Harold J. Bursztajn, MD

During the present COVID-19 pandemic, mental-health practitioners of all disciplines are becoming accustomed to a variety of telemedicine-enabled modalities for treatment and evaluation. A growing variety of telemedicine platforms are now in use. This development has produced an explosion of articles and other documents describing theoretical advantages and disadvantages of teletherapy in psychiatry and how it can best be carried out.

 For more than a decade we have practiced with the assistance of telecommunication technology for patient and examinee accessibility. Based on our own and our colleagues experience with clinical and forensic telepsychiatry, what follows are some practical pointers and potential pitfalls for clinical and forensic practitioners.

Over the past several decades, rural health care delivery, the courts, and prisons have increasingly relied on 

 to accomplish their work. This modality has increased access to examinations and improved care by medical professionals in remote geographic communities. However, it took the pandemic of 2020—and the suspension of some governmental regulations until an emergency no longer exists—to increase significantly the use of telemedicine. In forensic settings, telelinks are now used even by judges conducting trials, as well as in forensic competency evaluations, independent medical examinations, and tribunal hearings for evaluating claims of physician liability.

It is clear by now that telelink-enabled clinical and forensic evaluations are here to stay, given their evident convenience and cost savings. This is especially true in the forensic context, where the examiner and examinee, having no ongoing local treatment relationship, may be located in different regions of the country, or the examinee may be incarcerated or otherwise immobile. Moreover, elimination of the costs of travel allows for more frequent (virtual) meetings with patients, who can more easily maintain attention and concentration in shorter sessions. These may include persons suffering from psychosis, severe anxiety, depression, dissociation, fatigue, and/or lack of self-integration. Such meetings may routinely be preferred because the absence of travel, parking, and security requirements allows for more flexible scheduling and time- and cost-effectiveness.

Nonetheless, the authors believe that insufficient attention has been paid to concrete structural and behavioral details of this form of psychiatric work. There are practical issues to keep in mind that can increase the efficacy of clinical and forensic telepsychiatry, and steer clear of common pitfalls. (Except where otherwise specified, the term “interview” is meant to apply to both clinical and forensic interactions.)

It is important to establish appropriate video and audio platforms and to allow time to ensure that the preparatory technological setup for the interviews is working adequately. (When the interview is on the court premises, the setting and technical apparatus are predetermined.) As to what technological complaints need to be addressed, some evaluators have noted that poor lighting is a concern. Dark shadows, for example, can interfere with clarity of the visual image. In addition, disruptions in the video feed may interfere with accurate evaluation of the patient for abnormal involuntary movements (the AIMS test) used to monitor long-term effects of neuroleptics. On another sensory dimension, the sense of smell obviously cannot be utilized on video calls. For example, the odor of alcohol may go undetected—a significant potential omission. This limitation may necessitate alternative means of gathering otherwise olfactory-dependent data.

In the current COVID-19 emergency, free video platform setups, which have received HIPPA-compliant waivers from the federal government, may be used. However, the manufacturers may set time limits for the sessions that can compromise the needed length of an interview. Additionally, technical difficulties such as bandwidth and the absence of timely technical assistance may interrupt the flow of the interview. Such interruptions, if not adequately prepared for, may compromise the interview and affect the process of therapy or the findings of a forensic examination.

In forensic evaluations, problems may arise with connectivity for the attorney and/or the judge. The greater the number of persons on the video link, the greater the opportunities for technical interruptions, particularly when trying to connect with WIFI and cell phones. Allow time at the beginning of sessions to test and correct any audio or visual problems and plan for augmented bandwidth.

For a clinical interview, all participants have a role in establishing the appropriate guidelines. To begin with, it is important to establish who will schedule the sessions and provide the formal invitation. Some parties may prefer to originate the telecall interview to feel more in control of the session process. Generally, it is the party that initiates the link that is responsible for whether or not that link is HIPAA-compliant. Some patients who initiate telecommunication will wish to waive any applicable HIPAA-compliance requirement for the comfort of using a more familiar telecommunication pathway of their choice.

The visual environments of both parties can be expected to influence the dynamics of the interaction. While many interviewers practice in home offices, those are usually curated to some degree, with attention paid to the furnishings according to some concept of a professional space.

 By contrast, when practitioners who have not already set up home offices find themselves unexpectedly working from home in the pandemic, they may be working in their lived-in home. Both information and misinformation may emerge from this reality.

For this reason, some clinicians and evaluators, especially those who are novices to home office practice, prefer a blank screen that will not show personal effects in the office space or provide any indications of the geographic area of the assessment. Such details may expose clues to the whereabouts of secure locations needed in domestic violence or custody cases. Other practitioners use a virtual background, which, while reflecting an aspiration to neutrality, may also contribute to an aura of unreality. An inauthentic background can reinforce an interviewee’s predisposition to view Shakespeare’s metaphor of “All the world is a stage” (in “As You Like It”) in concrete terms. By contrast, appropriate objects visible in the office, such as works of art, can prompt helpful associations in psychotherapy or psychodynamically informed forensic examination. Regardless of the distinctive features of an interviewer’s office, it is often better that the background be the interviewer’s own authentic office.

The visual field of online practice has a number of potentially limiting factors. Awareness of these potential pitfalls is a vital step in increasing the efficacy of such practice.

For example, while video makes it easy to observe facial expressions and register tone of voice, the lower body, sometimes from the neck down, often is not visible. Some body language and aspects of dress are thus unavailable. This potential limitation may be particularly problematic in custody evaluations, where full body choreography in family evaluations is sometimes essential. The presence of the family can be a positive part of an online evaluation.

 However, if the interviewee is told to place him/herself far enough from the lens to permit such full viewing, facial expressions may be harder to see and the voice harder to hear. Varying the patient’s distance from the camera in the course of the interview is a potential remedial option when necessary. 

Telepsychiatry may not be the ideal or exclusive modality for young children, especially when they are overactive to the extent it is difficult to keep their attention or capture their interactions within the screen. However, evaluations for attention deficit disorders may be successfully accomplished using telehealth.

 The mindful observer may need to pay closer attention to information that may be more telepsychiatry-accessible, such as variation in eye movement, facial expression, and speech rhythm or tone, as well as to integrate this information into analysis of corroborative data.

In one such custody evaluation, a child being interviewed was noted to look away from the screen at times. It became clear that the parent, initially excused from the room, had returned, unnoticed by the interviewer, and witnessed (and perhaps influenced) the interview.

 screenings, it may help to visually take in the entire clinical gestalt of the family. Without an additional party running the cameras, many camera settings do not permit a full view of all parties at the same time. In such instances, more attention needs to be paid to the rhythm, timing, and tone of the family speech patterns. The visual gestalt may need to be further complemented by the auditory gestalt and corroborative data (eg, medical and school records, structured interviews, and psychological testing). 

Time may also be a relevant consideration, especially if clinician and patient are in different time zones. Some patients, uncertain about their appointment time, may be confused if placed in a digital waiting area until the doctor is available. Because of the recognized intensity of such meetings and the need for particular focus and attention, the session may need to be divided into 2 or more such meetings to allow breaks for either party.

In working with developmentally disabled individuals, some evaluators find that the lag in digital savvy can be a major holdup in the evaluation process, particularly with a deficit in WIFI and the staff’s inability to correct deficiencies. At times, the video feedback may be so distorted that the evaluator cannot get enough of the expressive language clues to understand the problem. This is made even more difficult when the staff is new and unfamiliar with the parties being assessed. The collegial relationship and teamwork between staff and evaluator are critical factors deciding the quality of the examination, particularly in agencies with increased staff turnover. With these patients, it is best to have a team in place, including a behavioral clinician, a nurse, and family members. However, be aware that some family members will not agree to participate in video sessions.

Some of the problems that emerge from online observations can be grouped under the rubric of potential distractions for both interviewer and interviewee.

Recording the session, as well as providing a record of the interview, may increase performance anxiety and attempts to manage one’s impression, especially in forensic examinations or adversarial proceedings, in which the examinee and others (family, attorney) have a stake in the outcome. The same applies to having a third party (such as an attorney) present. The distorting effect of recording or third-party presence in both the clinical and forensic contexts has been well studied.

 If such distortion is unavoidable (eg, by court order), special consideration needs to be given to minimizing it. In some states, such as Massachusetts, the recording of clinical interviews without permission of all parties is prohibited by law.

Some patients of all ages are more comfortable with audio transmission alone, as they are then less distracted by the close-up of the therapist’s face as well as their own. As in all therapy and evaluation, being aware and respectful of the wide range of individual variability, as well as of one’s own countertransference, is vital.

By contrast, the absence of the interviewer’s picture or the substitution of a photo for a live image may be experienced by some interviewees as inattentiveness or lack of interest on the part of the interviewer, much like analytic patients who cannot tolerate being unable to see the analyst. When an interviewer is aware of such a risk, asking the interviewee to describe their experience of the interview can be helpful. 

The picture-in-picture effect may have several valences, pro and con. For some interviewees it is a potent distraction. For others it may convey the reassuring presence of the examiner and/or an intrusive pressure to influence behavior. Not using picture-in-picture, especially in forensic contexts, may decrease some interviewees’ less authentic tendency to play to an audience. Clinicians and forensic examiners likewise may be distracted by their own faces or facial reactions, splitting attention from the interviewee. Alternatively, some interviewers find it helpful to see themselves as the process evolves, perhaps detecting their own countertransference reactions (eg, blind spots) and distractions. An interviewer’s awareness of these effects can help support the therapeutic alliance or the validity of a forensic examination.

How Therapeutic Issues Can Manifest in Telepsychiatry

Sometimes it is difficult to distinguish between interruptions or distractions attributable to technical imperfections or mishaps and those that have a deeper dynamic origin.

The session started on time, but when the questions moved into more affect-laden material, the examinee complained that they could no longer hear the examiner. After several attempts to resolve the difficulty, the interview was rescheduled. This change resulted in lost time for all parties. In this case, one might conclude that telepsychiatry was no longer time efficient. On the other hand, the ostensible technical breakdown might serve as an opening for exploration of sensitive material.

Awareness of a potential distraction can turn a potential video call pitfall into a therapeutic insight. Exploring the meaning of telelink-enabled communications in the course of treatment can be helpful not only for avoiding telelink-related pitfalls, but also for furthering the therapeutic process itself.

A patient who is a childhood survivor of the Shoah invariably kept her eyes glued to her therapist’s face on telelink. At one point she noted less cyberspace traffic than usual as background noise. Her associations to the changed transmission noise included the bombing she heard as a very young child in hiding. This exploration opened the path for a safer cyberspace discussion. Having less need to keep her eyes on the therapist’s face, she spoke more freely and with great insight into how her experience of social isolation as a hidden child at times shadowed her experience of danger and social isolation during the pandemic.

In telelink-enabled psychotherapy with an adolescent patient who had early issues around separation anxiety due to the father’s medical problems and a mother who felt the need to be immersed in work, processing the feelings of both being there and not being there opened up an avenue for more effective use of teletherapy.

When the patient is present in one’s office, one always knows what local emergency services to call in, which is not the case when the individual is a distance away. In virtual sessions, it is still sometimes necessary to have an appropriate emergency support network and backup plan at the patient’s site. In the rush to adapt to telehealth, there is a risk of omitting this step. Thus, for new patients, for some ongoing patients when indicated, and in high-risk populations of forensic examinees, a risk assessment should be completed at the beginning of every session, along with the standard brief technical check-in (“How’s the WIFI? Can you see me, hear me okay?”). Since interviews may occur at some distance from the practitioner’s location, and may even cross state lines, the practitioner should obtain phone numbers of local emergency services, police, family members, or significant others to assist in times of crisis. When indicated, the availability of such resources should be assessed and documented. 

During a teletherapy session, the patient became distressed and threw a chair at the monitor. A limit was set on this behavior, as it would have been had the patient and therapist shared the same physical space. The behavior was then explored for its meaning for the patient and the relationship.

, interviewers should know whether other parties are in the home or within earshot, and whether the session is being recorded. The use of HIPAA-compliant or -noncompliant telecommunications should also be identified. It is important to establish behavior limits, ensuring that the meeting is a safe time for communication without domination, bullying, or intimidation.

Many students are now spending much more time in the family home. One recalled that he had to go to a local coffeeshop or sit in the car to get needed WIFI for his session via cellphone and to be out of the hearing of family members. Obviously, a public setting poses its own privacy issues.

In one session a patient was discussing a sensitive marital issue when the spouse walked into the room.

Clearly, family privacy rules need to be set early in treatment. The patient may wish to bring others into the session; ideally, this would be discussed in advance. However, since the patient is already there, the opportunity for this step may be missed or scanted.

In addition, telepsychiatry poses some questions that the clinician or examiner needs to reflect upon, since a single size does not fit all patients or examinees; nor is telepsychiatry any more of a rote diagnostic-checklist exercise than in-person psychiatry. How does the new remote distancing process affect people of diverse cultures? How is rapport established between parties to encourage truthful disclosure? These are questions that need to be considered early in the process. Clinicians should inquire about the patient’s or examinee’s comfort during the process. 

Whenever possible, encourage patients to decide how and where the virtual interview will occur and proceed only with their agreement. They may have concerns about allowing someone into their home space; for example, an interviewee may be self-conscious about the appearance of their home environment. Inquire about what other options may be available for the interview: is there private space in a library or other accessible public building? For individuals needing an interpreter, how is this use accounted for in the responses to questions? How does this affect the 

It is essential to maintain a professional environment when working from home while connecting with the interviewee’s home space. Doing so requires an appropriate setting and attire, even if one is not fully visible to the patient. For example, interviewing from a bedroom or while wearing pajama bottoms is unwise.

It is the authors’ view that in some instances the casualness of the setting does present potential obstacles for maintaining appropriate boundaries, even when online. A messy environment in either the clinician’s or patient’s room may generate an atmosphere of laxity about the clinical work, leading to a loss of focus. On the other hand, with increased self-awareness and experience, a casual atmosphere can have the advantage of freeing all concerned from rigid formulations or habitual preconceptions.

The patient was interviewed at home. During the course of the session, the patient was suddenly lost from view. The patient had decided to take the therapist on a tour of the home and yard and was not aware that the WIFI did not extend outdoors.

A clinician reported that a patient partially disrobed in the session and had to be reminded of her state of undress and of the expected appropriate decorum.

 is not the same as in-person visits. Some patients feel that some things have been lost, such as empathy and respect. The shift to a virtual environment has shocked some patients, and some claim that physicians are seemingly less available and less empathic about patients’ concerns. One person complained that physicians seemed to be keeping their distance—even when the office was back up and running with appropriate personal protective equipment. Another patient, who had undergone major surgery for cancer, recalled that when they arrived for a follow-up visit, the treating physician spoke from the doorway and never came into the examining room

Has the patient-physician relationship suffered from this imposed distancing? Historically, it has been recognized that an emotionally vital and mutually respectful professional relationship between physician and patient offers some protection from lawsuits. The physician’s commitment to caring for the patient, even within the safe distancing of this pandemic, must be maintained.

Articles

When meeting patients online, mental-health practitioners must confront a host of issues. 

Telepsychiatry: Practical Pointers and Potential Pitfalls

The SARS-CoV-2 (COVID-19) pandemic has exposed a series of critical fractures in our social fabric. These social ruptures should concern medical health professionals, because social determinants of health not only drive chronic health conditions, but also create acute mental health vulnerabilities. At the same time, not every mental health issue requires a mental health professional for a public health response. There are simply not enough of us out there, and—most importantly—there is so much primary and secondary prevention that should be done to prevent debilitating anxiety and depression, traumatic stress, and other symptoms that drive functional impairment, disrupt supportive relationships, and increase risk of suicide.

A central site for such prevention is our educational system. Historically inequitable in its distribution of resources, it serves not only as a source of scholarly succor, but also as facilitator of nutritional security, safety, monitoring of well-being, and connection to services for family systems. Thus, as we properly give priority to frontline health responders and the fragile elderly as recipients of coronavirus vaccines, we must not undervalue education and neglect vulnerable teachers as deserving a measure of priority in the vaccination queue.

There seems to be some acknowledgment that the mental health crisis coming fast on the heels of the pandemic’s peak may drive deaths of despair in equal proportion.

 Little attention is being given, however, to the pandemic of false choices, or what Langer

 have called “Choiceless Choices” that people have had to make—and will be increasingly pressured to make in the months to come as health care institutions and businesses reopen and on-site work resumes. Such choiceless choices, long a subject of analysis in bioethically informed medical and legal practice, often involve tragic choices, in which any choice one makes can lead to a tragic outcome.

 Thus, many families who are dependent on schools for 

 childcare (including single-parent families and those in which both parents work) may face the choice between doing without food or rent money and failing to give children an environment for learning at home. In these circumstances, parents often feel helplessness, guilt, and shame for not being able to provide both financial stability and education, and children often feel they have become a burden on their worried parents. With such feelings amid social isolation and aloneness in the pandemic, there is now a likelihood that healthy resilience may be impeded across generations.

Choiceless choices tend to foster a climate of malignant competition and toxic perfectionism, as represented in Hyman Bloom’s 1953 drawing of Marsyas, the music satyr whose drive for perfection led him to provoke a malignant competition with Apollo, the Greek god of art.

One component of our mental health response must therefore be a substantial investment in our educational systems, from pre-K through high school. Curricular deficits must be made up, following the ongoing limitations of remote learning. Innovation and adaptation with respect to socializing are also a priority, given the need for physical distancing. There will be a need for nurses in every school, as well as for counselors who can screen for signs not only of anxiety and depression that may have arisen during the pandemic, but also of demoralization, alienation, and increased exposure to domestic violence that may have persisted and escalated under the pressures of family isolation and economic insecurity.

This current crisis provides a timely opportunity to introduce a broad repertoire of positive coping strategies that are developmentally appropriate across the school system, interventions that will serve our society for decades to come. Strong attention needs to be given to professional development for teachers, both to support their retention and to ensure that our children are sufficiently engaged, challenged, and inspired to envision themselves as something more than avatars in a virtual world of TikTok memes and YouTube novelties. By reintroducing a way of life beyond Zoom, we can avoid toxic coping strategies and empower resilience, thereby strengthening both the health care system and the economy.

In the conditions created by the pandemic, it is essential that we not lose sight of the good in pursuit of the perfect.

 There are, and will be, choiceless choices to be made and losses to be grieved.

 There is still time to shift the trajectory of this pandemic’s aftermath; the choices we make now may reflect both current and aspirational values. If we keep schools closed while reopening bars and gyms, we risk restructuring (or perpetuating) our value system in a way that not only creates a context for increased individual, interpersonal, and community trauma, but also perpetuates it across generations.

 Our capacity to make those choices and to grieve those losses, even as we strive to minimize them, will be vital to our—and our children’s and grandchildren’s—potential for post-traumatic growth as the pandemic eventually remits. 

History (past and present) suggests the societal stakes involved in the wake of pandemics—namely, that a robust investment in the educational system serves as a buttress against widespread alienation and further polarization in access to resources. An educated populace is fundamental to democracy and to a bioethically informed life. The importance of preserving and advancing a heritage of knowledge has long been recognized by many religious and spiritual traditions, including Judaism, as in Hyman Bloom’s painting of a rabbi saving the Torah in the midst of a calamity.

At a time when political systems have demonstrated such vulnerability, the global stakes could not be more evident. Given the direct impact of the school system on the mental and physical health of individuals and communities, we must recognize vaccination of teachers and school staff as a priority. There is much healing to be done outside the health care system, and the psychiatric community has a responsibility to recognize and highlight these opportunities.

is associate professor of psychiatry (part-time) and co-founder of the Program in Psychiatry and the Law at Harvard Medical School and president of the American Unit of the UNESCO Bioethics Chair (Haifa). He practices clinical and forensic psychiatry in Cambridge, Massachusetts.

is assistant professor of psychiatry at Harvard Medical School, co-chair of the MGB Trauma Informed Care Initiative, and Associate Vice Chair, Ambulatory Services, in Brigham and Women’s Hospital Department of Psychiatry.

1. Bursztajn HJ. Neither deaths from denial nor deaths from despair. 

https://www.psychiatrictimes.com/view/neither-deaths-denial-nor-deaths-despair

Versions of Survival: The Holocaust and the Human Spirit.

 State University of New York Press; 1982.

The Nazi Doctors: Medical Killing and the Psychology of Genocide

5. Haque OS, De Freitas J, Viani I, Niederschulte B, Bursztajn HJ. Why did so many German doctors join the Nazi Party early? 

6. Tanaka G, Tang H, Haque OS, Bursztajn HJ. Preserve Enduring Personality Change After Catastrophic Experience (EPCACE) as a diagnostic resource. 

7. Rabbis’ Teachings: Rabbi Ari Lev: The holiness of imperfection. 

, Yom Kippur 5777. October 12, 2016. Accessed December 1, 2020. 

https://www.kol-tzedek.org/imperfection.html

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https://www.psychiatrictimes.com/view/triage-trauma-moral-distress

Schools need to be at the heart of our response to the COVID-19 mental health crisis.

A Pandemic of False Choices

Mental health caregivers have all too often had to work in situations where patients’ needs far outstrip available resources. It is akin to the 

 experienced at times in emergency rooms, on the battlefield, or by clinicians dedicated to the care of underserved populations.

 The chaos and uncertainty generated by the COVID-19 pandemic mirrors historical reports of other global traumas, times when difficult decision making occurs amid great uncertainty, and tragic choices must be made.

 Making such choices can leave indelible effects on the human psyche.

The aftereffects of triage-like situations are often insidious and may remain hidden for years, sometimes expressing themselves somatically, psychologically, and behaviorally. Sadly, the COVID-19 pandemic has also challenged caregivers, as well as patients and their loved ones, forcing difficult triage choices. Experience reminds us that we need to be prepared for the aftermath of triage’s trauma.

Traumatic flashbacks, feelings of unconscious or dissociated survivor guilt or shame, and experiences of depression are common. Efforts to treat this posttraumatic spectrum of suffering, while often helpful if not curative, can also often fail, leaving clinicians concerned about what they have missed, how might they have been more helpful.

Much is written about the models and ethical issues raised by working with such individuals. How to help them remains a mystery. Clinicians are often left saying, “We’ve done the best we can, and it simply wasn’t good enough.”

Perhaps such self-flagellation and despair are the result of working from a limited perspective on the etiological components web of chance, causation, choice, and helplessness that entraps the individual in their suffering. Witnessing, experiencing, or perpetrating traumatic events does not only affect normative cognitive expectations; it also challenges an individual’s sense of self and fundamental expectations of their values. It can assault their 

: a sense of meaning and what is right and wrong, not simply as ethical choices, but as elements of their own inherent constitution and agency.

Moral integrity represents the depth of an individual’s inner core, not a simple dichotomy of right and wrong. As such, when a person’s moral integrity is jeopardized in some fashion, they lose touch with their inner identity. It may lead to overestimating or disowning personal agency as a protection against the aloneness and helplessness inherent in triage-limited decision-making. As a result, many of the components of posttraumatic suffering and chronic grief (such as guilt, remorse, shame, or considering oneself infallible) are experienced in a far deeper way, since the sense of meaning and existence are in jeopardy. Denial of uncertainty, compartmentalizing helplessness, and experiencing life-long anticipatory mourning are possible consequences. And when resilience is necessary, an inability to grieve helplessness and vulnerability can lead to culturally sanctioned, socially toxic prejudices.

Caregivers and patients suffering from moral injuries are different from those who are not. Moral injury means that an individual's self-definition is on the line. Efforts to mitigate their post-traumatic spectrum symptoms may only provide partial remedy for their problems. Individuals suffering greatly may become angry, blaming caregivers, in an effort to retain an illusion of control. They frequently experience feelings of doom greater than depression.

The aftermath of COVID-19 will likely leave many with posttraumatic spectrum and chronic grief. Many will also likely suffer from moral distress. “Did I do enough?” “I failed to take proper precautions.” “My god failed me.” Such cries of distress are likely to be misunderstood unless we recognize that they may well be expressions of existential moral suffering. Unaddressed, moral suffering may be a prelude to toxic resilience: dehumanization and destruction of members of a historically demonized and marginalized minority.

 Moral distress also may prompt self-destructive behavior, as in “

” from suicide, excessive risk taking, and looking for quick fixes or anesthesia via compulsive drug use.

Who can address such suffering? An initial step is to connect with those who have made triage decisions. Clinicians should make sure that they are not left with the choice of either feeling alone or being treated generically. Care providers must address a fundamental wish of perfectionism in themselves in order to be available to help those saddled with triage responsibility. While observing boundaries, at times self-disclosure of one’s own failures, fears and regrets in life can be helpful. As members of a supportive medical and mental health community, we need to be prepared to do no less during and after this pandemic.

Addressing moral distress is different. Post-triage trauma, confessions of regret are not enough. It is vital to recognize that there is a good deal of judgment inherent in decision making under conditions of uncertainty and limited resources. The key is to avoid both perfectionism and denial of responsibility, idle self-righteousness, and nihilism. Such insight can only be achieved in a safe space for conversation. As we recover and hope, it is vital to make time and resources available to treat not only checklist post-traumatic stress spectrum mental health symptoms, but also the larger, more persistent changes in personality and perception of self that constitute moral injury.

 is has been a faculty member of Harvard Medical School Department of Psychiatry Medical since 1976. He is co-founder, co-director and vice president of the American Bioethics Culture Institute, the American Unit of the International Network of the UNESCO Chair [Haifa] in Bioethics, Inc

 is co-founder of the Program in Psychiatry and the Law at Harvard Medical School and president of the American Unit of the UNESCO Bioethics Chair (Haifa). He is coauthor of 

Medical Choices, Medical Chances: How Patients, Families, and Physicians Can Cope with Uncertainty

 (1981/1990). He practices clinical and forensic psychiatry and risk management in Cambridge, MA.

1. Bursztajn HJ, Gutheil TG, Brodsky A. 

Ethics and the triage model in managed care hospital psychiatry

Other times, other realities: Toward a theory of psychoanalytic treatment.

4. Haque OS, De Freitas J, Viani, et al. 

Why did so many German doctors join the Nazi Party early?

5. Case A, Deaton A. Mortality and morbidity in the 21st century. 

6. Tanaka G, Tang H, Haque OS, Bursztajn HJ. 

Preserve Enduring Personality Change After Catastrophic Experience (EPCACE) as a diagnostic resource

Mental health providers who battle a pandemic may find that it unsettles their deepest sense of self.

Triage Trauma and Moral Distress 

Neither Deaths From Denial Nor Deaths From Despair

Weaving Beauty Into the Tapestry of the Pandemic

We want to be sure that just as when we treat psychiatric illness with medications or psychotherapy, there are no unintended consequences. The cure should not be worse than the disease; so must we be cautious about an exaggerated response to COVID-19.  To my mind, that is iatrogenesis.

More in this video with Harold J. Bursztajn, MD, Co-founder of the Program in Psychiatry and the Law at 

 and President of the American Unit of the 

 (1981/1990). He practices clinical and forensic psychiatry and risk management in Cambridge, MA.

The cure should not be worse than the disease; so must we be cautious about our response to COVID-19. More in this video with Harold J. Bursztajn, MD.

Slideshows

In a time of panic, despair, and demoralization, art continues to inspire the author's reflections as it has over the last 40 years. Here, he shares some images that he finds inspirational and helpful. Even in winter there is hope.

Prevention of Covert COVID Iatrogenesis

Local, state, and federal officials are rushing to implement massively life-altering measures in the current 

 even as we enter a situation that is still poorly understood. Given the initial level of denial, resulting in lack of preparedness and testing of inconsistent quality and quantity in different countries and regions, there will be deaths from denial that could have been prevented. We still lack valid data on the prevalence of the virus, fatality rates, or so-called “excess mortality” beyond what might be expected in the 2- to 18-month period that has been proposed as critical for this pandemic. There are, however, indications that, unlike during the influenza pandemic a century ago, fatalities from the coronavirus are occurring disproportionately among the fragile elderly and others with already reduced life expectancy because of underlying conditions that weaken their immune systems.

Our most vulnerable people deserve (as do we all) specific attention to prevention and special care-prevention and care that may be diminished by the drain on limited resources that a blind-panic community-wide quarantine approach, which diminishes the dignity of a community, makes inevitable. We have to be careful that in search for perfect COVID-19 community-wide contagion prevention perfection, we do not inadvertently enter into a malignant competition as to who can be more perfect at the art of prevention. Competition among individuals and communities striving for perfection in COVID contagion prevention can inadvertently dehumanize both individuals and entire communities. This is vividly illustrated by the post-Holocaust artwork of the Latvian born American painter Hyman Bloom, (1913-2009) 

. (Exhibited at the Boston Museum of Fine Arts 2019-2020). Marsayas, a musically gifted Satyr, aspired to outdo the artistic perfection embodied by the Greek god Apollo. Alas, such perfectionism ended as it inevitably does, in dehumanization of the self, of figuratively being flayed alive of one’s humanity.

Sweeping measures of debatable efficacy in saving lives strive for perfect prevention. We need to ask questions such as are we really closer to perfect prevention of death or are we further from the good life when a state’s police are ordered to stop motorists with out-of-state license plates. When  police are ordered to identify people as a threat to public health generically, as by their state license plate or whether they are wearing masks in even sparsely populated open air areas, there is the potential for abuse of power, and civil rights violations, humiliation, demoralization, and police and public health resource diversion. On the other hand, precise measures such as 

, recently initiated in Massachusetts, empower the identified individual with an understanding of the need to be quarantined.

Such measures respect dignity and agency and are not demoralizing for individuals-who can receive support while quarantined-or stigmatizing for entire communities. Avoidance of demoralization and stigma is essential in the current pandemic, which leaves those affected susceptible to the ongoing isolation and humiliation characteristic of 

Enduring Personality Change After Catastrophic Experience 

(EPCACE), a useful diagnosis unwisely eliminated from ICD-11. The catastrophic trauma for which many around the world are now at risk creates a timely 

, with its potential to support individual empowerment and the creation of healing communities.

In my psychiatric practice, I am now spending much of my time responding to panicked patients and advising colleagues who are faced with such patients. People who already experienced heightened anxiety, a sense of loss of control over their lives, concerns about mortality, or feelings of hopelessness, understandably find these difficulties exacerbated not only by the emergence of the virus but even more by an atmosphere of societal panic amid a sea of unknowns. Given my career-long interest in iatrogenesis (medically caused illness or injury), I need to ask whether draconian proposals with yet uncalculated consequences, such as indefinite, community-wide long-term quarantines, may prove to be a cure worse than the disease.

Surely, we must work to prevent deaths from denial due to the current lack of widespread testing accessibility. We must take appropriate precautions such as handwashing, staying home when ill, reasonable physical distancing, and reasonable restrictions on movement and large gatherings. But we must also consider at what point deaths from denial may yet be exceeded by deaths from disruption leading to despair. Bioethical analysis must consider that people also die of loneliness, of helplessness, of the feeling that their lives have gone out of control and likely will never return to normal. Then, too, there are the foreseeably devastating economic consequences of an ongoing breakdown of established networks of interaction and exchange. While we can all see ourselves as vulnerable due to the denial that preceded the emergence of the pandemic, not all of us can see ourselves as being vulnerable to deaths of despair. Yet unraveling the fabric of society will give many of the most vulnerable people ample reasons to despair and panic.

 by being condemned to work as sanitation workers fighting a typhoid epidemic in the Lodz ghetto in Poland, often spoke of the need to be realistic, yet not give in to panic and despair. The costs of panic and despair are many. Today, they include the racist scapegoating being directed at groups such as Asian-Americans and Hasidic Jews. There are also some who will exploit a chaotic situation for economic gain. Likewise, those who seek to concentrate political power can manufacture or inflame a crisis as a pretext for postponing elections, or pander to prejudices by proposing community-wide quarantine.

 is among the prudent alternatives to economically and socially devastating collective quarantines. In South Korea and Singapore, specific yet successful health measures have included reasonable precautions, targeted testing for those in massive public contact, identification of those infected and tracing their contacts, and contact-specific and infection-specific quarantine. Massachusetts has now become the first state in the nation to initiate contact tracing. This should be a nationwide policy. It is vital that we now ramp up testing, tracking, identifying, and quarantining those infected and their high-risk contacts and focus resources on those in need.

The pandemic need not leave in its wake community-wide, overwhelming despair and demoralization. Even as we implement effective and ethical public health measures, we can prevent the long-term 

 of panic-driven public health. Even under conditions of uncertainty, we can still treat communities and individuals with dignity, do the right thing, and be open to learn from those who in other times either suffered from EPCACE or were able to be effective during such catastrophes and resilient in the aftermath of those catastrophes.

, is Co-founder of the Program in Psychiatry and the Law at Harvard Medical School and President of the American Unit of the UNESCO Bioethics Chair (Haifa). He is coauthor of 

1. Tanaka G, Tang H, Haque OS, Bursztajn HJ. How catastrophe can change personality: why EPCACE is a clinically useful diagnosis. 

Local, state, and federal officials are rushing to implement massively life-altering measures in the current pandemic even as we enter a situation that is still poorly understood.

We can reasonably quarantine infected individuals, but we should not squander our social and moral capital by quarantining whole communities.

As the pendulum has swung from denial to near-pandemonium about 

 in the US and worldwide, sensible public health strategies to contain the spread of the virus must compete for attention with panic reactions like calling for quarantining people of a particular nationality. Today it is the Chinese, tomorrow perhaps the Italians.

As a psychiatrist, clinical ethicist, and citizen, I struggle with the reality that panic and hysteria spread more easily and quickly, covering more space in less time, than does hope. When hope cannot be offered in the form of a quick fix, there is a natural tendency to plunge into despair, leading often to counterproductive measures. The Internet, through its instant, indiscriminate communication of simplistic, reductive messages, is much better at spreading fear, panic, and hopelessness than at raising hope, which is best fostered by people working together and learning to trust one another.

For an inspiring model of communal hope and 

under a dire threat to survival, I find myself turning to the Fekalists, the prisoners condemned to be sanitation workers in the Lodz ghetto in Nazi-occupied Poland, my parents among them. The Fekalists, who disposed of human waste and cleaned sewers, had an average life expectancy of six months. Yet, instead of succumbing to despair under the most horrific conditions, they worked with physicians and nurses-also ghetto residents-to prevent an epidemic of typhoid fever from getting out of control. Had they not succeeded, for example, in keeping sewage out of drinking water, the Germans would have liquidated the ghetto.

My father later recalled a Jewish physician who secretly ministered to him after he had been wounded in a resistance raid to obtain vital building materials from a German supply house. “I will die here,” my father said to the older man. “One of us will, but it will be me,” replied the physician. “I do not have any way to treat you, but you are young. If you don’t give up hope, you will survive.” Indeed, the Fekalists did not give up hope. Instead, through solidarity, humor, and song, they helped preserve community morale and became the heart of the Lodz ghetto resistance. Among those who were saved were 14 people who, using the materials obtained in the raid on the supply house, built an underground bunker cemented over a riverbed. My parents married in that bunker.

If the heroes of that imprisoned ghetto could maintain a resilient community without scapegoating, we can do likewise under much more benign conditions. We need not assume that a catastrophic 

is at hand, and we must not resort to racist measures like demonizing and shunning an ethnic community. Such panic can easily become a self-fulfilling prophecy, with demoralization and economic chaos cascading into a life-threatening catastrophe. Far better to understand that life goes on and that hope and resilience can be nurtured, even amid cases of illness and death.

Fortunately, the Internet can also serve to convey practical preventive measures for individuals, families, and communities, like those being developed by the 

Centers for Disease Control and Prevention

 (CDC). For example, a blogpost by Ian M. Mackay and Katherine E. Arden titled “

So you think you’re about to be in a pandemic?

” (on the Australian website Virology Down Under) lays out useful recommendations such as staying at least two meters away from visibly sick people, washing hands thoroughly, trying not to touch your face, and stocking up a two-week supply of food and other essential household items. We can reasonably quarantine infected individuals, but we should not squander our social and moral capital by quarantining whole communities.

This article was originally posted on March 3, 2020, and has since been updated. -Ed

 is Co-founder of the Program in Psychiatry and the Law at Harvard Medical School and President of the American Unit of the UNESCO Bioethics Chair (Haifa). He practices clinical and forensic psychiatry in Cambridge, MA.

For an inspiring model of communal hope and resilience under a dire threat to survival over COVID-19 fears, the author turns to the Fekalists, the prisoners condemned to be sanitation workers in the Lodz ghetto in Nazi-occupied Poland, his parents among them.

Resilience, Not Panic, in a Time of Pandemic

Any psychiatric diagnosis has the potential for empowering the clinician to treat the patient’s suffering as well as inspiring the patient to participate in an effective treatment. Alas, diagnosis also has the potential for stigmatization and dehumanization. Whereas diagnoses of personality disorder all too often have been used to stigmatize patients, the rush to eliminate Enduring Personality Change After Catastrophic Experience (EPCACE) from the International Statistical Classification of Diseases, Revision 11 (ICD-11) is foreseeably an instance in which patients vulnerable to aloneness will be less likely to receive effective treatment and thus will become even more voiceless, further disempowered, and more vulnerable to humiliation throughout the life cycle’s inevitable stressors and losses.

EPCACE was incorporated into ICD-11 as a form of Complex PTSD (cPTSD) as of June 2018. EPCACE is defined as an enduring personality change lasting for a minimum of 2 years that a patient experiences following a catastrophic stressor (ICD-10). The events of the stressor must also be so extreme that one should disregard any genetic vulnerabilities or predispositions that would further influence personality changes. These experiences can include imprisonment in concentration camps, disasters, and long-lasting capture with a persistent threat to life.

ICD-10 EPCACE represents the experiences of a particularly vulnerable population group, one marked by great loss, separation from a community, and aloneness. Such isolation from nourishing connections is a major dimension of deep and enduring personality change. Especially in cases of massive psychic trauma such as the Holocaust, involving the loss of an entire community and its way of life, fundamental bonds of social connection, trust, and support are broken, and the individual is left profoundly alone. Such affective changes point to the insufficiency of research on survivors left in such a devastated state.

We acknowledge that there is great variability in the experience and suffering of survivors of catastrophic events. As with any clinical diagnosis, a diagnosis of EPCACE is no substitute for a formulation tailored to the needs of the individual patient and that patient’s family. An EPCACE-based formulation can highlight such factors as extreme helplessness and aloneness, whether human agency was the cause of the catastrophic event, whether the event involved humiliation of the survivor, and whether the survivor remained in the zone of danger after the catastrophic event. These factors may be evident both individually and transgenerationally, as they are in the suffering of some of the survivors of the Holocaust who remained in areas where anti-Semitism and its dangers continued to be prevalent.

With careful attention to individualization of formulation, there is evidence for the benefits of EPCACE being included in the next revision of DSM as its own unique diagnosis. While care needs to be taken to avoid a reductionist and dehumanizing misuse of the diagnosis of EPCACE, the presence of this diagnosis in standard diagnostic taxonomies of psychiatric disorders can guide treatment formulations to good effect. Furthermore, EPCACE is an integrative diagnosis that offers clinicians the capacity to transcend diagnostic categorization by bridging personality disorder with trauma-related disorder, fulfilling an integrated biopsychosocial approach.

Our proposal has strong historical precedent. By 1992, the concept of trauma-inflicted personality changes had been well studied, as described by Herman and colleagues

 and later confirmed by many others, including Beltran and Silove,

 In an effort to distinguish personality changes as a result of catastrophic events from those with other causes, the ICD-10 task force decided on the inclusion of EPCACE. Personality traits such as hostile or distrustful attitude toward the world and social withdrawal, chronic feelings of emptiness or hopelessness, of being on edge as if constantly threatened, and estrangement distinguished EPCACE from related disorders.

With catastrophic genocidal trauma that includes extreme helplessness, humiliation, and the destruction of a validating community, resulting in aloneness, there is also a potentially lifelong vulnerability to shame.

 Such personality traits may emerge post-catastrophe and then become dormant. Nonetheless, they may reemerge with disruptive life-cycle events such as helplessness, humiliation, separation, loss, and grief or with news events, such as can occur for Holocaust survivors when anti-Semitism reemerges. Similar events may result in seemingly divergent personality traits emerging among survivors or even within a survivor, such as when there is an intensification of efforts to avoid massive grief concurrent with a counterphobic adaptation.

To test the validity of such an EPCACE diagnosis, Beltran and colleagues

 undertook a comprehensive survey of clinical psychologists and psychiatrists: 89% of respondents agreed that personality can be altered by trauma occurring in adulthood. Of those 89% of respondents, torture and concentration camp exposure were identified by 91% and 90% respectively as likely to produce changes to personality, followed by 72% for war exposure, 66% for sexual assault, 57% for hostage situations, 52% for domestic violence, 25% for natural disasters, and 24% for motor vehicle accidents.

Despite this substantial evidence, only 16% of clinicians had ever used EPCACE as a diagnosis for their patients, although it had been a valid ICD-10 diagnosis for 7 years before Beltran’s survey. Those who responded to the survey also cited issues of symptom overlap between EPCACE and more commonly used diagnoses, specifically depressive disorders and borderline personality disorder. However, EPCACE is marked by stable changes in personality, whereas borderline and depressive disorders are marked by instability in mood and affect.

It is foreseeable that post-traumatic avoidance of reminders by both patient and clinician is even more pronounced in catastrophic trauma. This may be another factor that contributed to the underutilization of EPCACE in its debut as a diagnosis. Alas, the underutilization of EPCACE is a loss for a significant proportion of patients who might otherwise have united as a treatment community. This loss is compounded by the fact that aloneness is often seen in the transgenerational transmission of EPCACE-related suffering. Group therapy is therefore a vital modality in EPCACE treatment across generations and in fostering the transgenerational transmission of resilience.

A follow-up study of the validity and utility of EPCACE in 2008 by Beltran attempted to redefine the broad aspects of the diagnosis and identify the key criteria that described a person with EPCACE. Twenty-four mental health clinicians who worked with patients who had experienced war and sexual assault as well as recently displaced refugees provided valuable feedback. Not only were the key attributes of “A hostile or mistrustful attitude toward the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of being ‘on edge,’ as if constantly threatened, and estrangement” identified, but mental health practitioners felt significant features were excluded from EPCACE’s operational definition. These include “somatization, self-injurious/self-damaging behaviors, sexual dysfunction, and enduring guilt,” which if included would differentiate EPCACE from complex PTSD and strengthen the operational validity of the diagnosis.

 Since then, no changes to criteria or follow-up studies have been conducted to improve the utility of EPCACE.

Research into EPCACE has been limited, as manifestations of the core symptoms can often differ depending on viewpoints and type of trauma. A core feature of EPCACE such as “a hostile or mistrustful attitude toward the world” can be operationally expressed by multiple symptoms such as anger, aggression, and other countless variations.

 Holocaust survivors who were identified as “feeling as if the Holocaust experience was continuing” were more likely to suffer symptoms of mental disorder, whereas those who avoided the traumatic memories altogether had a higher mortality rate due to illness.

 Patients with a diagnosis of EPCACE may isolate themselves not only from their communities, but also from proper mental health care.

Alternatives to inclusion of EPCACE as a distinct diagnosis

Critics of the inclusion of EPCACE in diagnostic taxonomy claim that it lacks specificity and is insufficiently utilized. To address these concerns, Maercker and colleagues

 proposed to reconceive EPCACE as part of cPTSD in ICD-11. Following this recommendation, the World Health Organization trauma team eliminated the diagnosis of EPCACE.

 cPTSD incorporates patients with personality changes as a result of exposure to single or multiple traumatic experiences, as long as the requirement of three core features of PTSD is met; these core features include changes in affect, self-concept, and relational function.

Alas, modifying the diagnostic criteria for cPTSD to consolidate EPCACE and other trauma-related disorders may also lead to mislabeling and downgrading the seriousness of personality changes, as well as overlooking potentially transgenerational personality changes. Because different experiences may produce different neurological and behavioral effects, it would be unwise to disregard the type of event and its impact on affect.

A later study noted a more specific set of criteria that must be met, as well as additional symptoms such as changes to somatization, self-injurious/self-damaging behaviors, and sexual dysfunction that would largely be left out of the criteria for cPTSD.

 The current criteria for cPTSD-which encompass the majority of EPCACE cases tested by Keeley and colleagues18-faced diagnostic issues when practitioners became aware of the origin of the trauma.

Another argument against the diagnostic inclusion of EPCACE is symptom overlap between EPCACE and cPTSD. While there is a spectrum of post-traumatic disorders, with overlap among diagnostic categories, the presence of such similarities does not invalidate the clinical usefulness of an EPCACE-inclusive categorical approach in the initial process of clinical reasoning, differential diagnosis, treatment planning, and prognosis. Therefore, future ICD workgroups should reconsider EPCACE’s inclusion into cPTSD, given the weight mental health professionals place on traumatic origin, and restore EPCACE as a distinct diagnosis.

The American Psychiatric Association has opted for a more conservative route in DSM-5 by incorporating elements of cPTSD and EPCACE into the diagnosis of PTSD. DSM-IV had largely suffered from “poor interrater reliability of personality disorder diagnoses, poor stability over time, poor discriminant validity, and poor general coverage of personality disorder as well as poor clinical utility.”

 DSM-5 requires that adult patients being evaluated for stress disorders meet eight symptomatic criteria following exposure to trauma. Galatzer-Levy and Bryant

 found that the current diagnosis for PTSD could arise from 636,120 unique combinations of the eight criteria listed in the newly formulated definition. With so many combinations, PTSD has been utilized as an all-encompassing definition that lacks the specificity needed to adequately diagnose trauma. The diagnosis of trauma-related disorder should not be done on a one-size-fits-all basis, but rather should consider the elements of trauma and its disparate effects on individuals.

Why EPCACE should be reborn as a distinct diagnosis

As it currently stands, EPCACE has lost its core values in the newly revised ICD-11 and the previously published DSM-5. Given that EPCACE is marked by hostile attitudes toward society, withdrawal, emptiness, and hopelessness as well as constant vigilance and estrangement, the salient characteristic of the disorder is the sense of aloneness that leads to massive social disconnection. EPCACE has significant features in common with the kinds of compounding trauma seen in autism spectrum disorder or adolescent-onset psychosis as a person becomes isolated and marginalized. With EPCACE, patients suffer a loss of community and trust with the outside world. With the loss of community, as in the Holocaust, there is an ever-greater risk of the transgenerational transmission of trauma and far fewer transgenerational resources for resilience such as loving grandparents or an extended healthy family.

EPCACE should be a stand-alone diagnosis rather than a formulation because diagnoses are heuristics for formulations, which guide prognosis and treatment planning. Also, if diagnoses are missing key ideas, those will also be missing in formulations. Aloneness and vulnerability are distinct factors characteristic of EPCACE that are coherent only at the diagnostic level. Moreover, with catastrophic experiences the life cycle and transgenerational dimensions of trauma and resilience are more likely to be central.

The majority of mental health clinicians in active practice or completing graduate education will utilize either DSM-5 or ICD-11. When Evans and colleagues

 surveyed a global sample of psychologists, they noted that 78% of respondents opted for a diagnosis that is flexible enough to account for cultural differences. Severity of a diagnosis was highly rated as a goal of clinical care, as 88% of the respondents believed that it should take the form either of a subtype based on severity or degree of functional impairment or of a separate diagnosis.

Further research has linked trauma to quantifiable changes in personality. In a comparison of late-onset personality pathology due to wartime trauma with prior personality disorders, 24.3% of patients had a personality disorder develop only after exposure to catastrophic events. When compared with those who had preexisting personality disorders, those with late-onset personality pathology had a three-fold higher rate of PTSD symptoms. Moreover, there were higher rates of suicidal ideation and self-reported emotional distress compared with persons with pre-trauma pathology.

Additional research has shown not only physical changes to the brain but also transgenerational effects that pass from parent to offspring.

 Such a link between catastrophic experiences and personality necessitates the use of integrative criteria such as EPCACE, which will serve the interests of patients and empower clinicians in making treatment decisions.

Self-help networks for EPCACE patients not only ease personal growth but also offer a safe communal space for patient empowerment. For example, since the aftermath of World War II, displaced and persecuted populations have found themselves unified and united by their shared experiences. Illustrative are reports of suffering experienced throughout Europe by survivors of massive psychic trauma with loss of their nurturing emotional milieu. Having the capacity to identify such traumatized populations from various countries and backgrounds and to unite them under a self-help support network enables survivors to create community for one another and foster therapeutic approaches which, via an empowering community, seek transgenerationally to treat the transmission of trauma and encourage the transmission of resilience.

Aloneness, along with helplessness about being alone and feeling humiliated, has increasingly been found to be a major risk factor across the illness spectrum. Aloneness post-trauma and in the midst of grief, to which persons who suffer from EPCACE are highly vulnerable, can reasonably be expected to compound this risk factor. Therefore, the diagnosis of EPCACE can be an important step toward remediation rather than exacerbation of the aloneness, helplessness, and humiliation that, in a vicious cycle, can lead to further isolation.

This article explores why Enduring Personality Change After Catastrophic Experience (EPCACE) is a clinically useful diagnosis.