Sharon Packer, MD

“And then they crawled out of the garbage can, dripping with blood and covered in goo. One after another, looking like little babies, except they were dead.”

Was she describing that cheesy 1970s-era horror film 

, a Times Square special about a major obstetrical mishap that self-propelled and devoured every bit of beef in the freezer? Or did this concern a later cult craze for “Garbage Pail Kids” cards, which were far more benign but nevertheless bizarre and popular enough to be known by the acronym, GPK? Or was this imagery more personal—something to discuss in a psychiatrist’s office, which is exactly where she was? The source of her concern would become obvious moments later.

Meg breathed in before she continued. She shuddered as she spoke, but she shed no tears.

She gripped the sides of her chair, her chipped nails leaving deep indentations in the well-worn leather. Her scraggly body sunk into the overstuffed armchair. She practically disappeared in the furniture.

Her disheveled appearance spoke for itself. Her half-bleached blonde hair was stringy and unkempt. Sweat beaded up on her forehead, making matters much worse.

She was scared, not sad, as she recounted the dreams that reoccurred almost every night since her last procedure. And she emphasized the word, “last,” implying that there were many more before the most recent termination of pregnancy.

It would have been easy to label her symptoms as posttraumatic stress disorder (PTSD), a result of uneasy feelings about ending a pregnancy that was never intended and never expected. She freely admitted that she was intoxicated the night that she conceived. She could remember next to nothing about the event—not even the name of the man she met that evening—but she remembered everything about the nights that followed.

Meg was only 22 years old, yet this was the third time that she terminated an unplanned pregnancy. There was 1 difference between this time and the previous abortion. Meg’s OB told her she could not in good conscience continue to treat her and perform another procedure unless Meg saw a psychiatrist and addressed her drinking. In my experience, it is unusual but admirable that this OB focused on something other than the immediate medical situation.

“And how did she know about the alcohol?” I asked. Meg did not hesitate to tell me that her liver enzymes were elevated. According to the OB, that was an ominous sign in anyone, but especially in someone so young.

Having read the paperwork that she filled out before her first appointment, I already knew that Meg (or “Margaret Mary,” as per her insurance card) was Catholic. As she disclosed during her first appointment, she was not a lapsed Catholic or an “ex-Catholic” but a practicing Catholic who sometimes attended Sunday mass and always made it to midnight mass at Christmas. So, I expected Meg to feel conflicted about a choice that contrasted with the tenets of her church, a church that she still valued. Yet I was not surprised by her choice, knowing that individuals from religions that oppose abortion are just as likely to have an abortion as those from religions that condone abortions or have no religious affiliation at all.

I also knew that Meg had recently left detox—but a little too soon. She said she signed out against medical advice when she felt well enough to walk out.

“And how did you decide upon detox?” I queried.

Again, Meg was forthcoming. She reminded me that she stopped her alcohol intake abruptly, a few days before her scheduled procedure, as she was worried that alcohol might affect the anesthesia. Someone in the recovery room at the women’s clinic saw that her hands were shaking and suspected that her tremor was more than simple anxiety. As Meg recalled, her blood pressure was high even after the anesthesia wore off. The nurse feared that Meg would enter withdrawal, so she summarily sent Meg to the hospital—not because of complications from a legal abortion performed in a safe and sterile setting, but because of the aftermath of long-standing and unchecked alcohol overuse.

It is uncommon for healthy young individuals to go into delirium tremens (DTs)—which can cause vivid and frightening hallucinosis—but it is also uncommon for a young woman to drink as much as Meg did with impunity. Meg did not know it at the time, but women develop neurotoxic symptoms from alcohol at one-third less alcohol than men. Downing a pint of vodka each night was more than her emaciated body could endure. To look at her, one would wonder if she had “alcoholorexia”-– an unofficial, non-DSM diagnosis for weight-conscious women who save their calories for alcohol and starve themselves of food.

Over the next few weeks, Meg shared more details about her life goals and lack of goals. Meg was an “on again, off again” student who worked for a local coffee chain, putting in just enough hours to get health insurance and college tuition reimbursement. Sometimes she signed up for writing classes; at other times, she filled her schedule with painting studios. She never took enough courses in a single subject to earn credit toward a college major that would make her eligible for a degree. In many ways, Meg was the opposite of her deceased father, who had been a hard-working, highly-motivated, small-town doctor—until his drinking got out of hand. In other ways, she was strikingly similar to her father, given that they each had drinking problems.

Even though Meg knew little about the man who died when she was young, she still knew details that her hometown paper published: that he was found dead, alone, lying face-down on the floor, next to an empty bottle of booze. The article wondered if his death was accidental or intentional, since he succumbed a few days before a scheduled hearing at the medical board, where he expected to lose his medical license because of a botched procedure, presumably performed while under the influence.

Meg was unfazed by her father’s fate—or by the possibility that she inherited a genetic predisposition to alcoholism that could contribute to her own downfall as well. Data suggests that 40% to 60% of alcohol problems are inheritable, so many individuals with family histories of alcohol overuse exert extra caution. Meg was not one of those prudent people. Instead, she frequented the so-called art bars in the Village when she was not working the late shift at the coffee shop. She chose that shift because she was too hungover for the early morning shift that attracted bigger tippers on their way to work.

At the bars, Meg cavorted with itinerant artists, writers, and musicians who also devoted more time to upping their drinking than to perfecting their crafts. She envisioned herself as the next Mary Gaitskill, an author she admired who wrote short stories about the down-and-out crowd that she hung with.

Sadly, psychoeducation about the medical hazards of alcohol overuse did not dent Meg’s denial. For sure, these visions of dead babies had scared some sense into her, but then she countered with a quote from an art instructor, who said that Jackson Pollock gained fame from dripping paint on a canvas because he was too drunk to hold a brush. “So why would I expect my work to suffer?” she retorted.

When asked about alcohol’s impact on her writing style, Meg referenced Jack Kerouac, a drinker who cavorted with the Beat Generation before he died at 47 years old. Kerouac chronicled his road travels but otherwise lived with his mother. He popped Bennies to boot.

“Sure, he died young, and, yes, because of alcohol, but the world remembers him, and that’s a lot more than I could say for most sober people,” Meg said.

It was sad to see that someone who was so quick with counterpoints was also so blind to her own self-destruction. The telling moment came when Meg asked about me to comment on her abortion. She wondered if it was the abortion that made her suffer from so many nightmares. Then she asked my opinion about when life began. I suspect that she was hoping to hear medical data that countered her church’s stance, but I swiftly sidestepped that unsolvable argument.

“I’m not an expert in theology, but I do know something about embryology and the impact of alcohol on unformed fetuses.” There was no need to mention FAS or FASD or the many other manifestations of antenatal alcohol exposure

 to Meg—not at this point. Although it was impossible for me to forget.

“I also know about the medical consequences of alcohol overuse, and in women in particular.”

I was impressed because I encountered few individuals who knew that breast cancer—among many other cancers—is promoted by alcohol.

“Does that topic interest you? You seem quite knowledgeable already.” I tossed in those motivational interviewing techniques, with the hopes of making some inroads. That topic hit home for me because I lost about 1 patient a year to breast cancer that had been promoted by past alcohol use. Saddest of all was witnessing this in individuals who had stopped drinking and become sober years before, but not until after the damage was done.

Sensing Meg’s disinterest in pursuing this discussion, I took another course. “So, Meg,” I continued. “I realize that there are endless debates about when life begins, especially when it comes to making arguments for or against abortion.”

“What’s not open to debate, in my opinion, is that life ends earlier than it should when people continue to overuse alcohol,” I added. “Sadly, women bear the brunt of this uneven distribution of medical consequences, even though alcohol overuse is typically associated with men.” I have pamphlets from NIDA [the National Institute on Drug Abuse] about women and alcohol. Would you like one? Or you can look online. I can send you a link.”

I tried another sales pitch, hoping to appeal to Meg’s artistic inclinations. “Our government really did a good job with the graphics on the NIDA website. I think you would like them.” And that was the truth.

Having said my piece, I stepped off my soapbox, waiting to hear Meg’s response. Meg responded with a blank stare, neither agreeing nor disagreeing. The fear that was in her eyes at the first visit had been replaced by a dissolute look of indifference. Still, I hoped that something I said made sense.

In my mind, it would have been tragic to turn this discussion into a political or religious debate when the most important matter at hand was protecting Meg from premature loss of her own life because of her longstanding alcohol use. Her OB had already broken barriers by convincing her to see a psychiatrist and examine the causes and consequences of her behavior. Even though Meg refused Alcoholics Anonymous, there are still ways to acquire habits that lessen the likelihood of alcohol overuse.

I felt confident that offering treatments that could decrease Meg’s alcohol cravings, rather than rebuking her for choices she made in the past, was the best way to prolong Meg’s life. If that is not a topic that everyone can agree on, then what is? Still, I wonder how many opportunities to educate patients about avoiding alcohol misuse are missed simply because people get caught up in polemics on politics.

is an assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai in New York, New York.

1. Packer S. Jessica Jones, women, and alcohol use disorders. In Eds. Rayborn T, Keyes A. 

Jessica Jones, Scarred Superhero: Essays on Gender, Trauma, and Addiction in the Netflix Series

. McFarland & Company, Inc., Publishers; 2018.

Articles

A psychiatrist reflects on how we can educate patients about avoiding alcohol misuse without getting caught up in polemics on politics.

A Matter of Life and Death: When Abortion Wars Should Not Be Fought

Lilly was able to live as well as she did, for as long as she did, because the sun does not shine in Soho. In New York City’s Soho district, cast-iron constructions, built more than a century ago, cast long, dark shadows, much like the inky black shadows sketched for 

comic books. Narrow alleyways separate back-to-back buildings, leaving next to no room for shafts of sunlight to seep in. Film noir-style shadows are plentiful in that part of town, as they are in 

’s fictional Gotham City, which owes its inspiration to Manhattan’s cast shadows.

Soho began as a manufacturing zone, where floor-through factories did not demand sunny views of cityscapes. Yet today’s Soho is a fashionable area with no trace of its past. It housed my psychiatry practice for the last decade. When manufacturing left New York City, those large Soho spaces turned into artists’ lofts, which then gave way to art galleries. Gradually, pricey designer boutiques replaced galleries, and fashionably dressed shoppers and shop girls displaced artists.

Lilly was unlike other Soho shop girls who wore unaffordable dress samples that turned them into breathing billboards. She was an apprentice jewelry designer at an established shop on Prince Street, a few blocks from my office. Even though she was only an intern and still a student, she had already amassed an impressive portfolio. She was wearing one of her creations when she arrived at my office for her first appointment—a little late, because passers-by had stopped her on the street to ask where she sold her unique broaches. Such was life in Soho.

Lilly was referred by Fashion Institute of Technology (FIT) Student Health Services to resume attention-deficit/hyperactivity (ADHD) treatment that had begun in grade school. FIT Student Health Services addressed acute symptoms only and referred students with long-standing conditions to private psychiatrists like me. Records documenting treatment that started when Lilly was young had arrived in advance, making it easy enough to refill her prescription for amphetamine salts. It was equally easy to add a selective serotonin reuptake inhibitor (SSRI)—and supportive therapy—when her social anxiety surged in this city of strangers, and when she felt overwhelmed by the stereotypically assertive New Yorkers who surrounded her.

Previously, Lilly was treated at a federally funded clinic. This rural area grappled with physician shortages. Her stimulants did not relieve the dyslexia that caused her more distress than inattention—but there were no local resources for cognitive remediation to help with reading and spelling. Luckily, Lilly preferred an arts-related career that sidestepped academic studies.

As her social anxiety subsided, she shared details about her early life in small-town Phoenicia, which was a few hours from Manhattan, geographically speaking, but lightyears away on a cultural level. Lilly was forthcoming about her struggles in school and the fact that most of her family members lacked so much as a high school diploma, much less advanced degrees. Still, despite her dyslexia—or maybe because of it—Lilly created clever necklaces from discarded tin cans that she scavenged near the Esopus, where shabby trailer camps contrasted with picturesque waterfalls that attracted tourists.

Phoenicia was a simple place, known for camping and tubing and long stretches of tall, fragrant pine trees. There, Lilly’s mother tended garden at a vacation home owned by a Cobble Hill couple. Her father functioned as a live-in caretaker, allowing the family to live rent-free. Their basement apartment was drafty and cold in the winter, when the owners were away and the heat was off, but it was still better than the trailers that lined the riverbanks, according to Lilly.

Her family lived underground—no taxes, no voting—until Lilly applied for a state scholarship. But every weekend, her father packed his pick-up truck with a fresh supply of repotted hostas, selling them to second-home owners. Lilly joked about weekenders’ willingness to pay outsized prices for minimal efforts needed to propagate common plants that grew in their shade garden.

Eventually, Lilly’s father added her tin broaches and bracelets to his hosta display. This caught the eye of an elderly tourist, who suggested that she create a portfolio and apply for a scholarship to FIT so she could hone her skills and prepare for a “real world” career. Lilly had never heard the word “portfolio” before, but she was impressed when she heard that both husband and wife were college professors. So, she followed their advice. She won a scholarship, thanks to this chance encounter. Her creations also impressed a jeweler in Soho, who offered her an internship at his shop, with a chance to make jewelry from “real” metals, not just tin cans.

At each appointment, Lilly shared more details of her day-to-day life. She made her way to work early each morning, exiting the tenement apartment she shared with an elderly aunt on Mulberry Street, located a short, shaded block from my office. She scheduled the earliest appointment available and then darted between the shadows, crossing narrow cobblestone streets that paved those deep caverns created by cast-iron towers. To commute to FIT, she jumped on the N train at Prince Street, half a block away. To travel to her job at the jewelry store—which offered course credit toward her jewelry-making certificate—she sped down Prince Street in the opposite direction. Sometimes, she said, she headed for a hidden alley near Houston Street, where she studied at a library that was sheltered from public view, but which gave her full view of discreetly staged fashion shoots at the far end of the alley.

Lilly did not resent her limited itinerary, for she found the New York City crowds too overwhelming, and she appreciated the predictability of a set schedule. And Lilly’s life was indeed predictable until something changed in late winter.

For Presidents’ Day weekend, a classmate invited her on a ski trip at an upstate resort—and that was when things started to shift. Embarrassed to admit that she could not afford a lift ticket, much less skis, Lilly sat on the sidelines for hours, near the snow-covered and sun-drenched trails. Upon return, she complained that her hands hurt, and that her fingers turned blue.

Lilly was describing Raynaud syndrome, which could worsen with vasoconstricting stimulants. Still, it seemed odd that such a side effect started so suddenly, after so many years on the same medication. Besides, she lived further north, where winters were far worse, yet she never previously had such symptoms in the cold. Then the clues started to fall into place. She also began experiencing fatigue once she sat outside on the slopes, which was equally strange, considering that stimulants are energizing and are sometimes used (illicitly) to combat fatigue.

I was unwilling to write these symptoms off to side effects, but I was also unwilling to continue a stimulant that could conceivably worsen Raynaud’s, especially since the medication offered minimal benefit for Lilly’s major dyslexia symptoms. So, we tapered her off the ADHD medication, but the pain in her fingers persisted—even though she was on SSRIs, which can relieve Raynaud’s. It was time to see the primary care physician (PCP) to find other explanations for concomitant fatigue, Raynaud’s, and joint pain in a 20-year-old female. I ordered basic labs and added an ANA test. Her PCP referred her to a rheumatologist when the ANA read a telling 1:360.

Lilly was still waiting for a specialist appointment when college graduation came around. By then, she had a solid job offer from the jewelry boutique that hired her as an intern. Her family was ecstatic. To celebrate this unanticipated success, they scheduled a surprise family vacation, with plans to drive their battered old pick-up truck south and stay with relatives in Key West.

Sadly, the trip was not the intended celebration, but it did explain her symptoms. While walking outside in the intense Florida sun, Lilly developed a raised, red rash on her nose, which sounded like the butterfly rash of lupus. Her joints hurt so much that she sidestepped the subspecialist and accepted the soonest appointment available, with a nurse practitioner (NP).

Without reviewing her history—or noting that symptoms worsened with strong sunlight (or from reflected sunlight on snowy ski slopes)—the NP prescribed tramadol for pain and sent her on her way. Her family objected and drove her back to Soho to see me. I was sorry to see Lilly in such distress, but I was happy to hear that she deferred starting a potentially habituating medication before exploring safer approaches or identifying the source of her symptoms.

Luckily, Lilly’s rural health center had ties with the regional medical school. They landed her an immediate immunology appointment at the State University in Albany, near her family’s home. The good news was that she would be near her family, and she could continue to design for her new job remotely (but without accessing expensive metals that were available onsite only). Her father was thrilled to restart selling her creations from his truck, and she was relieved to return to an existence that was far simpler and slower than Soho. She could rest up with relatives while awaiting more targeted treatment—and simultaneously brace for possibly bad diagnostic news.

This story did not have the happy ending that we hoped for, but the ending could have been worse. I shudder to think of what might have happened, or how this syndrome could have progressed, had someone summarily dismissed her symptoms as side effects to psychotropic medication, without additional assessment. Fortunately, psychiatrists are physicians first.

Psychiatrists are physicians first. This case demonstrates why that’s important.

Because the Sun Doesn’t Shine in Soho

I feared the worst when my ordinarily reliable patient did not respond to my emails. No, not the worst, since suicide is definitely the worst, and suicide was very low on my differential, given this individual’s unwavering will to live, even under the direst circumstances. Still, doctor discussion boards frequently comment about ways to cope with a patient’s suicide, so this dreaded outcome is clearly high on the radar of many psychiatrists. Earlier in the pandemic, it was not uncommon to hear my residents detail their distress from witnessing so many patients succumb in New York City, which suffered far more than its fair share of pandemic fatalities. Back in the 1980s, and even into the 1990s, I myself lost several patients—as well as medical colleagues—during the AIDS epidemic.

Perhaps there is something about epidemics and mass fatalities that either inures one to such losses or at least leads one to brace for them and prepare for them. Consultation-liaison (C-L) psychiatrists who work in hospital settings no doubt confront end-of-life issues and patient deaths on a regular basis, as do psycho-oncologists, geriatric psychiatrists, and psychiatrists who work in hospice and palliative care settings. But for me, as an outpatient psychiatrist in private practice, it is rare to follow a long-term patient through a life-threatening medical illness that required extensive treatment, but which eventually ended—not 2 weeks after the original diagnosis, as predicted by a surgeon at a general hospital—but 2 years later instead, thanks to aggressive medical interventions available at a specialty hospital known for its “Hail Mary” approaches to otherwise incurable medical conditions.

During those years, this patient shared far more of their hopes and fears, their achievements, and their aspirations than they had disclosed in the years before when they confronted psychiatric symptoms alone, without any hint of what was to come. The last appointment focused on the escalating pain that they endured during their recent hospital stay—yet this individual retained their dignity and humanity just the same.

When this punctilious patient did not confirm their biweekly appointment despite repeat emails, a veil of dread descended on me. Eventually we reconnected, and they told me of a 2-week hospitalization admission that impeded access to cellphones. Hearing of a 2-week stay in a tertiary care hospital was ominous enough, but not hearing back from the patient after their last appointment was even worse. At the patient’s request, I had forwarded contact information for 2 pastoral counselors, but did not get the expected acknowledgement from this typically gracious individual who recently asked me to pray for them—even though they knew that we practiced different religions and they were quite committed to their own religious traditions.

“Any prayers would help,” the patient importuned, undeterred by any religious differences. Those were desperate words, spoken when one senses that one’s time is coming to a close.

Even though the last appointment had not been confirmed, I phoned the patient just the same. When my patient’s phone did not answer at our usual time, I left a voice message, consoling myself that their voice message remained active, yet still wondering about the worst. Then I dialed the spouse’s phone number, knowing that it was time to reach out to the emergency contact whose name had been listed several years before. That phone answered immediately. I introduced myself, and the spouse acknowledged me just as immediately. They addressed me by name, as if they were expecting my call. Without delay, they delivered the worst news—news that I was expecting, yet dreading to hear.

After wiping my tears, stifling my spontaneous sobs, and hearing the unrestrained sobs of the spouse, we spoke for a while, using the time that I had set aside for my now deceased patient’s appointment and knowing that they and I would never have another appointment.

My initial inclination, after ending that call, was to say Kaddish, the Jewish prayer for the dead, but I stopped myself—but not because the patient was not Jewish. The patient had, after all, beseeched me to add a prayer for the sick at the Saturday morning Sabbath service at the synagogue, although they themselves followed a very different faith. It was not a matter of religion that stopped me. My second thought was about boundary-breaking, which itself is close to a cardinal sin in psychiatry.

It is always difficult to draw the fine line between compassion and caring and overreaching in clinical care—but exceptional circumstances permit more wiggle room than is ordinarily accorded. I considered consulting the American Psychiatric Association’s (APA’s) committee on Religion and Spirituality. It crossed my mind to call my rabbi to ask for advice—until I remembered that one says Kaddish for 7 people only: a spouse, a son or daughter, a sister or brother, or a mother or father. (Those gender-specific rules were devised long before nonbinary identities came into being.) Some people say Kaddish for those who perished in the Shoah/Holocaust without leaving survivors.

In orthodoxy, only men say Kaddish, and female mourners are expected to find a male to pray on their behalf. This tradition is so ingrained that some 19th-century Yiddish authors, writing in first person, refer to their son as “my Kaddish”—and do not allude to “my son, the doctor,” like the more Americanized stereotypes. For having a son—rather than a daughter—ensured that a parent’s memory would live on forever when the son recited this prayer for the dead.

Gender roles, sexism, and religious regulations aside, there were other valid reasons for my hesitation. If people said Kaddish for anyone and everyone who passed, the world would be in a constant state of mourning, and that is not the goal of most religions (except perhaps world-renouncing religions that aspire to such sad states). But there was another, equally important reason it was not appropriate to me to say Kaddish for this patient—or for any other patient. Even though this patient’s passing caused me such pain, my saying Kaddish would imply that I felt the same degree of grief as the bereaved spouse, and that presumption would disrespect the spouse’s distress. Having never been widowed, I could barely imagine how painful it must be to lose one’s spouse, especially one so young.

And so, I answered my own question without consulting a rabbi or a committee on religion: No, it is not appropriate for psychiatrists to say Kaddish for their patients. I cannot speak about mourning practices in different traditions—and I am well aware that there are many, many varieties of Jewish practice and belief as well—but I felt relieved to realize that the rules of my own religion provided useful boundaries that went beyond the clinical practice of psychiatry. To channel my distress, I drafted this article instead, expecting that other psychiatrists have encountered similar dilemmas themselves, and perhaps this piece will help them put their own situations in perspective.

Can religion provide boundaries that extend beyond those of clinical psychiatry? 

Should a Psychiatrist Say Kaddish for Her Patient?

When English journalist and blogger Katie Mills asked me about gardening and its benefits for mental health, she reignited my interest in William Wordsworth. How fitting is that?

Wordsworth was an English-born poet, born in the countryside of Cockermouth. His mother died when he was almost 8 years old, and his father passed away 5 years later. After which, young William was sent to live with relatives.

 The year 2020 marked the 250th anniversary of Wordsworth’s birth. But as we reread his poems and rejoice in his ideas today, he is metaphorically reborn again and again. Some of those ideas are related to his recovery from depression, and other ideas can be considered deterrents of future depression.

Wordsworth’s impact extended far beyond the British Isles and well past the 19th century, for he birthed the romantic movement that spread across continents. He remains one of our most revered poets, with his 24-line “Daffodils” being the most-read poem in the English language.

 between Wordsworth’s poems, depression, and seasonal affective disorder and specifically about the beloved “

,” which opens with the words, “I wandered lonely as a cloud.”

 This implies that his seasonal affective disorder was dissipating—or possibly that a hypomanic state was developing—or that he simply exhibited spontaneous poetic impulses, which are sometimes called the “madness of the muses.”

Although seasonal affective disorder is not at the forefront of our thoughts, given that the darkest days of autumn are behind us, it is worth revisiting other ways that Wordsworth offset unwanted negative thoughts that pop up in almost all of us from time to time, and not only in autumn. Repeating Wordsworth’s words, which are excerpted from Mills’ blog

 and appear below (and on countless placards in Pinterest posts), may offer some solutions.

On the surface, these phrases sound similar enough to other examples of Wordsworth’s romanticism, where he extols the spiritual forces of nature and invokes its “natural supernaturalism,” to use literary critic M.H. Abrams’ terminology.

 It is easy to be smitten by these sentences for their poetic value alone. However, if we take a less ethereal approach to these lines and treat these passages as metaphors for psychiatric lingo, we can view this stanza as a prelude to cognitive behavioral therapy (CBT), which teaches us ways to change our thoughts and challenge spontaneous “cognitive distortions” that cause distress.

Per Wordsworth, and per CBT theories, we can indeed choose the way we think and thereby change our moods. In contrast to the determinist psychoanalytic stances that preceded redaction of reigning theories and invention of CBT by Aaron Beck, MD, we can rephrase reflexive reactions and replace maladaptive ideas—and thereby alter our attitudes and the emotions that follow. Per Beck, it is within our power to reverse the ways that we react to the world, to ourselves, and to others. In turn, that attitudinal about-face influences the way others react to us, and a positive chain reaction ensues.

Through our own volition, we can prune and pluck bad thoughts—those cognitive distortions that are akin to unwelcome weeds—while watering and nourishing better thoughts so that alternative thoughts blossom into fragrant flowers. Those flowers, in time, will drop their own seeds, setting off incessant cycles of flowers, flowers, and more flowers. We need not wait to “nip it in the bud,” as the expression goes, for flowers that we plant from seed can thrive and survive, with a little effort on our parts, rather than being overtaken by pernicious weeds.

By substituting clinical terms, such as cognitive distortions, for Wordsworth’s more literary rendition, we can retain the essence of both CBT theory and Wordsworth’s insights. Like growing flower gardens from seed, learning CBT skills takes time and effort—but not too much time and not too much effort. Although the end effects of sowing seeds or learning CBT are admittedly not instantaneous, the results that arrive the next season promise to repay our diligence many times over. We ourselves can plant seeds of happier and healthier thoughts that are akin to Wordsworth’s flowers, which appear after sowing seeds in early spring, watering the soil when needed, and following a few more simple steps.

It is worth remembering that wildflowers also spring from the soil spontaneously, without any human effort at all. The beauty of those wildflowers can overshadow unwanted and unplanted weeds—as long as we uproot those pesky, persistent weeds before they spread and strip the soil of nutrients needed for flowers to survive. Weeds can grow tall, block the sun, and absorb the rains to overpower our precious and more precarious flowers. Similarly, bad thoughts can eclipse good thoughts if we do not intervene. In other words, if we “weed” those bad thoughts from our brains by using CBT and other techniques, we can enjoy the equivalent of fragrant flowers in our minds.

To simplify matters, and to incorporate Wordsworth’s metaphors, we can sort our spontaneous thoughts into “weeds” and “wildflowers.” Whenever a bad automatic thought—also known as a “cognitive distortion”—pops into consciousness, we can remind ourselves that it is a “weed” and dismiss the idea immediately by categorizing it as such and arguing against it. “Jumping to conclusions,” “all-or-nothing thinking,” “expecting the worst,” “ignoring the evidence,” “catastrophizing,” “magnifying,” and “minimizing” are all weeds that we can uproot to make way for our favorite “wildflowers.” This is a far less unpleasant approach than the “aversive conditioning” advocated by certain behaviorists, who recommend wearing a tight rubber band around one’s wrist and snapping it against the skin when unwanted impulses or ideas occur.

My simple approach might not appear in Beck’s standardized CBT training manuals, and it is probably too simple to merit a grant that lets us test it experimentally to confirm its validity via “evidence-based medicine.” But it is easy enough to use on ourselves and test informally. My anecdotal data to date confirm that this technique is a useful warm-up for more time-consuming and standardized CBT techniques—and sometimes it is sufficient in itself.

We can just as easily compare this approach to time-tested “creative visualization” strategies used to treat people with posttraumatic stress disorder who suffer from spontaneous flashbacks of adverse experiences. Some sports coaches also use variants of creative visualization to encourage their charges to achieve more. In creative visualization, we substitute pretty and pleasant mental images for their annoying and anxiety-inducing antecedents. What can better offset automatic images of strangulating weeds than invoked visions of fragrant flowers, as seen in the mind’s eye?

Wordsworth had the right idea, even if current clinical terms were not part of everyday parlance when he wrote. And that is probably for the best because we might not have been graced with Wordsworth’s verses had effective clinical care been available in the early 19th century. Please forgive me that I feel compelled to end this article with a nod to Freud, who admitted that “Everywhere I go, I find a poet has been there before me.”

1. Wordsworth’s years of happiness and heartache. National Trust. Accessed January 10, 2022. 

https://www.nationaltrust.org.uk/wordsworth-house-and-garden/features/wordsworths-years-of-happiness-and-heartache

2. Packer S. Wordsworth’s wisdom during troubled times. 

. March 27, 2020. Accessed March 7, 2022. 

https://www.psychiatrictimes.com/view/wordsworths-wisdom-during-troubled-times-0

3. Packer S. Daffodils as antidepressants (what Wordsworth knew). 

. April 16, 2014. Accessed March 7, 2022. 

https://www.psychiatrictimes.com/view/daffodils-antidepressants-what-wordsworth-knew

4. Mills K. Gardening for physical and mental health. Poshh blog. September 24, 2021. Accessed March 7, 2022. 

https://poshh.co.uk/living/gardening-for-physical-and-mental-health/

Natural Supernaturalism: Tradition and Revolution in Romantic Literature

How have William Wordsworth's ideas about creative visualization influenced cognitive behavioral therapy in contemporary psychiatry?

Wordsworth, Wildflowers, and a Simple Prelude to Cognitive Behavioral Therapy

What gives people the courage to push on, even in the most untoward circumstances? Psychiatrist and psychoanalyst Victor Frankl, MD, PhD, broached this question in his best-selling book, 

 A survivor of Auschwitz himself and the founder of “logotherapy,” Frankl suggested that some individuals survived the devastating conditions of concentration camps because they found meaning in their work or in their relationships. According to Frankl, those who lost that sense of meaning simply shriveled up and died, even before the Nazis sent them to preordained deaths.

However, a comedian-turned-politician expressed his sentiments on the subject more cogently. The current Ukrainian president summed up his philosophy in a single yet striking paragraph. During a press conference on March 3, 2022, President Volodymyr Zelensky pronounced that “My life today is wonderful. I believe that I am needed. That’s the most important sense of life: that you are needed—that you are not just an emptiness that breathes and walks and eats something.”

Who among us would have guessed that Zelensky would be so optimistic, so appreciative, even so reflective at a time when he himself faces assassination threats, and when he literally watches his country go up in smoke—and when we, as bystanders, are inundated with footage of bombed-out buildings and images of mothers and children being murdered as they attempt to escape their war-torn homeland? Surely not me—yet his attitude started to make sense once I compared Zelensky’s reactions to Frankl’s observations, and when I reflected on the sense of mission that propelled so many medical students at a time when medicine was a “calling” rather than a “job.”

Zelensky did not aspire to find meaning in his own life, like Frankl and his entourage did. Rather, it appears that Zelensky has already identified what gives his life meaning, and it is the need to be needed and the opportunity to meet the needs of his people in any way available.

If we dig deep, we might find that many—if not most—physicians were also motivated by the need to be needed, so they acquired the ability to save lives, assuage pain, increase mobility, improve breathing, or whatever their specialty offers. Parents, in particular, are propelled by the need to be needed, and some fall into despair when their progeny no longer need them or reject the help they offer. Ex-military personnel also need to feel needed, which is why so many Americans jumped at the chance to join forces in Ukraine and to fight a just war that 

As psychiatrists, we routinely ask our depressed and demoralized patients why they will 

act on impulses to hurt themselves or take their lives, even when their desire to remain alive has waned. We rightfully feel reassured when individuals say that they will 

 commit suicide because someone “needs” them, be it family, friends, or even a pet hamster (as one patient recently informed me during her appointment).

At this point in time, so many of our colleagues are at the verge of burnout. Highly trained health care professionals have been leaving their posts in greater numbers than ever before. Is it because of the pressures of COVID-19, or is it simply a parallel to the “Great Resignation” that impacts the workforce overall? Or is it because entering data in an electronic health record; “treating the data, not the patient”; prioritizing administrative rules and regulations; and circumventing managed care restrictions—and tiptoeing around prior authorizations—preempts patient care, and so does not make doctors feel needed by the very patients they purport to help?

Let me answer my own rhetorical question: We know for a fact that the burnout epidemic began well before the COVID-19 pandemic emerged. So much has been written about burnout that I will not belabor the point. On its website, the American Medical Association (AMA) identifies many contributors to doctors’ demoralization.

 Some sources recommend “better work-life balance” to beat burnout—but is that the answer? It is fairly clear that most of the soul-sapping factors listed on AMA’s website share one trait in common: They make medical practitioners feel unneeded. It is better to identify creative ways to feel needed again and to help our colleagues stay in the fold—and that aspiration in itself is a good way to feel needed.

is assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mt Sinai, New York, NY.

Behind sandbags, Ukraine’s leader meets the media

. March 3, 2022. Accessed March 11, 2022.

. American Medical Association. Accessed March 11, 2022.

Reflections from the Russo-Ukrainian war and the importance of being needed.

“My Life Today is Wonderful. I Believe that I Am Needed.”

How fitting it is that an Englishwoman—journalist and blogger Katie Mills—reignited my interest in William Wordsworth when she queried me about gardening and how it helps mental health.

Wordsworth was an English-born poet, born in the countryside of Cockermouth. After his mother died when he was almost 8, and his father succumbed 5 years later, young William was sent to live with relatives.

 The year 2020 marked the 250th anniversary of Wordsworth’s birth—but he is metaphorically reborn again and again as we reread his poems and rejoice in his ideas. Some of those ideas revolve around his recovery from own depression, and other ideas can be seen as deterrents of future depression.

In years past, I wrote about parallels between Wordsworth’s poems, depression, and seasonal affective disorder, and specifically about the beloved “

Although seasonal affective disorder is not at the forefront of our thoughts, given that the darkest days of autumn are behind us, it is worth revisiting other ways that Wordsworth offset unwanted negative thoughts that pop up in almost all of us from time to time, and not only in autumn. Repeating Wordsworth’s words, which are excerpted from Mills’ blog,

 and which appear below (and on countless placards in Pinterest posts), may offer some solutions.

Per Wordsworth, and per CBT theories, we can indeed choose the way we think and thereby change our moods. In contrast to the determinist psychoanalytic stances that preceded Aaron Beck, MD’s redaction of reigning theories and his invention of CBT, we can rephrase reflexive reactions and replace maladaptive ideas—and thereby alter our attitudes and the emotions that follow. Per Beck, it is within our power to reverse the ways that we react to the world, to ourselves, and to others. In turn, that attitudinal about-face influences the way others react to us and a positive chain reaction ensues.

Through our own volition, we can prune and pluck bad thoughts—those “cognitive distortions” that are akin to unwelcome weeds—while watering and nourishing better thoughts, so that alternative thoughts blossom into fragrant flowers. Those flowers, in time, will drop their own seeds, setting off incessant cycles of flowers, flowers, and more flowers. We need not wait to “nip it in the bud,” as the expression goes, for flowers that we plant from seed can thrive and survive, with a little effort on our parts, rather than being overtaken by pernicious weeds.

By substituting clinical terms, such as “cognitive distortions,” for Wordsworth’s more literary rendition, we can retain the essence of both CBT theory and Wordsworth’s insights. Like growing flower gardens from seed, learning CBT skills takes time and effort—but not too much time and not too much effort. Although the end effects of sowing seeds or learning CBT are admittedly not instantaneous, the results that arrive the next season promise to repay our diligence many times over. We ourselves can plant seeds of happier and healthier thoughts that are akin to Wordsworth’s flowers, which appear after sowing seeds in early spring and watering the soil when needed and following a few more simple steps.

It is worth remembering that wildflowers also spring from the soil spontaneously, without any human effort at all. The beauty of those wildflowers can overshadow unwanted and unplanted weeds—as long as we uproot those pesky, persistent weeds before they spread and strip the soil of nutrients needed for flowers to survive. Weeds can grow tall, block the sun, and absorb the rains, to overpower our precious and more precarious flowers. Similarly, bad thoughts can eclipse good thoughts if we do not intervene. In other words, if we “weed” those bad thoughts from our brains by using CBT and other techniques, we can enjoy the equivalent of fragrant flowers in our minds.

My simple approach above might not appear in Beck’s standardized CBT training manuals, and it is probably too simple to merit a grant that lets us test it experimentally, to confirm its validity via “evidence-based medicine,” but it is easy enough to use on ourselves and test informally. My anecdotal data to date confirm that this technique is a useful warmup for more time-consuming and standardized CBT techniques—and sometimes it is sufficient in itself.

We can just as easily compare this approach to time-tested “creative visualization” strategies used to treat people with posttraumatic stress disorder (PTSD), who suffer from spontaneous flashbacks of adverse experiences. Some sports coaches also use variants of “creative visualization” to encourage their charges to achieve more. In creative visualization, we substitute pretty and pleasant mental images for their annoying and anxiety-inducing antecedents. What can better offset automatic images of strangulating weeds than invoked visions of fragrant flowers, as seen in the mind’s eye?

Wordsworth had the right idea, even if current clinical terms were not part of everyday parlance when he wrote. And that is probably for the best, because we might not have been graced with Wordsworth’s verses, had effective clinical care been available in the early 19th century. Please forgive me if I feel compelled to end this article with a nod to Freud, who admitted that “Everywhere I go, I find a poet has been there before me.”

1. Wordsworth’s years of happiness and heartache. 

Wordsworth’s wisdom during troubled times

Daffodils as antidepressants (what Wordsworth knew)

What do these have to do with CBT, creative visualization, and contemporary psychiatry?