Howard L. Forman, MD

by Adam Bisaga with Karen Chernyaev; New York: Experiment Publishing, 2019

Reviewed by Howard L. Forman, MD and Alexander Lichtenberg

Dr Forman is Assistant Professor of Psychiatry, Albert Einstein College of Medicine, and Director of the Addiction Consultation Service at Montefiore Medical Center, Bronx, New York. He is the Book Review Editor for Psychiatric Times. Mr Lichtenberg is a fourth-year medical student at New York Medical College and is currently applying for residency in psychiatry.

In recent years, hardly a day has passed without some news outlet mentioning the latest opioid epidemic. Indeed, there is a lot to cover: the origins of the epidemic in the promotion of opioid analgesics, the way opioids have torn apart families and communities across the country, and how lawmakers have attempted to respond. Doctors, patients, politicians, and journalists have all weighed in with different perspectives. As psychiatrists we see the destruction in our hospitals and clinics and many have grown weary of reading more and more tales of woe and chicanery masquerading as treatment.

Since so much has already been written, it is reasonable to wonder whether we need another book about this phenomenon? Dr Adam Bisaga, an addiction psychiatrist at Columbia University, makes the case for why we need more information-and urgently-in 

Overcoming Opioid Addiction: The Authoritative Medical Guide for Patients, Families, Doctors, and Therapists

. Despite the multitude of articles and books on the subject, there is little in the way of guidance for addressing opioid use disorder (OUD) that specifically addresses patients, their families, and non-expert medical professionals. Worse, there is even less accessible literature that is grounded in sound scientific evidence. Dr Bisaga, along with his coauthor, health writer Karen Chernyaev, seeks to fill that gap with this practical, intelligently constructed book.

The book is divided into four parts. Each can be read independent of the others since they cover similar material but address separate audiences. The first part describes the nature of OUD and its role in fueling the latest iteration of an opioid epidemic. The next part delves into the details of treating OUD with medication-assisted treatment (MAT), the only evidence-based means of managing OUD. The project of explaining and promoting MAT lies at the heart of the book and distinguishes it from other approaches to OUD that ignore, or may be hostile to, using any medications to treat OUD. The third section addresses the needs and concerns of family members of OUD sufferers, and the fourth part addresses patients.

What struck us most was the plain and direct language used in each part. The authors successfully distill their expertise in OUD into a text that can be understood by readers who have little or no scientific background. Free of medical jargon and pretentiousness, this volume will be especially useful for patients and their families looking for sensible advice in navigating the perils of OUD.

Dr Bisaga does not present MAT as a cure-all. To the contrary, he emphasizes the challenges of treating OUD with MAT and notes that OUD has no definitive cure. A key part of his argument is that more people should think of OUD as they would diabetes or any chronic medical condition. MAT, he writes, is a necessary but insufficient component of recovering from OUD.

He is remarkably conciliatory towards engaging with nonmedical modes of treatment-as long as those other methods do not interfere with MAT. For example, he encourages patients to try attending support groups such as Narcotics Anonymous, a 12-step program modeled after the popular Alcoholics Anonymous. However, he warns that some people in Narcotics Anonymous may not be accepting of individuals recovering with the use of MAT. The goal is to have MAT serve as a bedrock for patients to lead meaningful lives in a way that makes sense for each patient.

Whether for a patient, family member, or a professional working with OUD patients, 

 will serve as an invaluable resource for those who want to treat OUD with an evidence-based and compassionate approach. While trying to stop an epidemic can seem like an insurmountable task, Dr Bisaga has shown how progress can be made using medicine, one patient at a time.

This article was originally posted on 10/5/18 and has since been updated.

Articles

Since so much has already been written about the opioid epidemic, it is reasonable to wonder whether we need another book about this phenomenon? Experts make the case for why we need more information-and urgently.

Overcoming Opioid Addiction: The Authoritative Medical Guide

, but it may be more accurate to say she is a co-author, an editor, a dogged investigator of her own family’s history, and a sharer of her uncle’s memoir-a man who received a diagnosis of paranoid schizophrenia in his late adolescence. The book alternates between chapters Allen wrote and chapters that her Uncle Bob sent-a 60-page, single-spaced, typed-in-all capital letters manuscript-for her to edit and share. The book is timely but will also stand the test of time as an excellent contextualized first-person narrative of schizophrenia.

The release of the book comes amid a rising understanding that although we are 60 years into the antipsychotic era, these medications only partly help people with schizophrenia. In reading about Bob’s travels throughout the US, one comes across instances where working conditions, friends, and neighbors propelled Bob to periods of productivity and meaningfulness, despite the psychosis.

Another element of the book that makes it particularly relevant is its description of the sexual abuse and coercion of patients witnessed by Bob during several psychiatric inpatient stays. The #MeToo movement has brought growing recognition of the scale of sexual harassment, abuse, and assault across all arenas where imbalances of power exist. We would all like to believe that the care of vulnerable psychiatrically ill patients who are often placed on locked units for their “own good” would be immune to this societal ill. But, at the same time we know that these Pollyannaish beliefs cannot be true. As the people charged with fiduciary responsibility for our patients, the book motivates us to do more to protect our patients.

 includes cringe-worthy psychiatrists and heroic ones. One psychiatrist consistently refuses to engage with Bob but instead makes medication decisions without examination. Later, Bob meets a psychiatrist who works in both inpatient and outpatient settings to develop a treatment that is consistent with Bob’s values and hopes. Similarly, there are hospitals that patients seek out for their peaceful and healing environments while others are like prison.

Psychiatrists may find Allen’s book useful when considering the sacrifices families make to help their severely and persistently mentally ill loved ones get treatment. The financial and emotional toll is huge for those who seek access to mental health care for their loved ones or for those who advocate for them in the criminal justice system. Although laws governing patient privacy often prevent us from being able to reduce this toll, awareness can lead us to be more sensitive caregivers.

As a psychiatrist, I have sought to understand the minds of my patients who exist in both the “real” world and in the delusional world. Bob’s writing offers the reader an eloquent way of seeing the way these worlds flow seamlessly from one to another and back. My hope is that it will become a classic and universally read by all psychiatrists.

Dr Forman is Assistant Professor of Psychiatry, Albert Einstein College of Medicine, and Director of the Addiction Consultation Service at Montefiore Medical Center, Bronx, New York.

The release of the book described here comes amid a rising understanding that although we are 60 years into the antipsychotic era, these medications only partly help people with schizophrenia.

A Kind of Mirraculas Paradise by Sandra Allen

Fantasy, suicidal ideation, ecstasy, pride, shame, opportunities gained, opportunities lost, fortunes made and fortunes squandered-these are some of the topics that a psychiatrist will encounter. Often, they are the factors that drive people into states of mental illness or ones that perpetuate suffering. Each of these topics is given thorough consideration in a new podcast series, 

by Jon Ronson and produced by Lina Misitzis (available at 

 tells the story behind the wide availability of free internet pornography, the psychiatrist listener will quickly appreciate that this is only the beginning of the story.

, a book that told the story of nearly instant and almost universal shaming made possible by social media. In this book, he encourages all to consider others not as either “intelligent” “stupid” “moral” or “immoral” but rather everyone is a mixture of these and infinite other elements.

studies free internet porn as a continuation of his study into shame and its harmful effects. The stories he tells will resonate with practicing psychiatrists who now toil in the tidal wave that this pornographic expansion has set in motion; the unprecedented numbers of young people who now have video of sexual behavior living for eternity, the exposure to performance sex that is perfectly matched to and the emergence of younger generation of men unable to achieve arousal with their real-life sexual partners.

Mr. Ronson was interviewed in New York about 

in general and about its relevance to the practicing psychiatrist.

 I consider myself, I guess a storyteller. I try and find stories, mainly nonfiction, but sometimes fiction these days, that sort of shed light on the way the world works. And I suppose I'm always ... I'm pretty much always looking for stories that are kind of humanist, for want of a better word. And sort of stories ... The older I get, I think it's more stories that kind of bring people together as opposed to push people apart. So I guess stories about empathy and curiosity as opposed to what a lot of other journalists do, which is judgment.

 You have said in other interviews that you like stories about outsiders. And I was wondering, do you have any insight or ideas as to why this is the case?

 Yeah, I'm pretty sure. This famous British writer called Caitlin Moran said that it definitely goes back to the fact that I was bullied at school. And so I'm trying to make sense of the horrors of the world by going to the places where you might find horror and de-horrorizing it.

But I think I would say I'm definitely drawn to outsiders because both as a Jew and also as somebody who grew up in wrong town, I was an outsider.

as a continuation of your appraisal of internet shaming in 

 Yes, It's all about re-humanizing . . . It's all about people not thinking about the consequences of their actions on the internet. So that's a very big parallel between the two stories. It's about me trying to re-humanize demonized people-and also about making people think about ripples and consequences.

 Can you comment on what you perceived as the presence of mental illness in the pornography industry that you studied so intensely for this project?

 Suggest a sentence rephrase: When I started writing 

 I asked psychologist Ray Hymen, "Why are so many people who believe crazy things inside the intelligence services?" He said, "Because people are nuts. People are nuts inside the intelligence services; they're nuts outside the intelligence . . . They're just nuts."

And I thought, the other day I was talking, I was being interviewed by this really great British podcast they've got out and the interviewer asked "Yeah, but surely the porn world is full of people who've had really terrible childhoods, and are very sort of emotionally damaged." And I was like, "Yeah, but where else do you find people who've had really bad childhoods and they're really emotionally damaged? Everywhere."

 What do you hope most practicing psychiatrists take away from 

 I think it's about empathy and curiosity and compassion and being more important than judgment and suspicion. In many ways it's about trying to get people to rethink what they consider reputable and what they consider disreputable. And then speaking out about that.

While ostensibly The Butterfly Effect tells the story behind the wide availability of free internet pornography, the psychiatrist listener will quickly appreciate that this is only the beginning of the story.

The Butterfly Effect: An Interview With Jon Ronson

Ranger Games: A Story of Soldiers, Family and an Inexplicable Crime

With the exception of his last name, Alex Blum was as all-American a kid as one could conjure up for any afterschool special. Growing up in Colorado his only dream was to be an Army soldier and to serve his country as a member of its most elite infantry formation, the Rangers. Before his enlistment he coached youth hockey teams; he didn’t drink alcohol or use drugs because he worried they would ultimately make him a weaker soldier.

After completing basic training and the Ranger Indoctrination Program, Alex was days away from being deployed to Iraq to fulfill his dream of fighting for the US. He never made it. On August 7, 2006, he robbed a bank.

 (Penguin Random House), written by his first cousin Ben Blum, is the 400-page account of the life leading up to August 7, 2006, and the psychiatric considerations of what led to this seemingly inexplicable crime and its aftermath. While non-fiction, the psychiatrist reader will recognize the many fictions accumulated when a single event is visited over and over again, by patients and by ourselves. The reader of 

 will become familiar with many psychiatric explanations for aberrant behavior and see each held up to light to determine if they are “authentic.” Moreover, at a time when there are more living veterans of the Armed Forces than at any other time, the book gives an inside account of what many of our service men and women endure in order to serve their country. The book is a roller-coaster ride that you won’t want to end, but is over much too quickly.

: What other titles did you consider for the book and how did you settle on Ranger Games?

: The original working title was Bad Apples, referring to the typical military characterization of errant soldiers as independent bad actors rather than manifestations of systemic problems. After that I considered, Of Their Own Accord, the English translation of the official Ranger motto, Sua Sponte, which addresses the extremely complicated question of how freely the various participants in the robbery acted. Eventually my editor and I settled on Ranger Games, which points to the way our behavior, beliefs, and moral norms can be incrementally redirected through seemingly unreal situations, “games,” that appear to have no real stakes.

Modern military training operates on this principle-as does, increasingly, modern military practice, in which drone killings can be effected on a video screen from thousands of miles away. Specialist Luke Elliott Sommer managed to ensnare half a dozen elite soldiers in a ludicrous bank robbery scheme which they all thought at first was just a game.

 In addition to being “about” Alex, the book also considers family mythology. Mythology often replaces ugly fact with beautiful fantasy. What types of mythology do you think are helpful or were helpful to the Blums? Which were or are hurtful? Do you miss your family’s mythology?

 Good mythology preserves the heroic essence of history, uniting us in a vision of our best selves. Much of Blum family mythology centered around our grandfather, Albert Likes Blum Senior, who landed in Normandy shortly after D-Day. Alex and I grew up thinking of him as a maverick war hero. The stories about Al Senior conveyed core Blum family values: toughness, self-sufficiency, questioning of arbitrary rules and authority. On digging further into his story, though, I discovered that the mythology obscured some pretty ugly misconduct. Learning about my grandfather’s faults shed enormous light on certain unhealthy strains in our family culture. I’m not at all sad to see those myths go.

I’ve come to view mythology as a necessary container for truths we either don’t yet know or are not yet ready to face. Some mythology is explicitly for children: complex human stories boiled down into simple tales that can fill out with nuance the more children learn about human nature. Other mythology, for instance nationalist mythology, is addressed to those unexamined parts in all of us that haven’t grown into full enough understanding to process the uncomfortable historical truths that myths ignore.

 How do you feel about the Ranger Indoctrination Program? Am I wrong to have thought at one point that this is the worst thing I have ever read about and then later to question whether Alex accurately reported it?

 You’re right to question whether Alex was an accurate reporter of the extent to which the training influenced his participation in the robbery. Some of the rhetoric about the way it turned him into a mindless automaton is way overblown. But as a record of what recruits are made to endure, and of the emotional experience of enduring it, I’ve found no reason to doubt Alex’s account-other Rangers have read it and confirmed the basic facts. Whether for a fraternity or an elite military organization, initiation rites are meant to be agonizing. That’s what gives them their power. If they don’t break you, they induce tremendous loyalty and deep fraternal bonds. As long as we have war, I believe we’re going to have training of that kind.

 Do you have any thoughts on what you believe a therapist needs to know or should know about veterans of our elite forces who may seek help from a mental health professional?

BB: It was very hard for Alex to accept any pushback on his own deeply entrenched narratives about the Rangers and the crime before I learned enough about the Rangers to express what he viewed as the proper level of respect. The culture of elitism makes for a radical distrust of outsiders. Mental health professional should be open to what these individuals have to tell you. Much of what elite forces do is incredibly impressive and embodies values that we all hold dear.

 is a book that will leave the reader with lots of questions answered but also a desire to ask many more. One may ask where Alex Blum is today, and I can assure you that the book answers that questions. But telling you would be a spoiler and would cheat you of finding out for yourself by reading about the highs and lows that led Alex to his current state of being. If you cannot take the suspense but don’t have the time to (or don’t want to) read the book, you can email me and I will let you know (

An inside account of what many of our service men and women endure in order to serve their country.

Q&A: Ben Blum, Author of Ranger Games

Mind: A Journey to the Heart of Being Human

 is a thought-provoking book that offers a comprehensive, powerful definition of the “mind,” as an “emergent, self-organizing, embodied, and relational process that regulates the flow of energy and information.” Notably, a comprehensive, complex, and dynamic definition that is felt to be missing from a wide range of fields, including medicine, psychology, and even philosophy.

Throughout the book, Siegel explores the how, what, when, where, and why of who we are-all the while emphasizing and explaining the mind’s capability and how to characterize it. He invites the reader to join him on a journey using imagery, personal experience, science, and concepts of time as he works toward the goal of adequately ensuring understanding of the “mind” and “integration,” which could allow for better understanding of how to facilitate well-being.

This book provides an invaluable opportunity for readers to explore and reflect on their own experiences and their impact not only on professional lives and practice, but on personal lives as well. What follows is a Q&A . . . the exchange is between Ashley Ford, MD, and Daniel J. Siegel, MD. -Howard Forman, MD

 The mind is often studied and discussed, but you note that an actual definition is missing from a wide range of fields that deal with the mind, including from clinical practice and education to scientific research and philosophy. How do you define mind in your book 

 By linking a wide range of disciplines together, we offer this definition of one aspect of the mind as the emergent, self-organizing, embodied, and relational process that regulates the flow of energy and information. This view enables us to see energy and information flow as the fundamental element of a system from which the mind arises.

Where is this system? This flow occurs both within the body, including its brain, as well as in the sharing of energy and information between an individual and others and the environment in which the person lives.

What kind of system is this? The characteristics of this system include that it is open, capable of being chaotic, and non-linear, meaning that small inputs lead to large and difficult to predict results. Complex systems have emergent properties that arise from the interaction of the elements of the system; one of those processes is self-organization. And so the proposal is that one aspect of mind is this embodied and relational process that emerges from, and then regulates, energy and information flow within an individual (the embodied aspect) and between the individual and the world around (the relational aspect).

 How might understanding and exploration of the mind enhance someone’s personal life and assist in creating a healthier mind?

 This definition of the mind as a self-organizing process enables us to ask the question, what is optimal self-organization? The mathematics of complex systems-those that have these emergent self-organizing processes-reveals that when aspects of the system are differentiated and linked, when they are “integrated,” they move in a way that is flexible, adaptive, coherent (hold well over time or are resilient), energized, and stable (FACES). This flow comes when a complex system is integrating-when it links differentiated elements to each other.

When integration is blocked, chaos and/or rigidity arise. Amazingly, each symptom of every described syndrome can be viewed as chaos or rigidity. And so far, research on individuals with a range of psychiatric disorders has revealed impaired integration in the brain. The Human Connectome project has shown that the best predictor of a wide range of measures of well-being is how interconnected the connectome is-that is, how integrated the brain is.

 How would a better understanding of the mind improve the effectiveness of physicians and mental health providers?

 By offering a definition of the mind, we can see how the mind is both within us and between us, within the body and the brain, and within the relational connections we have with one another and the world around us. Our work as clinicians is greatly aided with this definition. It allows us to work with our relationships and our embodied brains in trying to move an individual’s life toward more integration in a range of domains-from how we connect with one another with respect, to how we link different aspects of our brain to each other.

A person-specific domain assessment can lead to treatments that are strategically planned to address a patient’s forms of blocked integration.

For example, studies have shown that physicians who offer an empathic comment, one that recognizes the differentiated internal subjective experience of the patient, have a clinical response in which the patient has a more robust immune response and can recover from a common cold a day sooner. That is an example of how an integrated relationship promotes health in the body.

 Can you discuss integration and how the emergence of impaired integration through chaos and rigidity has helped you understand patients with mental illness rather than categorizing them into a DSM grouping that might limit the understanding of who they are (p 198).

 Seeing the unique aspects of an individual is a challenge in any clinical encounter. By defining the mind as a self-organizing process, we can see that chaos or rigidity would be the result of a system that is not integrated. In this way, chaos or rigidity can be assessed in a person’s life to illuminate how some domain of integration may be impaired for this individual. This person-specific domain assessment can lead to treatments that are strategically planned to address this individual’s forms of blocked integration.

This model provides a way to view the broad spectrum of life’s challenges and helps the clinician see each individual as unique; to have treatments that do more than simply reduce symptoms, but also move the person to states of well-being. Instead of being clinicians who aim only to reduce symptoms, this framework enables us to define the mind and mental health and aim treatment toward well-being by promoting integration. This allows us to truly be mental health professionals as we promote health directly.

 Can you discuss the Wheel of Awareness Practice and how we can use it to “distinguish knowing of consciousness and the known”?

 With this model of the centrality of integration in health, energy, and information flow in seeing the essence of mind, I combined the research that suggested that consciousness was needed for change with the exciting findings of neuroplasticity to try to “integrate consciousness.”

Integration is the linkage of differentiated aspects of a system. With consciousness, we can distinguish the sense of knowing, of a receptive awareness, from that which is known. For example, you may have the sense of being aware of the word 

. There is your receptive awareness, or knowing, and there is the 

 itself, the known of the experience. In the Wheel of Awareness (which actually began around a table shaped like a wheel), the hub represents the knowing, the rim the known, and the spoke of the wheel the process of attention. With a systematic movement of the spoke around the rim, the practice enables 4 segments of the rim to be experienced: the first 5 senses; the interior senses of the body’s muscles, bones, and organs; mental activities like thoughts, feelings, and memories; and our relational connections. In an advanced step, the spoke is bent around and the experience of awareness of awareness is offered.

Doing the wheel enables individuals to learn about their mind as well as create more clarity and regulation of the mind through this process of integrating consciousness. The findings thus far have supported the notion that such a practice strengthens the mind by improving the 2 aspects of mind as a regulatory process: monitoring and modulation. With the Wheel practice, the focus of attention is stabilized so that energy and information flow is sensed with more depth and detail; and the individual also learns directly how to modulate that flow toward integration.

 As health care professionals, many of us have dealt with the “mind-blind” professor or a person who has discouraged us or made us question our decision to enter the mental health field. How might this book encourage future health professionals to enter the field of mental health? And how can we use “mindsight” to teach others about mental illness?

 Mindsight describes how we “see the mind” through insight, empathy, and integration. When we are mind blind, we do not sense the internal mental experience of ourselves or others, and we therefore cannot intentionally create integration.

My hope is that this book will make the mind something that is “real” in our scientific and clinical worlds. Insight and empathy are essential skills for the clinician to have that enable the mind of the self and others to be sensed and respected. The book offers some personal reflections and hard-earned scientific discoveries into the nature of mind and of mental health that can benefit anyone interested in how to professionally help the mind grow toward well-being.

 In your book, you discuss how those with a history of long-term trauma, abuse, and neglect have an impairment in the development of their mind and in the integration of their brain. How can this be repaired with therapy?

 Psychotherapy in its various forms may be all about harnessing the power of the therapeutic relationship to inspire people to rewire their brains toward integration. What this means is that where attention goes, neural firing flows, and neural connection grows. When therapists learn about the science behind the notion that integration is the basis of health, they are empowered to see the relational and the embodied nature of mind itself, and how this self-organizing process moves the individual, family, or even society toward well-being with the process of integration.

Trauma is an assault on integration relationally that creates compromises to integration in the brain. Therapy is an integrative relationship, one that can harness the power of relationships to grow the neural integration needed for healthy regulation to develop.

 Why did you choose to write this book as a narrative, using imagery, and providing your own subjective experience to portray your message?

 I made the decision to synthesize both story and science with the notion that mind itself is a deeply subjective experience and also an objectively observable process, and so the experience of reading the book reflects these distinct ways of exploring the mind and mental health. Readers are invited to explore their own experiences of mind, of chaos and rigidity, and of how to bring more integration into their personal and professional lives.

 You remark that if we think of the mind as relational, as integrated identity, people will understand that “we” is just as important as you or I. How will the acceptance of “we” improve our connections with others?

 Data reveal that in studies of longevity, happiness, and mental and medical health, the primary shared factor is supportive social networks-relational connections to others. That’s the “we” of our lives. We also know that getting good sleep, exercising, being grateful, and being present in life as it unfolds in our subjective experience also promote well-being-improving our immune system’s functioning, raising levels of the enzyme telomerase that repairs and maintains the ends of our chromosomes, and optimizing epigenetic regulation to help prevent inflammation. That’s the “me” of our lives.

To integrate our identity, we can embrace these differentiated sources of identity and then link them: Me plus We equals MWe. That’s an integrated identity that science would suggest is the way we can bring more well-being into our individual and collective lives.

How might a better understanding of the mind enhance someone’s life and optimize a clinical encounter?

Being Human: An Interview With Daniel J. Siegel, MD

Dr. Forman: Unfortunately, your new book 

 could not be timelier. Is there one thing that you see the media or politicians consistently getting wrong with respect to mental illness and mass shootings?

Dr. Gold: Well, there are multiple things they get wrong-but my area of expertise is mental health, and from a mental health perspective, they could not be more wrong when they continue to repeat that the problem with gun violence in this country is due to failure to adequately address mental illness. It is true that the mental health system is underfunded and fragmented-especially for people with acute serious mental illness. However, most serious mental illness is only weakly associated with violence of any kind-and with gun violence in particular. Most people with serious mental illness are not violent; most people who are violent do not have serious mental illness. Individuals with mental illness are responsible for about 3% to 5% of all types of violence in the US-when they do become violent, they are most likely to assault family members or commit suicide.

 committed by individuals with serious mental illness against strangers is one of the rarest forms of gun violence in the US. Of the approximately 33,000 firearm deaths each year, two-thirds are suicides. Less than 1% of all firearm deaths in the US occur in the context of 

 by individuals, with or without mental illness. So unless the media and politicians are talking about suicide deaths by firearms-which they never are-they are simply perpetuating negative 

The thinking goes like this: only someone who is crazy would commit such a horrible act and kill innocent people. We all know that crazy people are dangerous and violent; therefore, it must be people with mental illness who are behind these horrible acts. However, mass shootings are not invariably associated with people who have acute mental illness or a history of mental illness. Some do, but some don’t.

Improved funding and resources for mental health systems and treatment would of course be welcomed. However, the repeated calls to “improve the mental health system” heard after mass shootings do not result in increased spending or funding. They merely serve as a politically expedient method to avoid talking about instituting sensible firearm regulation.

Moreover, the refrain to keep guns out of the hands of the mentally ill does a disservice to American society:

 and negative stereotypes associated with mental illness, making it less likely that those who need treatment will receive treatment.

 It does not result in improved funding of or access to mental health treatment.

 It allows politicians and media to avoid discussing sensible gun regulations.

 Because no effective change results, the American people have come to believe that “nothing can be done” to stop the high toll of gun violence, despite the fact that we are the only country in the world with this kind of civilian gun violence problem.

Dr. Forman: Many leaders who oppose increased gun regulation point to improving access to mental health care as the solution to 

 in America. How much do you think improved access to mental health care can drive down gun violence?

Dr. Gold: Improved access to mental health care would likely have a substantial effect in decreasing suicide rates. Suicide is the 10th leading cause of death in the US, and the 2nd leading cause of death among adolescents and young adults. About 40,000 people commit suicide each year. More than half commit suicide with a firearm. Only 2 interventions have evidence indicating effectiveness in regard to decreasing suicide: mental health treatment is one of them, the other is restriction of lethal means. So yes, mental health treatment is likely to decrease suicide rates overall, including probably some percentage of 

However, if you are talking about firearm homicides-of which there are about 11,000 a year-even with adequate mental health resources and access for everyone in the US, you would not significantly affect rates of 

. Most of these by far are variations of interpersonal violence-domestic violence, even “gang” violence, which is often interpersonal. Since mass shootings committed by individuals with or without mental illness typically account for less than 0.5% of all gun deaths per year, improved access to mental health treatment is not an effective intervention.

Dr. Forman: Do you believe it could be an effective way to drive down deaths without any changes in gun regulation?

Dr. Gold: For reasons I’ve cited here, no. Since most gun violence toward others is not committed by individuals with mental illness, improved access to treatment would be ineffective for this type of gun violence. Suicide is a different story-as many as 90% of people who commit suicide have a history of or an active psychiatric diagnosis at the time of death.

Dr. Forman: What policy prescriptions, if any, would you make on a federal level for reducing gun violence in America?

Dr. Gold: Many interventions are possible and supported by evidence already available. We need to look at evidence of dangerousness, ie, 

, with or without mental illness. Mental illness should be taken out of the equation as it is not a productive line of discussion.

 The evidence indicates that times of risk/crisis can be identified. For example, women are often killed by firearms in the context of domestic violence. Right now, individuals under a permanent, but not temporary domestic violence restraining order are prohibited from having firearms, which has been effective in decreasing the 

 in these situations. However, the time of highest risk of harm for women is when they attempt to leave a relationship. When they first apply for the restraining order, they get a temporary order (the permanent order comes later). Why not extend firearm prohibition to temporary as well as permanent restraining orders?

Another example is the case of felons who are categorically prohibited to own firearms, even though not all of them have committed violent crimes. It is the history of violence, not the conviction, that is highly associated with 

 of future firearm violence. Why not tailor firearm prohibitions to anyone convicted of a violent felony or misdemeanor-particularly if it involves use of a firearm.

 Public education programs and legal interventions to separate individuals from firearms at times of crisis are needed, along the lines of “friends don’t let friends drive drunk.” Family members and friends are often aware when someone they care about is going into a crisis. We need to educate people to ask and offer to hold firearms for their loved ones until the crisis passes (as we do when an individual may be suicidal).

) Legislation based on the model of domestic violence would allow family members to petition the courts for a firearm restraining order at times of crisis, when law enforcement can be authorized to temporarily separate an individual from firearms. Such a law went into effect for the first time in California on January 1, 2016.

Dr. Forman: What are the top facts you think every psychiatrist should know about the connection between mental illness and gun violence?

 in the home, not just whether they are firearm owners. Evidence shows increased risk of suicide and homicide in homes where there are firearms, regardless of who owns them.

) If there are firearms in the home and children/teenagers, it is mandatory that guns are safely stored. Guns should be kept unloaded and locked, separately from ammunition, which should also be locked.

 There is no such thing as safe storage of a firearm in a home where someone is in crisis with, for example, depression, psychosis, or substance abuse; is distraught over the loss of a relationship or job; has a recent diagnosis of serious medical illness; or has dementia. People with family members who fall into these categories, especially if one of them is a teenager or young adult, should not keep guns in the home.

Dr. Forman: Do you think suicide is a below-the-radar gun-related tragedy? Do you believe there are any policy changes that would reduce suicide rates?

Dr. Gold: Why does suicide go below the radar? Many people feel it shouldn’t count because it is self- inflicted. Also, it is 

; many people are ashamed to acknowledge or admit that there might be an issue in the family. We need to recognize that there are many different types of gun violence, and suicide is one of those types. Interventions to decrease the morbidity and mortality of gun violence must include evidence-based policy that addresses suicide risk as well as homicide.

Mounties, Cowboys, Avengers-and the Cultural Script of Gun Violence

James L. Knoll IV, MD and Ronald W. Pies, MD

Gun Violence, Stigma, and Mental Illness: Clinical Implications

[[{"type":"media","view_mode":"media_crop","fid":"51298","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_6995954752670","media_crop_h":"306","media_crop_image_style":"-1","media_crop_instance":"6326","media_crop_rotate":"0","media_crop_scale_h":"200","media_crop_scale_w":"119","media_crop_w":"182","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":" ","typeof":"foaf:Image"}}]]Liza H. Gold, MD, is an internationally renowned leader in forensic psychiatry. In addition to her book 

, Dr. Gold is a co-editor with Robert I. Simon, MD, of the 

American Psychiatric Publishing Textbook of Forensic Psychiatry

. She has been honored numerous times for her work, including the American Academy of Psychiatry and the Law’s (AAPL) Seymour Halleck Award for distinguished contributions to the field of forensic psychiatry. Her books 

Sexual Harassment: Psychiatric Assessment in Employment Litigation

Evaluating Mental Health Disability in the Workplace

 are essential for anyone who works in these fields and have both been honored by the American Psychiatric Association and the AAPL with the Manfred Guttmacher Award. Her expert opinion has been sought by sources including ABC, PBS, CNN, and NPR. As psychiatrists who practice in an era with gross distortions about the connection between mental illness and gun violence, it is incumbent on us to contribute to public discourse with sound information and guidance. It is very fortunate that Dr. Gold has given us a book that will help us to do so.

What policy prescriptions, if any, would you make on a federal level for reducing gun violence in America? That question and more answered.

Gun Violence and Mental Illness: Talking With Liza H. Gold, MD

 is a moving biographical book based on a young veteran’s experience with PTSD. Throughout his book, we enter Morris’s world and glimpse at what it means to experience trauma. It is not only captivating, but it is an extremely well-researched book that considers PTSD in personal, historical, and clinical contexts. With the large number of men and women returning from Iraq and Afghanistan, this book will prove invaluable to those of us who are called upon to help them recover as fully as possible. What follows is a Q&A . . . the exchange is between Talia Tuvia, MD, and Mr Morris.

You highlight that social support plays an important protective factor against PTSD. How can society offer more social support to those who experienced trauma?

Americans are terrible listeners as a rule. There are many ways to conceptualize what PTSD is, and one way to think about it is as a failed conversation between survivors and regular citizens. Rape victims and veterans of war often return to the everyday world and feel isolated and misunderstood-in some cases even marked by a kind of scarlet letter. One way for such people to feel empowered is to find a way to tell their story, which requires a willful act of imagination on their part. But a raw, unprocessed story of survival is unfinished if it is never heard by another human being. So I think on the most basic emotional level, we as a society need to learn to be better, more skillful listeners.

This also means making room in the culture for survival narratives to take place. One of the only rape memoirs that currently exists in our culture, a book that has saved many lives-Alice Sebold’s 

-almost never happened. The book was realized because a perceptive graduate advisor of Sebold’s (Geoffrey Wolff, then at the University of California, Irvine) encouraged her to write down her story, to get it out of her head so that she could move on to her other work. Consider that for a moment. It shows in microcosm how the culture at large might work: active listening and the processing of trauma through narrative. This also means that survivors need to do the work in figuring out a way to tell their stories and to make them heard.

I think that we also need to move beyond the stereotypes of who veterans are in America. Currently, the culture seems to recognize only 2 types: the Navy SEAL hero and the homeless vet holding a sign by the side of the road. Speaking for myself, it was very hard to talk to Americans when I got back from Iraq because people’s pity and political preconceptions always got in the way. And I think saying “thank you for your service” has become a way of avoiding a deeper, more meaningful exchange about survival, sacrifice, and loss. We’re over a decade into these wars, and there’s almost no room for nuance or an emotional understanding of the experience of serving in a place like Anbar, Iraq.

 You discuss the difficulties of explaining trauma to someone who has not experienced it. What can psychiatrists do to better understand patients’ experience with trauma?

 With respect to veterans, one thing psychiatrists can do is pay more attention to the nuts and bolts of military life, the daily existence of overseas service. In my mind, there is nothing more important that a clinician can do to strengthen the therapeutic alliance than to sit down and read a book like Phil Klay’s 

 These books impart a kind of credibility. These books give clinicians a window into the experience itself, and in far greater detail than a movie or a newspaper article.

Trauma to me is all about context and coming to an understanding of why a specific event was so horrific. This level of understanding is impossible without a grasp of the particulars of a survivor’s experience and the culture to which they belong. If you are treating rape survivors, I would recommend Alice Sebold’s 

; for refugees, Ismet Prcic’s award-winning novel 

; for natural disaster survivors, Sonali Deraniyagala’s excellent memoir 

 If President Obama named you Secretary of Veterans Affairs (VA) tomorrow, what are some of the changes that you would implement to improve the mental health care veterans receive through the VA system.

 Wow, that’s a gorilla of a question. Well, one thing that I would commit to straight away would be to have clinicians schooled up on the basics of modern American military life. The VA today is this industrial-scale treatment delivery system and trying to work it from the inside is a Herculean emotional challenge for so many vets, and the whole mad swirl of it is just too much. So many times, I would walk into the big hospital at the VA San Diego, get a look at the scene, and say, “Nope, not today.” So just to have clinicians and the guy sitting behind the information desk have an idea of where your mind might be, as a person whose trauma happened in the context of this big unfeeling bureaucracy (ie, the military) would save lives. And I hate to sound like a high school English teacher, but on a certain level, this kind of education comes down to reading books and listening to vets rather than dictating to them.

When I underwent prolonged exposure therapy at VA San Diego, I gave my therapist a copy of Tom Ricks’ 

 an award-winning history of the Iraq War. I just wanted him to know what a CH-53 was. What an up-armored Humvee looked like. He never read it. Why? Because he was a graduate student and he had a thousand other commitments. So for me, the end user, the veteran, that meant I was stuck in a room day after day talking to a very smart, well-educated, well-meaning young man who nevertheless didn’t know the first thing about Iraq or life in the Marine infantry.

Many of these problems have been solved by the retail-style Vet Centers, which are smaller, semi-autonomous care facilities that exist within the VA system. But most veterans don’t know about them because they’re not a part of the VA’s large “Evidence-Supported Treatment” campaign, which is where the action is right now. So the Vet Centers need better marketing and need to be integrated into the overall VA campaign plan to combat PTSD, rather than being treated like the red-headed stepchild of the system, which is how it works now.

Which brings me to my next point-some senior psychiatrists within the VA that I interviewed for my book confided in me their fear that today’s crop of young clinicians have been so thoroughly schooled in the mass-produced, one-size-fits-all treatments like prolonged exposure and cognitive processing therapy that they don’t even know how to do individualized therapy any more.

 there are major problems with these therapies. Specifically, the VA’s number one PTSD therapy-prolonged exposure-has a significant adverse effect profile that the VA refuses to acknowledge. It’s driving veterans away from treatment by telling them that the only way forward is by having them forcibly re-tell the stories of their worst traumas over and over again. Which is exactly what I was told-“We’ve done the science. Your feelings, your insomnia, your nightmares don’t fit into the paradigm. Sorry.”

The VA likes to counter these sorts of criticisms by simply repeating the company line that prolonged exposure has the best empirical track record out there when, in fact, much of the evidence for this therapy is drawn from studies of rape victims; so again, there is this fundamental misunderstanding of what being in a war is like that is simply lost on most clinicians within the VA. Combat operations have a cumulative effect that is qualitatively different than sexual assault, which is more often a single event, but no one on the inside will admit this publicly because it doesn’t fit into the current clinical paradigm. In the meantime, veterans drop out of therapy, and in some cases end up killing themselves.

 You state that alcohol, taken in moderation, is one of the best drugs for treating PTSD. I think the idea of encouraging alcohol consumption in patients suffering mental distress is scary for most psychiatrists. Can you say a few more words on how alcohol worked for you and/or have you seen it work for other people?

 Advocating alcohol use in even the smallest amounts is taboo in American medical circles, in part because of our puritan legacy and partly because of the influence of quasi-religious groups such as Alcoholics Anonymous, whose methods have come under scrutiny recently by writers like Lance Dodes.8 In my book I make an argument that is really just common sense: having a couple of drinks can be beneficial. Alcohol reduces anxiety and allows access to emotions and inner landscapes that are unavailable during sobriety.

A similar argument can be made about marijuana and MDMA [3,4- methylenedioxymethamphetamine]. Researchers who attempt to look into clinical applications for these substances are often banished to the fringes of the medical community because of a kind of close-mindedness that masquerades as empiricism. This is yet another example of the importance of understanding how culture and history inform the conceptualization of trauma by societies. Ben Shephard,

 a controversial British historian, argues that “culture is more important than biology,” with respect to trauma. I sometimes tend to agree with him.

 and David Brooks both have had high praise for your work. It is very likely that all of our readers by this time have either heard interviews with you on NPR or read about your book in print or digital media. As our readers are mainly practicing psychiatrists, what do you hope they, in their professional capacity, will take away after reading your book?

I hope that readers come away with a greater sense of what trauma is like from the inside, from the perspective of a veteran, from the perspective of a rape survivor, from the perspective of a genocide survivor, as well as an understanding of PTSD as a historical entity. Conversations within the medical and research communities are almost completely dominated by physicians. In allocating resources, addressing what works and what doesn’t work, one almost never hears from patients or nurses and this robs the conversation of richness and an essential context.

Medicine today is dominated by a campaign for evidence-based treatments. In the main, this is a good thing. Nevertheless, trauma doesn’t happen in a vacuum and not enough attention is being paid to other non–data-driven forms of evidence. Good journalism is a form of evidence. Anecdotes and case studies are a form of evidence. Literature in the form of poetry and novels is a form of evidence. I hope that your readers can get a greater sense of how stories of survival over the centuries from Odysseus to Siegfried Sassoon to Alice Sebold can inform the healing process in a positive way. When I interviewed Steve House, an acclaimed mountaineer, about his recovery from a very serious fall, his drive to get better motivated me to take charge of my recovery in a new way. In short, stories are some of the best medicine out there.

Dr Forman is Assistant Professor of Psychiatry at Albert Einstein College of Medicine and Director of the Addiction Consultation Service at Montefiore Medical Center in the Bronx, NY. Dr Tuvia is a third-year psychiatry resident at Albert Einstein College of Medicine, Montefiore Medical Center. Mr Morris, a war correspondent and a former Marine, is the author of The Evil Hours, published by Houghton Mifflin Harcourt in 2015.

: The American Military Adventure in Iraq, 2003 to 2005. New York: Penguin Books; 2007.

http://opinionator.blogs.nytimes.com/author/david-j-morris/?_r=0

The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry

The Long Road Home: The Aftermath of the Second World War

A Q&A with David J. Morris, author of The Evil Hours, a moving biographical book based on a young veteran’s experience with PTSD. 

The Evil Hours

Interview by Christopher Aloezos, MD and Howard L. Forman, MD

 in which he explores the seemingly new and growing phenomenon of public shaming. With the advent and expansion of social media, we are seeing more and more of mass shaming. Until this book, shame on this unprecedented scale has never been so thoughtfully studied and explored. The topic of shame in general is of great importance and interest to the field of psychiatry because shame exists at the core of many patients and their psychopathologies. As social media continues to grow and play a larger role in communication, in social connectedness, and in relationships, public shaming will increasingly find its way into our offices and at the bedside. As such,

 is an insightful resource for many clinicians.

[[{"type":"media","view_mode":"media_crop","fid":"38110","attributes":{"alt":"public shaming","class":"media-image media-image-right","height":"296","id":"media_crop_2852348753082","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3781","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â©PeterO'Toole-Shutterstock","typeof":"foaf:Image","width":"211"}}]]This interview has been edited and condensed for clarity.

 Many of your books cross paths with the field of psychiatry. I’m curious about how you became interested in this field.

 Yeah, it’s funny-I agree with you about that. I think it’s coincidence; I guess maybe it’s the type of journalism that I do, and psychology, psychiatry, and maybe anthropology, they’re all kind of connected, right? They’re all about trying to work out why we, humans, behave the way that we do.

I’ve always been a writer, a nonfiction writer, who is interested in humans and human behavior rather than someone who’s interested in facts and figures. I guess there’s always been that connection. If I hadn’t become a writer, I might have ended up in psychology or psychiatry. Hopefully not anthropology, because that sounds a bit more boring.

 You probably didn’t delve too greatly into the childhoods of the people featured in your book, but I was wondering whether experiences during childhood perhaps partly explain why some responded really well and with resilience to being publicly shamed while others didn’t fare so well.

 That’s a really interesting question. You’re right, I didn’t really go into detail about these people because my assumption, actually, was that most people respond fairly badly to a shaming. And so, there’s this sort of myth about our age-some people think, oh you know, all the youth of today, they’re all shameless. Look at the way they’re walking around, shamelessly.

That’s nonsense. Shame, as you guys know, is very much alive and well but it’s just moved elsewhere, for instance, to people who are accused of misusing their privilege, and so on. They’re the people who’ve been shamed. A public figure may not feel ashamed if photos of him naked appear on the Internet, because he doesn’t feel like he’s done anything wrong, and rightly so, as far as I’m concerned.

I suppose the answer to your question, just from my research over the past few years, is that almost everybody handles shame badly. It’s a very rare person indeed who handles it well.

 In your research, did you encounter any examples of what would be considered the opposite of public shaming: public empathy?

 I’m meeting Monica Lewinsky tomorrow and I’m going to ask her, but my fairly strong guess is that her TED talk had a hugely powerful, positive impact on people’s perception of her. You know, getting a standing ovation from the entire TED crowd was probably legitimizing, in the same way that many of the people in my book are so much happier since my book came out, I’m sure it’s the same, in a sense, for Monica.

Concerning Monica’s standing ovation, I’m going to tell her tomorrow that I still think we’ve got a long way to go. People may have given Monica a standing ovation because we now no longer see sex scandals as being particularly terrible things, but I bet you half the people who gave Monica a standing ovation would still happily tear apart Justine Sacco.

 What do you think psychiatrists can get from this book to help their patients who have been shamed, either publicly or privately?

 The first thing I want to say is that I’m really, really glad you’re taking my book seriously; I think it is a valuable book in that respect.

Shamers, underestimate how profoundly traumatizing it is to be shamed. Some people would tell me that they would wake up in the middle of the night forgetting who they are. You can probably tell me, but that sounds to me like a symptom of PTSD.

With the advent and expansion of social media, we are seeing an increase in the phenomenon of mass humiliation. In this Q&A, we learn what surprised the author of a book on public shaming.

Author | Howard L. Forman, MD