Michael Blumenfield, MD

 This film is about a situation, whereupon the death of his father, a man discovers that he has a half sister and a nephew that he never knew about. This is not an unusual situation and, in fact, there are many variations on this story that play out in life all the time. In this blog, I will briefly discuss this phenomenon and give 3 disguised examples that I know about from real life.

I invite readers to present additional examples, and clinicians, who have some insight into this phenomenon, to feel free to comment on this blog.

This movie really highlights a situation that probably occurs more often than most people realize. When the man, who is in a relatively stable marriage, is promiscuous and fathers a child in a relationship outside the marriage, he is faced with a decision. He could acknowledge the reality and choose to stay with his current marriage, or leave his original family (presumably with a divorce) and establish a family with his new child. His original wife of course can make this decision for him by deciding that she would not want to live with him anymore. (The second woman might not want him either.) In a real-life setting, it is possible that the father may not even know that he has created a child, as the mother of the child may wish not to tell him.

There are also situations in which a couple has a child but don’t want to establish a relationship, and the man moves on. He then has a family at a later date and does not tell them that he has fathered a child earlier in life. Still other variations are possible, such as when a single woman becomes pregnant and gives the child up for adoption, and then goes on to live her life and perhaps ultimately have a marriage and children, but never mentions her past history.

I am sure there are other variations, including twins separated at birth, siblings separated at early age and not having full awareness of the other, etc. Even before the discovery of the unknown family member is made, the parent who knows the secret has the burden of keeping the secret and not being able to be truthful with people to whom they are very close, usually a spouse and children. This can lead to guilt or fantasies of what happened to the secret child. The child who only knows that their biological parent has abandoned them, can never know the reason why and may incorporate fantasies involving their self-worth or even grandiose thoughts about a parent who will someday rescue them. A well-meaning story that the missing parent died will of course backfire when and if the parent someday does appear, and all must deal with this major piece of deception no matter how well meaning. Our ideas of self are founded on our life history, including early childhood experiences, memories, and fantasies that are influenced by all variations and the nuances of the major players who influenced our earlier life.

There are an unlimited number of circumstances, which could lead to the discovery of unknown family members. One scenario could be the reveal by a guilt-ridden parent later in life, or perhaps in his or her will. In the movie we reviewed, the father wanted to leave money to his daughter from the earlier relationship in his will, and he asked his unsuspecting, but somewhat alienated, son to deliver this money to the unknown sister so the two siblings could meet and perhaps be reconciled. In this case, neither of the siblings knew of the existence of the other, although the brother’s mother knew and kept it a secret, and the sister’s mother (now deceased) probably also knew. In adopted children, there are many cases where a grown child finds out the name of the adoption agency and then sends a message to the unknown parent through the agency, asking if the long-lost parent will meet with them. This was played out in the movie, 

In the age of artificial insemination, sperm and ova donations, new developments in genetic testing, the Internet, search engines, and social media, there are many new possibilities for discovering a previously unknown family member. Once a previously unknown family is identified, the child very often has a strong desire to know about the biological parent and also to meet and relate to the siblings, usually half siblings, who share one parent in common. What is it about knowing about the presence of a biological family member, who has not influenced your life for many years, which makes connecting with that person so important? Is it because you share some genetic makeup in common or come from some common heritage that drives the need for establishing this relationship? Is there a need to fill a void of being alone that can be corrected by meeting someone who shares some part of you?

In the case of the newly connected siblings, is the desire to rectify the mistake of the parent(s), who were not able to construct a complete family for all of their children?


I would like to present 3 real cases (disguised) to illustrate some of these issues. I was not the therapist for any of these patients, so I cannot claim any knowledge of the underlying dynamics.

. A successful attorney married for the first time at age 35 to a 28-year-old woman. They had 3 children and a fairly close-knit family, and he never had any extramarital relationships. He died at age 65, and 10 years later, a 45-year-old man contacted the now 67-year-old widow and told the following story. He lived in another city with his mother and had been told that his biological father was a successful attorney with whom she had a close relationship, and he had subsequently died. (In reality, he left her after she became pregnant and moved to another city.) She told her son his last name, which was an unusual one. He searched for it on the Internet and easily located him since he was fairly well known in his field. He never told his mother that he had information about his biological father.

After his mother died and he was married with an 18-year-old son, he located the widow of his biological father and told her who he was. He asked permission to visit her and wanted to meet her now grown and married children and any other close family members. She agreed (she had known about her husband’s previous relationship prior to their marriage, but not about this child) and asked her children if they wanted to meet him. The oldest son was not interested, but the other two agreed. An older sister of the deceased husband was not interested, but her grown son was agreeable. The younger, married, middle-aged children of the deceased attorney established a good relationship with the “new family member,” and they would visit each other when they happened to be traveling cross country to each other’s cities for other events.

Eventually the oldest son of the deceased father found that he had certain hobbies in common with his half brother (ie, sports car racing and golf), and he would join in these get-togethers and began to relate to him. The grandson of the older sister of the deceased man was able to help the son of the new family member to get a job in the entertainment business. The grandson and all of the deceased attorney’s siblings and his widow now consider him part of their extended family. When asked why he decided to seek out his other family, he said that he felt he owed it to his son to try to give him the extended family that he didn’t have.

. The new young wife of a well-known sports figure dies in childbirth, but the infant boy survives. The father is devastated and gives the son up for adoption to a distant cousin whom he doesn’t have any subsequent contact. The boy is raised by 2 loving parents, and when he is a teenager, he is told the name of his famous biological father, who supposedly has no interest in seeing him. When this child is a grown man of 50 years, he is in a movie theater with his wife, watching a documentary about his biological father.

At one point in the movie, the sports icon recounts that he feels badly that many years ago he had a son that he never met after his wife died in childbirth, and he wonders what happened to him. The grown son is stunned by the interest shown in him, and he contacts the filmmaker and asks if he could contact his biological father, who now lives in another country. The filmmaker agrees to arrange an all-expenses-paid reunion if he could film it. The father is now a grandfather, as is the son, and after an initial meeting, both families meet each other and subsequently keep in touch and visit from time to time.

. A teen mother gives her out-of-wedlock daughter up for adoption. She is brought up by 2 loving parents. When she marries and has children of her own, she decides to track down her biological mother. She hires a private detective who is ultimately able to find her mother, who lives alone in another city and has no other children. The daughter keeps in touch with her, introduces her to her family, visits her periodically, and brings her to various family events.

These cases are obviously the bare facts and raise many clinical questions about the psychodynamics that are at play. What is clear is the strong need on the part of at least one person to connect with a long-lost person or family. There also appears to be an acceptance and probably a strong need on the part of the other family member or members to reciprocate. I welcome discussion from people who have had such experiences to give further insight into this situation. I also particularly welcome the insight into the psychodynamics of such situations by clinicians who have had the opportunity of treating such people. Please respond to the comments section of this blog.

I also suggest that this area is ripe for survey research, case reports with clinical discussion of the theoretical implications, and psychodynamic and psychoanalytic theories on this subject.

[Editor’s note: This article, originally posted on Dr Blumenfield’s blog, is published here with permission from the author. The original post can be found at 

http://www.psychiatrytalk.com/2012/07/discussion-of-the-phenomena-of-unknown-family-members/

Blumenfield M. People like us: a film about a previously unknown family member. June 30, 2012. 

http://www.psychiatrytalk.com/2012/06/people-like-us-a-film-about-a-previously-unknown-family-member/

Articles

The discovery of an unknown family member can bring about joy or grief, and raise many clinical questions about the psychodynamics that are at play within families.

Discussion of the Phenomenon of Unknown Family Members

Attempted and completed suicides both represent a major clinical and public health challenge. 

 as the 11th leading cause of death among persons over age 10 (33,289 suicide deaths were reported in the US in 2009).

 Drs Tondo and Baldessarini noted that 90% of suicides occur in persons with a clinically diagnosable psychiatric disorder. Patients with major depression or bipolar depression have a 20- to 26-fold increase of mortality rate over the general population. It was also stated in this article that fewer than a third of persons who commit suicide are receiving psychiatric treatment at the time of their deaths. The authors further noted that there is only inconsistent evidence that antidepressants may help prevent suicides.

It was thought that the strong association between the rapidly expanding use of antidepressants and the moderately declining suicide rate in the US and in other countries were indirect evidence of effectiveness of antidepressants in reducing suicide.

Several studies have shown that mood disorders have been associated with increased suicidal behavior. This is especially true in patients with a mixed, manic-depressive, or dysphoric-agitated state, and perhaps also in those with anger, aggression, or impulsivity-all of which are particularly prevalent in bipolar disorder and may contribute to the unusually high suicide risk in persons with this disorder. In such patients  (especially those who are young), antidepressants may lack a beneficial effect or even increase suicide risk, at least early in treatment. Long-term treatment with mood stabilizers, particularly lithium, may be a more effective component of comprehensive clinical management aimed at suicide prevention.

From clinical experience we know that psychological conflict, psychological trauma, grieving, interpersonal conflict, and other psychological issues can all contribute to self-destructive behavior that  can result in suicidal behavior. Suicidal gestures that may have been initiated to get attention or manipulate others can inadvertently result in a completed suicide. There are special issues concerning suicidal behavior in the military where recent studies have shown more soldiers are killed by suicide than in combat. There are special issues concerning suicidal behavior in children and adolescents. Bullying behavior including cyberbullying has been shown to induce suicidal behavior in young people.

Suicidal behavior can be quite complex as well deadly. It should go without saying that psychotherapy is usually necessary in treating patients who have suicidal ideation or who have demonstrated such tendencies or actions. Frequently, it may be combined with medication and sometimes it is the treatment of choice without medication.

Suicide prevention is a challenging issue, not only for mental health professionals but for leaders in the military, teachers, parents, and for us all. We need to recognize that there are many mental health issues that have to be faced in the 

We shall try to discuss many of these issues in future blogs. I am also pleased to announce that suicide will be a major part of the theme of the May 16 to 18 meeting of the 

American Academy of Psychoanalysis and Dynamic Psychiatry

 (of which I am the current President). The meeting will be held in San Francisco (just before the meeting of the American Psychiatric Association in the same city). A very interesting and informative program with outstanding speakers is being developed and will be announced shortly. I will also provide further information about this program in future blogs and you can 

[Editor's Note: Dr Blumenfield orginally published a version of this piece, titled "Let's Talk About Suicide," in his blog, 

Patients with major depression or bipolar depression have a 20- to 26-fold increase of mortality rate over the general population. Suicidal behavior can be quite complex as well deadly. It should go without saying that psychotherapy is usually necessary in treating patients who have suicidal ideation or who have demonstrated such tendencies or actions. Frequently, it may be combined with medication and sometimes it is the treatment of choice without medication.

Suicide: Complexities and Treatment Challenges

Early in the morning of the Colorado shooting, I received phone calls from various news outlets asking me to give an instant psychiatric opinion on the shooter in the terrible incident in Colorado. I knew nothing about the incident and could never comment specifically on a person I had not examined and of course couldn’t talk about someone that I did examine.


I understand that there is a strong public interest when something like this happens. There is a natural inclination to believe that the shooter must have been “crazy,” meaning a person with a mental disorder. This is a way of distancing oneself from abhorrent behavior. The fact is, 1 of 5 people in the US are believed to have significant mental problems. But it is also true that people with severe mental illness (usually defined as schizophrenia, often with delusions, bipolar disorder, or severe depression) are no more likely to show violent behavior than those without these conditions. Such persons should be even less inclined to violence when they have been properly treated. Even when one looks at the relatively small incidence of violent behavior seen in people discharged from a psychiatric hospital, [this behavior] is usually directed at people known to the patient rather than random violence.

My reading of the scientific literature doesn’t tell us anything about this particular alleged shooter in Colorado. The suspect may very well have been psychotic (out of touch with reality) and have ideas and thoughts that led him to do this act. Whether or not he was psychotic, I am confident if we knew everything about his life experience, inner feelings, and thoughts, we would be able to understand his anger or his fantasies that led him to plan and carry out this horrible deed. There is also the possibility that he used alcohol and or drugs that disinhibited him or even made him psychotic. Although his lawyers may very well mount an insanity defense and try to prove that he was under the influence of a mental illness, they will have a difficult task, especially because this was obviously planned and deliberately carried out rather than impulsively done. Even if we can understand the psychological determinants of this behavior, it doesn’t in any way justify or excuse it.


People will no doubt make comparisons with the Columbine High School shooting that by coincidence occurred in nearby Littleton, Colorado. There also were several other similar type school shootings in recent memory. The US Secret Service conducted a 

 of the attackers and the circumstances involved in 37 incidents of targeted school violence that occurred between 1974 and 2000. They concluded that a history of having been the subject of a mental health evaluations, diagnosed with a mental disorder, or involved in substance abuse did not appear to be prevalent among the attackers; however, most of the attackers showed some history of suicidal attempts or thoughts, or a history of feeling extreme depression or desperation. Most of the attackers felt bullied, persecuted, or injured by others before to the attack.


There also was the well-known 1966 case of Charles Whitman, the Texas Tower sniper. He was a student at the University of Texas in Austin who killed 16 people and injured 32 others before he was killed by the police. It turned out that he had a dysfunctional family and used amphetamines, but he was also determined to have glioblastoma, which is an aggressive brain tumor. It was believed that this brain tumor played a role in his actions.


The event in Colorado is obviously a tragedy for the victims and their families which will never be forgotten by those close to anyone touched by this event. It will cause painful grieving among the families and friends of those who lost their lives. It will also cause symptoms of PTSD in persons who witnessed this event in person as well as many who will be impacted as they follow the story in the media. Young people will be particularly vulnerable as they identify with people like themselves who were looking forward to an enjoyable fantasy movie and instead were confronted with a reality that they could have never imagined.

Editor's note: This article was originally posted on Dr Blumenfield's blog. You may Join the Conversation below or comment on 

The shooting in Colorado is obviously a tragedy for the victims and their families which will never be forgotten by those close to anyone touched by this event. It will cause painful grieving among the families and friends of those who lost their lives.

Psychiatric Considerations in Colorado Shooting

Questions to consider when reading the case:

•Should the therapist do anything with this information?

•Is the therapist required to notify anybody?

•What are the  legal  and therapeutic implications?

Being a psychotherapist is a complicated job. Not only must you be knowledgeable about human behavior, psychodynamics, and various techniques of doing therapy, but you have to be prepared for unexpected dilemmas. Two cases are presented below which bring up potential legal and ethical issues as well as technical considerations, which the therapist has to take into account to best help the patient.

These vignettes are based on real cases which I have either been involved with as the therapist or as the supervisor or I have read about them or have been told about them by a colleague. Some details may have been changed to protect confidentiality.

All the of cases are at least 10 years old. Readers of this blog are welcome to express their opinion about the cases. We all recognize that in a real clinical situations, there would be much more information available about the patient which might help in making a decision. In a future blog, I will present further discussion about these cases.



The patient is a 26-year-old young woman who came into therapy because she was depressed about her inability to complete things. She had started college twice and dropped out, and as a adolescent, she came home from sleep-away camp twice. Her goal was to go to nursing school some day in the future. She had many friends but had trouble keeping a boyfriend, She was attractive but was somewhat inhibited and only on occasion would allow herself to have sexual relations, which she would enjoy. Her parents were divorced when she was 6 years old. Her father, a physician, would visit her periodically when she was a child. When she was older, she would visit him and his new wife. She always felt close to them and their 2 children. Her own mother was an alcoholic, and when she was younger, her mother’s behavior was quite erratic. At times she was physically abused by being slapped around. Other times she would have to take care of mother by making food for her and sometimes would even stay home from school. Despite poor attendance, she got good grades. She herself does not drink or take drugs. She shows no evidence of a major depression or psychotic symptoms. She is often moody but doesn’t appear to have hypomania. She becomes angry when she is disappointed. As a preadolescent she saw several therapists and she had 2 or 3 brief trials of therapy in the past 3 years  including several weeks of a trial of an SSRI, which she didn’t feel made any difference. She is currently in treatment with a psychodynamically oriented psychiatrist who has decided not use medication at present. She has been coming for 4 months, 2 times a week (Tuesday and Friday). She says this is the first time she is making progress in therapy because she feels she can talk freely and is not being judged.

During her last session on a Friday very close to the end of session, she said, "Whatever we say here is completely confidential, isn’t it?” The therapist replied, “Why do you ask this question?”  The patient then went on, “You know that babysitting job that I have been doing every Saturday night for Mr and Mrs Woodman, my neighbor’s 15-month-old child? Well, last week the kid was a real problem. He was whining all the time and wouldn’t listen to me. The final straw was that he spit on me. I lost it and slapped him real hard across the face. His face got really red and swollen. I put some ice on it. I will never do that again.” The therapist, was stunned and before she could say anything, the patient said, “Well, I know my time is up,” and she got up and left.

, where this case was originally posted. You may Join the Conversation below or comment on 

Being a psychotherapist is a complicated job. Not only must you be knowledgeable about human behavior, psychodynamics, and various techniques of doing therapy, but you have to be prepared for unexpected dilemmas.

What Should a Therapist Do in These Situations?

Antihypertensives at Night: When You Snooze, You Lose?

 published in the  Journal of the American Medical Association  concluded that depression is associated  with a significantly increased risk of stroke morbidity and mortality. This means that if you have depression you are more likely to have a stroke and die from a stroke as compared to a situation where you didn’t have depression.

This is quite relevant to a large number of people since depression is quite prevalent in the general population. It is estimated that 5.8% of men and 9.5% of women will experience a depression e episode in a 12 month period. The lifetime incidence of depression has been estimated at more than 16% in the general population.

This research study was by Dr. An Pan  and four colleagues from the Harvard School of Public Health and Harvard Medical School. The research was a meta-analysis and a systematic review which meant that the authors studied research of many studies on this subject The ended up looking at 28 prospective cohort studies comprising 317,540 participants which reported 8478 stroke cases during a follow-up period ranging from 2-29 years.

Their scientific analysis of the data demonstrated that depression is associated with a significantly increased risk of developing stroke. They also found a positive association of depression with a fatal stroke.

The authors discussed a variety of mechanisms which depression may contribute to stroke. Depression has known neuroendocrine effects. For example t there is a dysregulation of HPA axis ( hypothalamic-pituitary-adrencortical axis which can cause high blood pressure. It has been shown that depression effects platelets and leads to  dysfunction which causes abnormalities in the clotting mechanism. There are also abnormalities in the immune and inflammation systems which could influence stroke risk..

Depression is associated with poor health behaviors such as smoking, physical inactivity, poor diet, lack of medication compliance and obesity, all of which may contribute to stroke.

Depression has already been associated with coronary heart disease, diabetes and hypertension. (

See an earlier blog on depression and heart disease

 which raised the question whether people with depression should be taking aspirin to prevent heart attacks).

The data from the recent JAMA study also suggested that it is possible that antidepressant medication may be associated with stroke risk but this may be a false impression since medication use can be a marker of depression severity and many of the studies that the authors looked at lacked information on dose and duration of medication use.

There are some limitations of this study and the findings don’t prove 100% that depression causes stroke. I would imagine that it is conceivable that the genetic markers for stroke and depression could be located in close proximity leading to such impression of this effect. However even if there is no causative effect (although I believe the research strongly suggest one), the association of these conditions clearly calls out for great attention being paid to this association. There is an opportunity for doctors who see patients who are at a high risk for stroke to be referred for treatment of depression. Also patients who are being treated for depression should be encouraged to be seek medical attention and assistance in reducing all the other risk factors for stroke whenever possible.

Depression is a serious condition and is very treatable. Treatment works! Patients who have 

 should be treated whether or not they are at a higher risk for stroke and other diseases.

[Editor's Note: Dr Blumenfeld orginally posted this piece on his blog at 

http://www.psychiatrytalk.com/2011/10/the-connection-between-depression-and-stroke/

A recent study concluded that depression is associated with a significantly increased risk of stroke morbidity and mortality.

The Connection Between Depression and Stroke

President Obama announced that he would begin sending letters of condolence to the families of troops who kill themselves in combat zones. He noted that this was a decision that was made after a difficult and exhaustive review of the former policy and he added, “I did not make it lightly…This issue is emotional, painful and complicated but these Americans served our nation bravely. They didn’t die because they were weak.”





There has been a long standing campaign to get the President to change the previous policy, led by families who had soldiers die by suicide. Various veteran groups, members of Congress and  mental health professions, including myself have been publicly advocating that the President change the policy . . . 

This article was originally posted on Dr Blumenfeld's blog at 

. Click here to read the remainder of this article. Dr Blumenfield invites you also to listen to his interviews on 

No Condolence Letter for Families of Solders Who Commit Suicide

Military Kids With Deployed Parents Experience Higher Risk of Hospitalization

There Are No Vaccines for PTSD and Suicides in the Military

President Obama announced that he would begin sending letters of condolence to the families of troops who kill themselves in combat zones. He noted that this was a decision that was made after a difficult and exhaustive review of the former policy.

Suicide: Troops' Families to Get Condolence Letters

What should psychotherapists do if they realize that they don’t like a particular patient who has come to them for help?

First of all, we should realize that it is a virtue that a therapist can recognize and acknowledge to themselves negative feelings towards a particular patient. One can’t expect to like every person you meet and just having some negative feelings isn’t necessary a contraindication to working with someone. If the feelings are minor, it should not interfere with the treatment and the therapist would keep these feelings in mind but proceed with the treatment. In fact as will be described, the awareness of such feelings may actually assist the therapist in carrying out effective therapy.

Therapists are usually trained to reflect on their own feelings as they work with a patient, particularly when they are aware of strong positive or negative feelings. In the case in question, where the therapist is becoming aware that he or she doesn’t like the patient, the self-oriented question is “Why don’t I like this patient?” The answer may be obvious, such as the patient is inconsiderate, self centered, prejudiced, anti-my-political- or -religious beliefs, etc. One doesn’t necessarily dislike a person who meets such criteria, and therapists in their self reflection need to include the contemplation of “What do I know about myself that might help me to understand these feelings?” It may be that the patient reminds you of a significant person in your life or certain situations which have occurred to you. One more additional self-directed question should be “Can I work with my own feelings and try to help the patient or are these feelings too strong for me to objectively work with the patient?" Also, "Am I just not inclined to work with the patient, even if I understand why I feel this way?”

If the awareness of the dislike for the patient comes during the initial consultation and the therapist is not inclined to work with the patient, it may be relatively easy to refer the patient to a a colleague. A therapist not uncommonly will refer a patient to another therapist after the initial consultation if a therapist with special expertise might be better suited to treat the patient or if the therapist and the patient’s schedules don’t mesh for setting up ongoing therapy. On occasion, the consulting therapist might feel, after an initial consultation, that the therapy should be by a person of another sex, background, or age. While these situations are less common, it may happen. Therefore, referring the patient to someone else whom you feel will work better with the patient after initial examination of the patient is ethically proper. Our guideline is to 

 to the patient and do everything in the patient’s best interest. It is most likely you would only be hurtful to the patient to explain that you don’t like them and that is why you are making the referral, so you shouldn’t do that.

This may put you in the position of having to tell a “white lie” by saying that your 

 or that you are sending them to another therapist whom you feel is better suited for them (although this may technically be the truth). The therapist has to make the decision whether to discuss the reason for the referral. If the reason was one in which there was a good possibility that another therapist might have the same problem (ie, the patient was a member of the Ku Klux Klan or was a 

) it would be best to discuss this with the potential new therapist in order to find someone who could separate their own personal feelings and work with the patient. When the reasons were totally personal (the patient reminded the therapist of someone or some personal situation), such a discussion would not be necessary. In such case, a general reason or a scheduling problem could be given for the referral or you could share this information with the new therapist.

 for the patient occurs during ongoing therapy, referring the patient to someone else becomes more complicated as interrupting the therapy would have to be weighed against the therapist concluding that they can’t help the patient due to their own feelings. 

 trained therapists are usually trained to recognize and to work with their own 

 and this would be the preferred mode of operation. This approach not only facilitates insight into self but also has the opportunity to facilitate ongoing therapy. The therapist should always have the option to seek assistance through a consultation with a colleague, a clinical  supervisor, or their own therapist and certainly if they themselves are in ongoing therapy–this situation should be closely examined. Therapists should be constantly monitoring their own feelings, and the awareness of some negative feelings about the patient is not unusual.

In fact the experienced therapist knows the kind of issues which push their own buttons and an emotional reaction to the patient may be the first opportunity to identify some conflict within the patient that both the therapist and the patient may not have had a conscious awareness.

 This article was originally posted on Dr Blumenfield's blog at 

http://www.psychiatrytalk.com/2011/03/when-the-therapist-dislikes-the-patient/

What should clinicians do if they realize that they don’t like a particular patient who has come to them for help

When the Therapist Dislikes the Patient

Is there empirical evidence that supports the efficacy of psychodynamic psychotherapy?

In the next 5 minutes, Dr Michael Blumenfield will discuss an 

 on this topic–an article that he has nominated as his choice for Top Paper of the Year.

Dr Blumenfield is president elect of the American Academy of Psychoanalysis and Psychodynamic Psychiatry and Sidney E. Frank Distinguished Professor Emeritus of Psychiatry and Behavioral Sciences at New York Medical College; he is also a past speaker of the Assembly of the American Psychiatric Association. He has a private practice in Los Angleles and he writes a blog, 

, as well as periodically contributing to the 


1. Shedler J. The Efficacy of Psychodynamic Psychotherapy. 

http://www.apa.org/pubs/journals/releases/amp-65-2-98.pdf

Is There Empirical Evidence That Supports the Efficacy of Psychodynamic Psychotherapy?

Dr Shedler's article begins as follows: "Empirical evidence supports the efficacy of psychodynamic therapy. Effect sizes for psychodynamic therapy are as large as those reported for other therapies that have been actively promoted as 'empirically supported' and 'evidence based.' In addition, patients who receive psychodynamic therapy maintain therapeutic gains and appear to continue to improve after treatment ends. Finally, nonpsychodynamic therapies may be effective in part because the more skilled practitioners utilize techniques that have long been central to psychodynamic theory and practice. The perception that psychodynamic approaches lack empirical support does not accord with available scientific evidence and may reflect selective dissemination of research findings." For a pdf of the full article, 

Podcasts

The efficacy of psychodynamic psychotherapy is supported by empirical evidence. Patients have reported residual therapeutic gains following treatment.

The latest information released by the US Army reveals that last year American soldiers attempted suicide at the rate of about 5 per day. There were 160 successful suicides last year and during June the rate was 1 per day. Military research has reported that one in 10 Iraq veterans may develop a severe case of PTSD.



We Are Not More Dangerous to Ourselves Than The Enemy 


As statistics such as these continue to emerge there is a continued outcry that something should be done about this. A report issued by the US Army in my opinion minimized the fact that these psychological causalities are a result of combat and the realities of war. The army review concluded “simply stated, we are often more dangerous to ourselves than the enemy.” It went on to say that commanders have failed to identify and monitor soldiers prone to risk-taking behavior and as a result suicides among soldier have soared. I believe that this is a misguided view that somehow if we did the right thing we could prevent these events. There were 250 recommendations in the recent report and the Army has already implemented 240 of them. While these are positive things done to provide good mental health care, they won’t prevent PTSD and sadly it won’t eliminate suicides.



We haven’t been able to prevent the increasing number of Americans being killed by IEDs. War is hell and soldiers get killed. We train them the best way that we know how but inevitably soldiers die when there is a war. Maybe one soldier, despite the best training available isn’t quite as good in a combat zone as another one. Some may be able to know when to zig rather than zag. Some have better instincts than others and that may make them more likely to survive. Some inherently may be able to handle the stress of war better than others. However, the best training in the world and all the preventive measures in the world will not eliminate combat injuries and death. Nor can PTSD and suicides be avoided. The most combat-savy soldiers in our military cannot hide from a bullet with their name on it nor can the most well-adjusted soldiers avoid being affected by extraordinary human experiences in a war zone.

Of course we should always strive to improve our training, safety, and efficiency in the battle field. And of course we should always strive to provide the best medical care (which includes psychological care) to our soldiers.



Soldiers Injured With PTSD Deserve to Receive a Purple Heart
Families Deserve Presidential Condolence After Soldier Suicide 

We honor our soldiers who are injured serving their country. We give Purple Hearts to soldiers who have been wounded, and bury with honor those who have given their lives for their country, with the exception of those soldiers who suffer psychological injuries. There is no Purple Heart for them. There is no letter of condolence from the President to the families of those who died from suicide. This is outrageous! These men and women have all volunteered and knew they could be in harm's way. 

 as if they purposefully became psychological causalities. There is no way to minimize the grief of their loved ones but this failure to acknowledge their loss only compounds it.



At the last Assembly of the American Psychiatric Association I co-authored an action paper with Roger Peele asking the APA to take a position asking the president of the United States to write letters of condolence to families of soldiers who have died by suicide. It was passed by the assembly and now awaits action by the board of trustees. The voice of American psychiatry on this particular issue will be a powerful influence on the president, who has previously said that he will reconsider the current policy. I also look forward to seeing our APA president make public statements on this issue once it becomes an APA position.

The latest information released by the US Army reveals that last year American soldiers attempted suicide at the rate of about 5 /day. There were 160 successful suicides last year and during June the rate was 1/day. Military research has reported that one in 10 Iraq veterans may develop a severe case of PTSD.

Empathy is the ability to put yourself in someone else’s shoes and understand what they are feeling. This is something that psychiatrists try to do in our everyday work. Those of us who have worked in medical schools have struggled with the question of whether or not we can teach this to young men and women who are learning to be doctors or whether it is something that they either have or do not have. Certainly I have seen medical students who seemed to be decidedly lacking in this quality, just as I have seen students to whom it came very naturally and some who were far more empathic than I was as a student or even after years of experience.

Choose Empathic Students in the Admission Process

I have gone through many phases in trying to figure out how medical schools can graduate doctors who have this empathic quality. My first thought was to try and influence the selection process so students who seemed to have this natural quality would be chosen. I had the opportunity to join the admissions committee of the medical school where I taught and participated in the interviewing and selection of prospective students.

Actually, there were a few psychiatrists already on the committee along with other medical specialists and basic scientists who would be training the students in their preliminary non-clinical years. It was relatively easy to determine which students had this quality in abundance and which students did not.  I could see the tears in a student’s eyes as he or she told me about experiences which he had known someone who had been ill or disadvantaged and how this had motivated him to want to be a doctor. I remember the caring response of one student to me as I was suffering with allergies with my eyes running on a particular day that I was interviewing her. On the other hand I could detect the intellectual response of students who ticked off their many volunteer activities or told of their dedication to finding the cure of cancer because it  would then increase life expectancy. However, when it came down to the votes on the committee, a student being the most empathic would never trump the one with potential to become a world famous doctor.

I had opportunity to see if it were possible to teach students to be empathic. It was traditional in our medical school for psychiatrists to teach students interviewing technique both in formal lectures and at the bedside. In preparation for a formal lecture I made a video tape (we were not yet using DVDs) in which I had some senior students act as doctor and patient in a hospital room in various scenarios. In one of them the “doctor” asked the “patient” if anyone in her family had a cancer. The patient began to cry and said her daughter died of cancer. I then showed three possible responses. In the first one the doctor just continued with the interview and kept asking questions. In the second scenario, the doctor got up and excused himself and said he would come back later when the patient was feeling better. In the third case the doctor offered the patient a tissue and said that he was sorry. Obviously the third  vignette was meant to be the correct one, and most students seemed to get it. However, a group of Asian students approached me after the lecture and told me that they did not agree with the choice of the best vignette. In their particular culture it was a sign of respect to let a patient be alone in that particular situation. Excusing one self and walking out of the room was the correct response as far as they were concerned.  So I began to realize that this was not an easy task.

Each week I would take a group of three students to an actual patient’s bedside to practice doing an interview. The patients knew they were “students in training” but usually responded to them as if they were doctors taking a history from them. On a particular day, before we entered the room, I told the student who was to do the interview that sometime during the interview he must use the following words, “that must have been very difficult.”  The student proceeded with the interview with the other two students and myself standing by the bedside. At one particular point in the interview the patient started to talk angrily about how she hated to go through all these tests when she knew she was going to have an operation anyway. The student was a little flustered by the patient’s emotion but then he remembered and said, “That must be very difficult.“ The patient’s demeanor changed and she continued in a very friendly and cooperative manner. At the end the interview the patient remarked to all of us that “this doctor was the most caring physician that I have seen in the hospital.” In our post-interview discussion the student was beaming (his overall interview actually was quite poor). I asked why did he think that the patient thought he was so good. He couldn’t answer, apparently feeling he had just done a good job. The other students understood and were able to appreciate the value of the comment that he had made at the right time. However, the next week I suggested the same technique to another group of students who objected to this approach. They felt it was artificial, phony, and they did not want to be actors when they were trying to be doctors. Other groups had similar responses. This was another indication of how teaching medical students to be empathic was quite complicated. 

After several years my teaching and clinical work took me away from this particular type of medical student teaching. One day, however, I encountered the following situation. I was a psychiatric consultant called to a difficult situation in the medical emergency room.  A male patient in his thirties with multiple traumas did not survive a motor vehicle accident and died in the emergency room. The mother of the patient became hysterical and out of control. Nobody could calm her down. A first year medical resident (two weeks out of medical school) was the only one to stay in the room with her while she screamed and berated the hospital, the doctors, and the medical system. After he patiently stayed with her during the tirade, he gently asked if there was anything he could do for her. She said, “Yes, remove the damn tube from his mouth “ (the breathing tube from her son). While he knew this was not usually the procedure because of the preference of the medical examiner, he did so in her presence and then turned to her and asked if she would like to help him clean up the body. She agreed to do so and he asked the nurse for a basin of water allowing her to clean her son’s face. He stayed with her until she was ready to leave. When I asked him later how he felt and how he was able to do this, he told the following story. Recently his best friend had died. In his own grieving, he repeatedly thought of how painful it was for his friend’s mother and how he had imagined such a loss would affect his own mother. He also recalled how his friend’s mother said many times that she was bothered by seeing the IV lines in her son’s arm after he died.

Empathy is a very complicated issue. The capacity for empathy does vary from person to person. We need to provide teaching and mentoring to our students on this subject, and we need to listen and be empathic to them in regard to their previous experiences. It is no different than our obligation to be empathic to our friends, family, and especially our children. This will make future generations better doctors and better people. 

Empathy is the ability to put yourself in someone else’s shoes and understand what they are feeling. This is something that psychiatrists try to do in our everyday work. Those of us who have worked in medical schools have struggled with the question of whether or not this is something that can be taught.

Author | Michael Blumenfield, MD

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