location and ensure they have a secondary plan in place if the telehealth connection is lost at any point during the appointment, and 3) providers should expect to spend more time building rapport with the child, particularly if it is an initial appointment.

Because of the pandemic, a lot of families are starting with the pediatrician’s office. Many pediatricians still have dedicated clinicians running telehealth appointments. There are also providers that patients and families can access through more dedicated mental health organizations, like Community Mental Health Centers (CMHCs) or Federally Qualified Health Centers (FQHCs) that have behavioral health programs. CMHCs and FQHCs also generally accept Medicare and Medicaid, so if a particular patient is not on private insurance, these organizations are good options for access to mental health services.

Potential Limitations for Using Telehealth for Children

While telehealth is as effective as in-person care in many cases, there are certain scenarios where it may not be the best fit for a patient or family.

For example, if the patient is younger than 6 years old, it may be more challenging to get them to engage virtually. Then, for some patients on the autism spectrum who need applied behavioral analysis as part of their treatment, telehealth may not be the best course of action.

For more rural communities that have persistent challenges with broadband, COVID-19 helped open up regulations around audio-only appointments as a lifesaving option (before COVID, many individuals in those communities would have to go without care). However, audio-only appointments can pose particular challenges with children, especially younger children, who are not able to verbalize their feelings and emotions effectively over the phone. That is where organizations or providers might see the advantage of having the virtual platform through a centralized location, like a pediatrician’s office or a clinic that has a well-established connection. In this case, telehealth can be an effective tool for organizations to hire psychiatrists who are not necessarily from their communities, but who can adequately serve their patient populations.

“Thomas” is a 10-year-old patient who experiences difficulties with depression and social isolation. As a native Spanish speaker in a rural Texas community, Thomas needed a bilingual psychiatrist with whom he could have regular appointments to build a relationship and get the treatment he needed.

Thomas and his family sought out a CMHC that covers 9 counties in central Texas. This CMHC had recently begun utilizing a telepsychiatry partner to expand its services. That partnership decreased their 9-month wait time for an appointment to 2 months, which allowed Thomas’s family to get their son the care he needed.

As we look forward to a future where telehealth plays a much more significant role in long-term mental health care, it is important to think creatively about where we can insert telehealth services to make the biggest impact on children. The next steps to building a better system through virtual care may include incorporating telepsychiatry appointments into schools; increased partnership between health care organizations and formal telepsychiatry organizations who can help them access nonlocal providers to address their community needs; and making referral resources readily available for patients and families looking to get their child seen by a high-quality psychiatrist.

The most important thing practitioners and health care organizations can do right now is continue thinking about ways to increase access. It is crucial that mental health services do not move backward and, instead, embrace virtual care as integral to their future operations. 

is a double-boarded psychiatrist with nearly 20 years’ experience and is currently the Medical Director of Outpatient Services at 

1. National Council for Mental Wellbeing. New study reveals lack of access as root cause for mental health crisis in America. News release. October 10, 2018. Accessed September 9, 2021. 

https://www.thenationalcouncil.org/press-releases/new-study-reveals-lack-of-access-as-root-cause-for-mental-health-crisis-in-america/

2. National Council for Mental Wellbeing, Medical Director Institute. The psychiatric shortage: causes and solutions. March 29, 2017. Accessed September 9, 2021. 

https://www.thenationalcouncil.org/wp-content/uploads/2017/03/Psychiatric-Shortage_National-Council-.pdf

3. Loades ME, Chatburn E, Higson-Sweeney N, et al. 

Rapid systematic review: the impact of social isolation and loneliness on the mental health of children and adolescents in the context of COVID-19. 

4. Leeb RT, Bitsko RH, Radhakrishnan L, et al. 

Mental health-related emergency department visits among children aged <18 years during the COVID-19 pandemic — United States, January 1–October 17, 2020.

5. Centers for Disease Control and Prevention. Data and statistics on children’s mental health. March 22, 2021. Accessed September 9, 2021. 

https://www.cdc.gov/childrensmentalhealth/data.html

6. American Psychiatric Association. New nationwide poll shows an increased popularity for telehealth services. May 27, 2021. Accessed September 9, 2021. 

https://www.psychiatry.org/newsroom/news-releases/New-Nationwide-Poll-Shows-an-Increased-Popularity-for-Telehealth-Services

Articles

43 of 50 states are experiencing a severe shortage in psychiatrists specializing in child and adolescent care. Telehealth may be able to help. 

Increasing Access to Quality Mental Health Care Through Telepsychiatry

I am living in Milwaukee, and anyone who likes professional mens’ basketball knows that the Milwaukee Bucks won the National Basketball Association championship this past summer for the first time in many years. That, of course, has some psychological benefits for the city’s self-esteem, as do most all sports championships.

Broadway is Back, But Should It Still Be Called The Great White Way?

This past Wednesday they also won a different kind of championship. They have hired Lisa Byington to be the first woman to work as a full-time television play-by-play announcer for a major mens’ professional sports team. This follows advances for girls and women in various aspects of national sports.

Though there will not be any public celebration like after the basketball championship, perhaps in the long run it will turn out to be more important for the development of an equitable and self-actualizing society.

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

Milwaukee has won a different kind of championship: raising up women’s careers. 

The Milwaukee Bucks Win Another Championship!

is a retired US Navy Commander and military clinical psychologist with more than 26 years of military service.

A most pronounced characteristic of the cases seen early in their illness is the profusion with which new symptoms appear and disappear. As time goes on, without treatment, a more stabilized syndrome crystallizes.

Those who have worked with combat veterans know that they are a group of patients who require a special degree of honesty and compassion. According to the US Census Bureau, there are 18.0 million veterans living in the United States, 17% of whom are women.2 In addition, at any given day, 1.4 million men and women serve on active duty, along with 718,000 civilian personnel. Another 1.1 million Americans serve in the 

. It is estimated that 7% of the US population has military experience, which is 

. Among post-9/11 veterans, 43% have a service-connected disability,

 perhaps related to the fact so few in modern society (less than 1%) serve in the all-volunteer military, requiring citizen-soldiers and their families to carry the burden.

Unfortunately, institutions charged with caring for veterans are often unhelpful. The Veteran’s Administration’s (VA) lack of transparency is a significant handicap for veterans and family members seeking treatment and explanations for their mental illnesses. Researchers, clinicians, and journalists are unable to find answers to important questions about the impact of war on veterans and their families. How many post-9/11 veterans have been diagnosed and/or treated for posttraumatic stress disorder (PTSD)? How many veterans have been diagnosed with any other mental health-related condition?

Statistics From the Veterans Administration

It is hard to say. The VA’s annual reports on Analysis of VA Health Care Utilization Among Operation Enduring Freedom (OEF), Operational Iraqi Freedom (OIF), and Operation New Dan (OND) Veterans, stopped being publicly available in 2016. Nevertheless, based on 2015 data, we can say that over a million post-9/11 veterans are using VA healthcare, and mental disorders are prevalent in this population (

 Aside from the fact the data are outdated, the data also captures only those veterans going to the VA. The VA does not keep track of those seeking counseling from the 360 veteran centers across the country

; nor those who seek help through the private sector; nor the largest subset of veterans and military personnel who suffer silently. Of course, there are multiple millions of family members and caregivers within the military population, those critical for the military veteran, are not covered for any services.

Differences in the Treatment of Military Versus Non-Military Populations

Psychiatric Casualties: How and Why the Military Ignores the Full Cost of War

 we were asked to opine on what clinicians should know about treating military populations (

read an introduction to Dr Russell and Dr Figley’s book 

.). First and foremost, while it is true that war changes everyone, it is also a great disservice to assume that most or all citizen-soldiers who served in the military and/or deployed to war zones, are fatally damaged goods. Going to war often signifies both the best and worst of times for veterans. Military populations offer fertile ground for studies on resilience and posttraumatic growth (PTG) among specialties within the service branches.

On the flip side, it is important not to view evidence of resilience or PTG as indicating an absence of mental or physical health-related problems. Another potential mistake is to assume that current or former military personnel must have suffered war trauma, and that is the primary or sole issue that leads them to seek mental health services. In reality, the all-voluntary military faces a wide-range of potential traumatic stressors that are inherent occupational hazards including combat, training accidents, transportation accidents, terrorist attacks, military sexual trauma, victims of crime, natural disasters, humanitarian relief missions, peace-keeping missions, along with other common stressors in the civilian sector (ie, domestic violence, childhood abuse, motor vehicle accidents, betrayal trauma, racial trauma, etc). The wise clinician is alert to the fact that even if a service member is a combat veteran, their distress will likely be a combination of factors, not just a product of combat experiences.

Next, clinicians should be sensitive to a host of risk factors and trauma-related conditions that are not entirely unique to military populations. Like police, federal and state law enforcement, and related professions, combat veterans, may deal with 1) the psychological impact of killing or seeing others killed; 2) having been wounded-in-the line of duty; 3) exposure to the presence of traumatic grief and complicated bereavement of fellow officers or from the death of a loved one, including one’s combat buddies; 4) moral injury from participating or witnessing killings, legal or otherwise; 5) intense survivor guilt, 6) co-occurring traumatic brain injury or phantom limb pain in amputees; 7) posttraumatic anger and sense of betrayal trauma; 8) handling of human remains; 9) being a prisoner-of-war by war enemy, drug cartel, or a political party; 10) chronic pain conditions; 11) opioid misuse; and 12) secondary trauma and compassion fatigue.

Similarly, war has taught us time and again that human beings have manifest traumatic stress injuries. These injuries cross a spectrum of possible conditions, and that diagnosis like PTSD represents only a sliver of possible afflictions.

 Historically, war or other traumatic stress injuries are often divided into 2 broad classifications: 1) neuropsychiatric conditions that consists of the culturally accepted diagnostic labels of the day such as PTSD, mood disorders, anxiety disorders, psychotic disorders, impulse control disorders, substance use disorders, neurocognitive disorders, eating disorders, sexual disorders, personality disorders, and others, and 2) medically unexplained physical symptoms (MUPS) which include chronic fatigue, headaches, chronic pain, atypical cardiac symptoms, idiopathic seizures, autoimmune conditions, and others.

In the 21st century, the Department of Veterans Affairs 

, “such as chronic pain and fatigue, are common in the general and military veteran populations” and that “Chronic Fatigue Syndrome (CFS), Fibromyalgia (FM) and Irritable Bowel Syndrome (IBS) are among the most commonly diagnosed medically unexplained conditions.” However, there are far more potential MUPS diagnoses. These include noncardiac chest pain, pseudo seizures, multiple chemical sensitivity. Other studies on MUPS in the current war cohort indicate a high frequency of somatic complaints (

 Additionally, OEF/OIF veterans with and without a diagnosed mental health condition were treated in the VA for 222 types of MUPS.

As many clinicians are aware, somatic complaints are often considered a cultural idiom of distress.

 This is particularly true with military populations whereby stigma and fear of career reprisal can be so oppressive. The career-related stress makes it more likely to complain of headaches, back pain, and sleep problems as opposed to emotional symptoms.

Common Obstacles Military Populations Face to Receive Proper Mental Health Care

By far, the biggest obstacle that current and future military populations face regarding mental health care is the pattern of a sustained, self-inflicted mental health crises plaguing generations of Americans and society since World War I.

 These largely preventable catastrophes are caused primarily by chronic neglect and lack of accountability by the military and its government. Our most 

 noted 10 foundational lessons of war trauma identified by every military cohort since WWI. These lessons are essential to meeting the wartime mental health needs:

1) Recognizing that war inevitably causes large numbers of legitimate spectrum of war stress injury;

2) Adequate research, planning, and preparation are indispensable during both war and peace;

3) A large cadre of well-trained behavioral health specialists is compulsory during times of war and peace;

4) A holistic, public health approach to war stress injuries necessitates close collaboration with the private sector along with full mental health parity; 

5) Effective mental health services demand the empowered leadership of an independent, unified, organizational structure, a behavioral Health Corps, providing integrated, well-coordinated continuity of care equal to medical services;

6) Elimination of mental health stigma, barriers to care, and disparity should be a priority for leadership, as it directly affects individuals, families, and military readiness;

7) Ensure ready access to high-quality mental health services, including definitive care prior to military separation or discharge;

8) Families must receive adequate mental health and social support during and after military service;

9) Accurate, regular monitoring and reporting are crucial for timely, effective, management of mental health needs; and,

10) Robust dedicated mental health “lessons learned” policy and programs are integral to meeting present and future needs and prevent crises.

Despite being learned again at the end of every war, these lessons have not substantially improved veterans’ care. Perhaps the best evidence that little progress has been made comes from a Department of Defense (DOD) Task Force on Mental Health. In 2007 it identified

A single finding underpinning all others: The Military Health System lacks the fiscal resources and fully trained personal to fulfill its mission to support psychological health in PEACETIME or fulfill the enhanced requirements imposed during times of conflict (p. ES2).

The time for action is now. The human and financial costs of un-addressed problems will rise dramatically over time. Our nation learned this lesson, at a tragic cost, in the years following the Vietnam War. Fully investing in prevention, early intervention, and effective treatment are responsibilities incumbent upon us as we endeavor to fulfill our obligation to our military service members. 

This is a stirring plea for action, but the DOD offers no concrete proposal on where to start, or a sense of when we will know when it is enough. Without concrete proposals and ongoing commitment to investing in prevention, early intervention, and effective treatments, pleas like this one will remain empty.

Have we learned our lessons? More than 6 years into a shooting war, 99 urgent recommendations were made by the DOD task force, all reflecting neglect of the military’s well-documented centuries of “lessons learned.” The media, Congress, and Commander-in-Chiefs alike still have not met their responsibilities to investigate the reasons for gross negligence that harm countless members of the military population for this and future generations.

From our vantage point, the military is positioned in a unique leadership role within the broader society. It could inspire other leaders to step up, be accountable, and finally call for ending the stigma surrounding the mental health of its members. The question remains: why has the US government and its military refused to learn its war trauma lessons and what concrete actions are necessary to end the generational cycle of neglect and crises?

is a retired US Navy Commander and military clinical psychologist with more than 26 years of military service

is the Paul Henry Kurzweg, MD, Distinguished Chair in Disaster Mental Health at Tulane University and founder and director of the Tulane 

Those who served: America’s veterans from World War II to the War on Terror

. US Census Bureau, U.S. Department of Commerce. June 2020. Accessed September 15, 2021. 

Analysis of VA health care utilization among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans, from 1st Qtr FY 2002 through 3rd Qtr FY 2015

 (October 1, 2001—June 30, 2015). June 2015. Accessed September 15, 2021. 

5. Russell MC, Figley CR. Generational wartime behavioral health crises: Part one of a preliminary analysis. 

6. Hoge CW, Terhakopian A, Castro CA, et al. 

Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans.

Medical care needs of returning veterans with PTSD: their other burden.

Idioms of distress among trauma survivors: subtypes and clinical utility.

9. Russell MC, Figley CR. Investigating recurrent generational wartime behavioral health crises: Part two of a preliminary analysis. 

10. Russell MC, Figley CR, Robertson KR. Investigating the psychiatric lessons of war and pattern of preventable wartime behavioral health crises

. Journal of Psychology and Behavioral Science

11. Arthur D, MacDermid S, Kiley K, et al. 

An achievable vision: report of the Department of Defense Task Force on Mental Health

. Department of Defense Task Force on Mental Health. Defense Health Board. June 2007. Accessed September 15, 2021. 

What psychiatric illnesses are most prevalent among veterans? And how can clinicians help them overcome obstacles to care?  

Treatment of Military Populations

is a psychiatrist in Philadelphia, Pennsylvania and is affiliated with Hospitals of the University of Pennsylvania-Penn Presbyterian.

Despite the increasing number of older adults with 

, there is limited evidence to guide its treatment in older patients.

In the past, the treatment of bipolar disorder and mania in older adults was based on uncontrolled studies. As an aggregate, these studies suggested that 

 may be effective in treating bipolar disorder in late life. However, concerns about lithium’s safety in older patients led practitioners to using lower concentrations than what was used in middle aged adults, or to avoid lithium altogether.

 that balances efficacy and adverse effects for patients in this age group.

The goal of the first double-blind study comparing the safety and efficacy of lithium and divalproex in the treatment of late life mania attempted to answer these questions. The study, conducted at 6 academic centers and funded by the National Institute of Mental Health, was a randomized 9-week double-blind parallel group trial of lithium and divalproex in patients with bipolar I disorder in a current manic, mixed, or hypomanic episode. Patients were aged 60 years or older.

The average maximum dose of lithium was 780 mg ± 315 mg with a serum concentration of 0.76 ± 0.35 mEq/L. The average maximum dose of divalproex was 1200 mg ± 550 mg with a serum concentration of 74 ± 21 mg/L. Limited use of lorazepam or risperidone was allowed in the first 3 weeks of the study for agitation or insomnia. After 3 weeks of treatment, risperidone up to 4 mg a day was used for an inadequate response to lithium or divalproex.

The attrition rates by study end (51% on lithium and 44% on divalproex) were not significantly different, and they did not depend on age or medical burden. The reasons for attrition were nonadherence, poor tolerance, and lack of efficacy. Patients tolerated both medications equally.

In terms of efficacy, both medications were beneficial in reducing the Young Mania Rating Scale (YMRS) score, but lithium lowered scores slightly more, with moderate effect size. Patients with more severe mania at study entry did better on lithium than on divalproex. Response rates (defined as at least 50% reduction of YMRS from baseline) in the lithium and 

 groups were 63% and 57%, respectively, at week 3 (nonsignificant) and 79% and 73% at week 9 (also nonsignificant). The cumulative rates of remission (YMRS ≤ to 9) were 46% and 44%, respectively, at week 3 (nonsignificant) and 70% and 63% at week 9 (nonsignificant). Seventeen percent of patients taking lithium and 14% of patients taking divalproex received adjunctive risperidone after the third week of treatment (

). The proportion of patients needing adjunctive risperidone was not statistically different between the 2 treatment groups.

The study authors concluded that efficacy and tolerability of lithium and divalproex are comparable in the treatment of mania in older adults. “Treatment with lithium or divalproex with conservative serum concentration targets, combined with limited use of rescue and adjunctive medications, was tolerated by older patients with mania, and it benefited a substantial proportion of them,” the authors reported. “These results suggest that treatment guidelines for older persons with bipolar disorder should emphasize greater use of lithium and less exposure to antipsychotics.”

1. Young RC, Gyulai L, Mulsant BH, et al. Pharmacotherapy of bipolar disorder in old age: review and recommendations. 

2. Young RC, Mulsant BH, Sajatovic M, et al. GERI-BD: a randomized double-blind controlled trial of lithium and divalproex in the treatment of mania in older patients with bipolar disorder. 

In older adults with bipolar disorder, what evidence is there to guide treatment? 

Treating Mania in Older Adults With Bipolar Disorder

is associate professor at the University of South Carolina School of Medicine - Greenville and medical director and division chief for Adult Inpatient and Consult-Liaison Services for the Department of Psychiatry and Behavioral Medicine at Prisma Health - Upstate. 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

I recently was introduced to Courtney Madeira by a mutual friend. Courtney is a kindred spirit and fellow poet who has a passion for storytelling. She recently shared a poignant piece, “Blue-Gray,” that resonated with me. I witness firsthand the daily struggles my patients with substance use disorders face. Addiction is a debilitating illness that has deleterious effects on the health of our nation. Furthermore, it can impact the individual suffering from the illness as well as their interpersonal relationships.

“Blue-Gray” is a palpable narrative that illuminates the importance of continued advocacy and support for a population that is often stigmatized and longing to be understood.

I am thankful for opportunity to share Courtney’s talents with a diverse audience. I embolden us to continue to seek understanding and perspective through the power of stories.

is associate professor at the University of South Carolina School of Medicine - Greenville and medical director and division chief for Adult Inpatient and Consult-Liaison Services for the Department of Psychiatry and Behavioral Medicine at Prisma Health - Upstate. 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 

Understanding addiction through new, creative lenses can offer a fresh perspective. 

Substance Use: The Importance of Advocacy 

has been writing a poem about his experience of being a doctor every month for the past 23 years in

in a column called “Poetry of the Times.” He is instructor in psychiatry, University of Massachusetts Medical School, Worcester, MA

For more of the Any Good Poem Series, see 

Videos

"The moon drops one or two feathers into the field..."

Beginning

Perhaps you have heard that Broadway theatre in New York has opened up again, hopefully to the safe benefit of New Yorkers and visitors who love live theatre. On September 14th, 

 all reopened. If you are familiar with these shows, collectively they celebrate and reflect much of the cultural diversity of the United States.

Reducing Islamophobia Through Apology and Afghan Resettlement Support

And yet, as part of the publicity for those openings, the nickname for a large section of Broadway is still being used. It is “The Great White Way,” which originally referred to the lighting illumination of Broadway that emerged at the turn of the 20th century. Even the title of a book published last year, 

The Great White Way: Race and The Broadway Musical

, used the term. A strong contention of the book is the hidden racial agendas of these musicals. The author, Warren Hoffman, argues that at least until recently, the history of “The Great White Way” is the history of so-called white identity. The trouble now with the nickname is our concern with 

, and that nickname can exclusively suggest the greatness of the way of white people.

Perhaps, then, there should be a call for a new nickname for Broadway which will be less racist. How about “The Great Broad Way,” with “broad” referring to our diversity? Or, “The Great Colorful Way,” referring to all the various hues of our skin? Maybe you have other suggestions. If so, let us know.

Perhaps it is time to retire Broadway’s nickname in favor of one more representative of our diversity. 

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

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

Many years ago, I read of a young woman—an institutionalized patient with schizophrenia—who approached her psychiatrist, “Dr Rosen,” and asked him a question: “Dr. Rosen, do you water the roses in your garden?” The doctor was rushing to some meeting and hardly had time to think through his answer. He assumed that the young woman’s question was merely an example of the thought process disorder that characterizes schizophrenia, whereby his name (“Rosen”) was conflated with “roses.” If memory serves me, Dr. Rosen answered rather brusquely, along the lines of “Sorry, got to run, let’s talk later.” Sometime following this interaction, the patient was seen sitting alone, weeping softly. Only later , upon reflection, was Dr. Rosen able to understand what his patient had been trying to ask him: “Will you take care of me, Dr. Rosen, just as you take care of the roses in your garden?” Although he heard her question, he had not listened attentively to what his patient had left unspoken.

This vignette brings us to the Hebrew word 

. (Not to be confused with that sweet confection made with sesame paste—that’s 

.) Hakshavah is difficult to translate into English. Although usually rendered as “attentive listening,” hakshavah is more subtle and more complicated than that. It has affinities with what psychoanalyst Theodor Reik, PhD, (1888-1969) called, “listening with the third ear.”

 It is what rabbinical scholars describe as inner listening, which requires attaining “an inner quiet and avoiding the great noise that envelops us in this world.”

 Hakshavah means not only listening empathically to what someone is saying, but also listening to what they are 

saying. This may sound like some arcane Zen paradox, but I believe that it is close to the core of our profession.

The concept is well-illustrated in a tragic event recorded by the philosopher and religious scholar, Martin Buber, PhD (1878-1965). Buber is best known for his classic work 

 (1923), in which he distinguished between 2 archetypal relationships: “I-Thou” relations, in which one individual views another as a full-fledged human being, worthy of respect, understanding, and empathy; and “I-It” relations, in which one individual treats another as a kind of useful object. Unfortunately, we often treat others as mere agents of our own needs—in effect, as walking utensils—and relate to them in an I-It fashion

Rather than truly making ourselves completely available to them, understanding them, sharing totally with them, really talking with them, we observe them or keep part of ourselves outside the moment of relationship. We do so either to protect our vulnerabilities or to get them to respond in some preconceived way, to get something from them.

Tragically, on one occasion, Buber was unable to achieve the very sort of I-Thou relationship he championed. It seems he was hard at work editing some mystical text when his doorbell rang. A very distraught young man asked Buber if he could speak with him. Impatient to return to his scholarly work and a bit annoyed by the intrusion, Buber somewhat reluctantly agreed to hear out the man. Buber answered the questions the young man asked but, as Buber later acknowledged, “I didn’t try to answer the questions he didn’t ask.” A short time later, Buber learned that, apparently, the young man had killed himself.

I am guessing that many of us who have been in the field a long time can recall a few encounters like this. Listening attentively is hard work, especially when we become distracted by our own thoughts, problems, and egocentric preoccupations. In her book 

, the French philosopher, mystic, and political activist Simone Weil (1909-1943) put it this way: “The capacity to give one’s attention to a sufferer is a very rare and difficult thing; it is almost a miracle; it is a miracle… Above all, our thought should be empty, waiting, not seeking anything, but ready to receive in its naked truth the object that is to penetrate it.”

How can we pay attention in the right way? The rabbis, writing about hakshavah, instruct us to “Listen from your heart, not from your ears.”

 They are referring to a kind of introspection that is needed when we try to listen attentively to others. Hakshavah is “not an ability of our intellect – it is rather a ‘heart’ ability. It is to listen with our heart, to listen to what’s going on inside ourselves.”

I realize that all this may sound quite esoteric and a bit new age-y. But in my view, psychiatrists can make use of these insights in very practical ways, particularly when dealing with patients who evoke strong counter-transference feelings, such as those with borderline personality disorder. In working therapeutically with these patients, listening with the third ear can be extremely difficult when we find ourselves experiencing anger, frustration, or feelings of professional inadequacy. (As one therapist put it, “The rewards with these patients often come in the next life.”)

It is even harder to listen to what severely disturbed patients are not saying but may be communicating through their nonverbal signals and body language. Attending to such nonverbal nuances is roughly what Reik meant by “listening with the third ear” to the patient’s “speech of silence.” For example, Reik asks us to pay attention to the patient’s

[D]ress and peculiarities in his gestures...an olfactory nuance; a sense of touch while shaking hands...the manner in which [the patient] glances up or looks...the minutest movements [that] accompany every process of thought; muscular twitches in face or hands and movements of the eyes speak to us as well as words.

Attending to our countertransference with challenging patients requires a certain inner quiet, as we process our emotional reactions to their non-verbal signals: a frown, a look of anger, a slight slumping in the chair. However, if we as therapists cannot “listen to what’s going on inside ourselves” in reaction to the patient’s nonverbal communications, we will not be able to achieve hakshavah. As I was taught in my residency: When working with borderline personality disordered patients, “It’s not the words, it’s the music.”

To process our patients’ subtle cues on a deep level, we need, as much as possible, to empty our thoughts of egocentric concerns. Easier said than done, of course. As Weil recognized: Such deep attentiveness “is a very rare and difficult thing.”

And yet, hakshavah is critical in our work with patients. As the rabbis put it

When you really listen to others from an inner place in yourself, you don’t just hear his words; you hear the feelings going on inside him…When you listen to others who come to you with their problems, don’t just listen to what they are saying. Listen to what’s going on in their heart. Feel their pain and their other emotions; don’t just superficially hear their words and take note of what they are saying. When you listen to them from your inner self, you feel another’s feelings as he talks to you.

Indeed, this is how we water the roses in our garden.

is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and Editor in Chief emeritus of

1. Safran JD. Theodor Reik's listening with the third ear and the role of self-analysis in contemporary psychoanalytic thinking. 

Inner Silence Series: 22 Gateways to Developing Solitude (Hisbodedus) ‘as an Ideal Path to Intimacy With God.’

 Unedited internet version V5. July 10, 2019. Accessed September 10, 2021. 

https://bilvavi.net/files/Inner.Silence.Series.pdf

3. Martin Buber (1878 – 1965). Jewish Virtual Library: A Project of AICE. Accessed September 10, 2021. https://www.jewishvirtuallibrary.org/martin-buber

4. Kidadl Team. 100 Simone Weil quotes from the French philosopher and activist. kidadl. February 18, 2021. Accessed September 10, 2021. https://kidadl.com/articles/simone-weil-quotes-from-the-french-philosopher-and-activist

Paying attention to what is not said is near the core of our profession.

Hakshavah: Listening to the Speech of Silence

is a first-year resident at the University of Vermont Medical Center.

It was my first overnight call shift, and I had just gotten a page for my third Emergency Department (ED) consult. I was the on-call psychiatry resident at the hospital, meaning I saw anyone coming into the ED due to a mental-health-related crisis. Many things can be categorized as mental health crises, but they are often cases dealing with suicidal thinking or action, psychosis, mania, and drug or alcohol use.

About 10 minutes after I got the page, I was sitting in the patient’s room listening to them describe the events of this past year between fits of tears. My heart pinched when I heard the inevitable: “I have been trying so hard to find anyone that can help, but the wait lists are so long…” In an ideal world I would have treatment options at my fingertips and distribute them with lightning speed to everyone coming to the hospital in a severe crisis. But, for many reasons, this is far from reality.

From the start of the COVID-19 pandemic, experts have 

 of an inevitable mental health crisis that would follow the devastation of such a massive unprecedented event. Now, almost a year and a half since the virus was 

 a global pandemic, this crisis has arrived. Despite this well-predicted and publicized outcome, not much was done to prepare systems. Importantly, few actually realize what a mental health crisis looks like at the frontlines—and just how many individuals and systems it affects.

This July, I started my first year as a psychiatry resident. On our first day, the program director sat me and my fellow interns down to have a frank discussion about what we were walking into. With our brand-new ID badges, we listened as she described mental health care as a stream that ebbs and flows. And right now, she emphasized, it was a tsunami. The ED at our hospital was filled with what are called 

. Boarders are patients that are in the ED exclusively for a psychiatric reason, but because the system is so backed up, there is nowhere else for them to go. So, what happens to them? They wait, and wait, and wait in a place never meant for more than an extremely short length of stay.

During the first day on the job, a psychiatry resident sees patients who need help, but there are problems with the system designed to help them. 

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