Sharon Packer, MD

Sometimes, on a summer Sunday, I sit outside on my covered porch and contemplate my shade garden. During that time, I also think about my patients, and the lessons that my garden has taught me about them. It may sound strange to compare patients to plants—so let me explain.

Before we became physicians, and even before we started medical school, we were premeds, studying basic biology as well as botany. In Biology 101, we learned about animal habitats and which animals thrive in which habitats, and which would not survive in those same circumstances. Some settings are suitable for some creatures, whereas others are not. Polar bears, for instance, do well in the cold and the snow, whereas tropical birds and butterflies require the opposite conditions. Move those polar bears into the Amazon, and those polar bears will be no more. Many of us learned similar basic biology lessons much sooner, simply from visiting zoos.

Since most of us do not keep polar bears in our backyards, I will not belabor the point and will not pontificate about animals and ecology. Better to talk about gardens, which are more common.

In the popular imagination, gardens need sunshine, as well as good soil, and the right amount of rain, so that roses and so many other beautiful sun-loving flowers can grow. Yet I can look out on my shade garden and see many other lovely flowers which were planted or potted. To my right, are stairsteps covered with caladiums, of many different varieties. I wish I could list each species by name, but I can say with certainty that all their leaves come in a magnificent array of colors, with each leaf shaped like an elongated heart. Some are a dusty red, with green borders, and some are green with red trim. Some have green veins running though reds, whereas others are white, with green stripes, and so on. There are so many permutations to these shade flowers, and so many variations—but they share one thing—they need shade and may wither and die in full sun.

A few feet above those stair steps sits a balcony, surrounded by white fencing, some of which remains in the shade, and some of which continues into the sun. From those railings that rest above the caladiums hang scrolled wire baskets, filled with begonias. Some begonias are off-white, while others are pale pink, and yet more are coral or a deeper red that many might call vermillion. The colors and textures of the begonias play off the translucent shades of the caladiums below, although the shapes and sizes of the begonias are dramatically different from the large, elongated leaves of the caladium. But begonias and caladium have something in common: both prefer shade and cannot tolerate the sun.

While I applaud many advances in our field that help patients lead more productive and more pleasant lives, I sometimes think that we can help some even more by helping them find their own natural habitat.

If you will bear with me just a little bit more, let me mention one more garden, straight ahead of me, in full frontal view, shaded by towering pine trees that drop sticky pinecones each fall. By this time of the summer, the hostas are in full bloom, having grown wider and taller each year. They, too, come in many different hues, and many different varieties, even though each of them is some shade of green. A true horticulturist could name each and every one, but I am content to call each of them beautiful, with no need to know more for now. In the sweltering heat of summer, they sprout long stems with pale lilac flowers. In the early spring, those same rows are occupied by pink daffodils that also thrive in the shade, in contrast to their better-known cousins that demand full sun. I adore those sun-loving narcissi also, with their yellow and orange and gold trumpet-shaped crowns, and which proclaim the start of spring.

I could go on and on about each plant, shrub, and flower in my gardens, but let me explain why I am comparing plants to patients.

Patients Who Found Their Place in the Shade

As humans, we have the hubris to believe that we can change nature and impose our wills on biology (hurricanes, wildfires, and floods notwithstanding). Sometimes we can succeed at altering the course of nature, and often, we should—but not always. For sure, human-made irrigation systems made Israel’s deserts bloom, replacing sand with fruit trees to feed the population. Without surgical interventions, children born with club feet could be left with lifelong limps, unable to ambulate fully. And so on and so forth. Yes, modern medicine has worked miracles for many, often offering longer and healthier lives. But how does psychiatry fit into this picture and how does that impact psychopharmacology in particular?

While I applaud many advances in our field that help patients lead more productive and more pleasant lives, I sometimes think that we can help some even more by helping them find their own natural habitat—even if it is not an environment that is envied by others.

Let me provide 2 patient examples to dramatize this point. Let me call one “Ms A” and the other “Mr B.” Ms A was already an attorney, albeit one who hated reading and writing—and especially arguing. Yet she chose law on the advice of her parents, who dismissed her wish to become a baker, unmoved by the wonderful creations she made for friends and family. Ms A did well in grade school, high school, and college, well enough to be admitted to law school. Yet her concentration dropped as she studied legal details that held little interest for her. A local doctor diagnosed her with attention-deficit/hyperactivity disorder and started her on stimulants, despite the absence of an early history of attention problems, and apparently without inquiring about her interest in the subjects that she studied. With these pharmaceutical aids, she earned her JD, passed the bar, and was hired by a mid-sized law firm in midtown Manhattan. Although her parents were thrilled by her seeming success, (her analogue to a garden’s sunshine), she was unhappy sitting at a desk, staring at a computer screen, when she wanted to be baking.

Because she was so unhappy, she went to each happy hour after work, and soon enough developed an alcohol use disorder. She started coming in late for work when she was not calling in sick. Luckily, the bar association offered help to their members and referred her to treatment, which by this time included antidepressants as well as anti-craving medications. We also added behavioral activation to encourage her to engage in pleasurable activities (and to increase the odds of overcoming depression, as reported in 

Instead of idling away her after-work hours at local watering holes, she signed up for culinary classes. Her mood brightened enough, and her concentration cleared enough, for her to decide on her own to complete a culinary certificate and to change careers. As she put it, she preferred to “knead dough” rather than to make more dough. No longer sitting in a chair for hours on end, she could wander around a commercial kitchen at will. She decided that she no longer needed the stimulants that were prescribed to push her through an education that she disdained. In short, she found her shade garden where she could not just survive, but thrive—even if it was not the sunny rose garden that her parents recommended.

Mr B’s situation was somewhat different. Always a shy man, Mr B found solace in his college computer classes that required limited human interaction—and that also promised a bright financial future. It came as no surprise that he landed a good-paying coding job after graduation, but it was an unpleasant surprise when he became paranoid while working in a large open space rather than a confined cubicle. Soon enough, he accused coworkers of plotting against him, and engaged in enough arguments to lose the job. He never had frank auditory hallucinations—only barely audible intermittent whispers—but, in hindsight, his evolving symptoms sounded ominous. It was easy enough to find another job, given his high-level coding skills and the high demand for such skills, and it was surprisingly easy to squash those emerging psychiatric symptoms with a low dose of an atypical antipsychotic.

All might have worked well, had he not developed involuntary facial twitches from his new medication. To avert worse consequences in the future, he reluctantly agreed to stop the medication, even though it had brought him so much relief. We substituted cognitive behavioral therapy techniques instead, and watchful waiting. Then, Mr B was literally saved by the pandemic. Everyone in his office was forced to work from home. Without the untenable proximity to his coworkers, his paranoid symptoms abated, even in the absence of medication. The erratic whispers evaporated. Even his productivity improved, and his supervisor commended him. When the company owners spoke about reopening the office, we opted to request accommodation under the Americans with Disabilities Act, which would allow him to work from his family’s home. Better to work from home than to wind up in a hospital setting, should his rudimentary symptoms return and progress to a full-blown schizophrenic break, which could impair his cognition in the future and interfere with his employability. For Mr B, his home office was his shade garden, where he could survive and thrive.

Is there a moral to this story and a special message to psychiatrists? Yes, there is. These 2 cases of 

 demonstrate the interactions between humans and their environments.

I wish I could claim to have discovered the concept of human ecology, but I cannot. This term was coined many decades earlier. Although we discuss the impact of climate change on human well-being, human ecology is not a concept that we typically discuss in contemporary psychiatry, but perhaps this concept deserves consideration. The concept of human ecology traces back to Carl Linnaeus, MD, whose name we heard in those biology and botany premedical courses taken while we were 

 to becoming physicians. Linnaeus is best remembered as a taxonomist who categorized both animals and plants—but he was much more than that. Linnaeus was both a botanist and a physician who probably would have appreciated how gazing at gardens can add insights into treating patients.

is assistant clinical professor of Psychiatry and Behavioral Sciences at Icahn School of Medicine at Mt Sinai, New York, NY.

1. Park LT, Zarate CA Jr. Depression in the primary care setting. 

Articles

Different flowers need different levels of light, water, and shade. What would it mean to treat patients with a similar amount of care? 

Lessons From my Garden About Patient Care

FIRST MAN: We should defend ourselves. An eye for an eye, a tooth for a tooth.

TEVYE: Very good. And that way, the whole world will be blind and toothless.

- From 1970 script of the play “Fiddler on the Roof” and often attributed to Mohandas Gandhi

“The three ingredients for healing relational wounds are safety, truth, and reconciliation, and in that order.” - Alisha Moreland-Capuia, MD

Achieving peace in the Middle East is a monumental task that seems to be ever evasive, daunting, and out of reach. A cease fire is welcome, but a far cry from what we want to achieve—lasting Middle East peace. The violence is also spilling over into increased conflict between groups in the United States. Muslims and Jews are subject to worrisome degrees of Islamophobia and Anti-Semitism. The Palestinian-Israeli conflict is an extremely complex tangle of issues to resolve, but a solution is possible, and imperative.

Both sides and their supporters need to abandon ultimately futile and self-defeating acts of violence and retaliation. Instead, they must embrace a more comprehensive and humble vision that takes into consideration the historical, geographic, religious, and cultural context of two cousin tribes that have wounded each other over generations. It is like a longstanding family conflict in which family members stop talking to one another and replace talking with hatred, necessitating therapeutic family interventions. Despite the reservations that some psychiatrists have on entering the social conflict sphere, these are, in fact, areas of psychiatric expertise.

As psychiatrists we know group dynamics. We know our tendency to scapegoat “the other”. We know how the powerful can divide and conquer less powerful groups. We know how to analyze leaders. We know the temporary but necessary pain of revealing and processing the truth. We know from Abraham Maslow, PhD’s pyramid of psychological needs that safety and security must be fulfilled before higher levels needs can be completed. We know that often deeper levels of traumatic causation need to be processed and dealt with before healing can meaningfully occur.

This is not a naive proposal by any means, though it may seem so to some. Inevitably, many will disagree with any Middle East analysis. Rather, it is a plea for change because doing the same thing over and over again, expecting different results, is the very definition of insanity. Constantly suspecting each other’s motives has not moved this protracted struggle even an inch out of square zero. As good as prior endeavors were—that is, things could have gotten even worse—they have not been nearly enough.

There are many intricate political and psychosocial dynamics that come into play to make this mission look impossible; however, fighting parties in other parts of the world have managed, for the sake of their children, to reach some kind of compromise that benefits all involved. Children in the blessed land should not continue to pay the price of our ignorance, false pride, and generational bigotry.

As Muslim, Jewish, Christian, Hindu, and Sikh psychiatrists, in a bio-psycho-social-spiritual model we sense this is a moral and spiritual crisis. We support peace among nations, safe and secure homelands, and opportunities for all. This is not at its essence a fight between Muslims and Jews, or between Arabs and Israelis. This is an ideological and practical war that often intentionally feeds cultish misinformation, especially via the internet, which artificially arouses emotions, leading to relieving emotional tension by ever-increasing violence. Peace-loving civilians lose their lives, while extremist groups and fear mongers run rampant.

Unfortunately, the media usually chooses to focus on the negative events occurring in the Palestinian-Israeli conflict, and ignores equally dispiriting, yet equally important, inter-ethnic tragedies taking place in places like Kashmir, Myanmar, China, Syria, Yemen, Iraq, and elsewhere around the globe. This disproportionate attention to one particular locale in the Middle East only enflames matters more. It leads the public to believe that this is a unique situation, when it is a tendency of human nature that needs to be overcome everywhere. Despite our paradoxically doing so in this paper, we include other examples and intend to address them more in the future.

Perhaps we can learn and apply a few lessons from countries like South Africa, Rwanda, and Bosnia, where warring tribes have seemingly learned to live together. The Truth and Reconciliation Commission was especially effective in helping to bring South Africa out of apartheid without a bloodbath. 

Big problems get resolved only when broken down into small pieces. The use of dialogue can—and should—start in our households, small intra- and inter-faith circles, and cultural communities. A group of international and interfaith psychiatric caregivers have come together to create a community of care and have produced two requested, well-reviewed books that can be used as tools towards healing: 

From these sources, here are some ideal prescriptions to start with:

- Dignity for all, established by working together respectfully for a common end

- Humiliation for none, which means hearing each other out

- Apologies by all, as saying “I’m sorry” and meaning it begins the healing of many wounds

- Gifts to the others, such as sharing assets and promoting each other’s strengths

- Neutral peace-maker(s), or the calling in of trusted third parties, which may ideally need to include mental health experts

- Teaching tolerance to children, both by parents and educators

- Addressing intergenerational trauma, which includes that affecting political decision-makers

Also, as psychiatrists, we know very well that an illness cannot be cured unless we address its root causes, and similarly we have the moral obligation to call for the immediate dismantling of bigoted and violent ideologies, dictatorships, and all structures and systems that support them. They are so damaging to the body, mind, heart, soul, and spirit of so many of the people.

These are simple, though not simplistic, aspirational goals. They are meant as an antidote to the common lament about how complex these situations are, so often leading to excuses about what cannot be done and what cannot be tried. Prayer and mourning must be supplemented with action.

We need a few small steps in addition to this manifesto. Some that could be taken by SPIRIT and like-minded groups include: joint business projects, a student exchange, common textbooks (especially in the early grades), shared vacation spots, media consultation, and joint research. We must look towards innovative and out-of-the-box solutions.

Members of SPIRIT are available for consultation and discussion. We welcome other like- hearted psychiatrists of any religious background, as well as those who are agnostic or atheist, to join our SPIRIT.

is practicing psychiatrist in Providence Healthcare System, Portland, OR. He has provided psychiatric and humanistic care to trauma survivors around the world.

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. He has recently been leading Tikkun Olam advocacy movements on climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

is Clinical Professor and Chair of Psychiatry and Behavioral Science at the University of North Dakota School of Medicine and Health Sciences.

is an associate professor of psychiatry at Harvard Medical School and a Fellowship Site Director for Brigham and Women's Hospital.

is Professor Emerita, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.

is a Professor of Psychiatry at Cooper Medical School of Rowan University. He is active in several national and regional organizations and published and presented on International Medical graduates, culture, religion, family psychiatry, gender issues, etc.

serves as Assistant Dean of Clinical Education at Charles R. Drew University and Chief Medical Officer of Kedren Health Systems Inc.

is Medical Director of Child and Adolescent Psychiatry Clinic and Multidisciplinary Autism Program at ChristianaCare, Delaware.

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

is a psychiatrist, the author of more than 300 peer reviewed papers, founder of Critica, and board member of the Social venture Fund for Arab Jewish Equality in Israel.

is Professor Emeritus in Psychiatry at the University of California at San Diego, as well as the author of more than 100 professional articles and 6 books.

interested in exploring the intersection between childhood political trauma with immigration stress. She has been recently offered a full-time research appointment as a Visiting Researcher at Harvard University, in Cambridge, Boston.

is a doctor working in frontline psychiatry for the National Health Service at South London and Maudsley NHS Foundation Trust in the UK.

is a Clinical Associate Professor of psychiatry at the Stanford University School of Medicine where she is the Director of the Stanford Muslim Mental Health & Islamic Psychology Lab, and the Director of its community organization: Maristan.org. She also serves as the Associate Division Chief for Public Mental Health and Population Sciences as well as the Section Chief of Diversity and Cultural Mental Health in the Department of Psychiatry and Stanford.

1. Moffic HS, Peteet J, Hankir A, Awaad R. 

Islamophobia and Psychiatry: Recognition, Prevention, and Treatment

https://www.springer.com/gp/book/9783030005115

2. Moffic HS, Peteet J, Hankir A, Seeman, M. 

Anti-Semitism and Psychiatry: Recognition, Prevention, and Interventions

https://www.springer.com/gp/book/9783030377441

A cease fire is welcome, but a far cry from what we want to achieve—lasting Middle East peace.

An Interfaith Psychiatrist Prescription for Middle East Peace

 (COVID-19) crisis continues, we hear more and more about the current—and projected—mental health fallout from illness, lockdown, job loss, forced relocation, loneliness, loss of friends and family, and death. Data about the direct neuropsychiatric sequelae of COVID-19 infection in addition to the indirect social or economic consequences are also mounting. Yet we do not hear about individuals with social anxiety disorder, or individuals on the high end of autism spectrum disorder (ASD), who are also socially anxious and relieved to be working from home.

Free from the social pressures of the job site, many of these individuals report feeling less distress overall. They are not necessarily free from anxiety altogether; their anxiety focuses on fears of being forced to return to offices when the epidemic ends. They are perturbed by the prospect of sacrificing the social obligation-free sanctuary that they have serendipitously and unexpectedly enjoyed during this strange time.

 taken of a group of workers; it found 80% wanted to continue to work remotely at least part of the time after the pandemic. Individuals with social anxiety disorder presumably comprise some small part of the 80%, yet it is unlikely that all 80% of the WSJ sample want to work remotely for the same reasons as the patients I am discussing. The article, “Is a Home Office Actually More Productive? Some Workers Think So,” detailed the motivations of generic employees, focusing on financial and family drivers of their choice of workplace, but does not break down data by personality type or DSM diagnosis.

Before commenting on experiences relayed to me by the aforementioned subgroup of my patients, let us first look at the better publicized psychiatric fallout from the COVID-19 crisis. Centers for Disease Control and Prevention (CDC) 

 from late June 2020 state that 40% of the American population were facing COVID-related depression, anxiety, stress-related disorders, or substance use.

high-risk groups, noting that financial stressors, including epidemic-related job loss, along with limited savings to cushion the blow, increased an individual’s risk for mental health sequelae.

 about increasing drug and alcohol use are equally grim from a medical and mental health point of view, given that liquor sales skyrocketed during lockdown, as per several articles in the WSJ.

 Anonymous liquor store owners have said that demands for their stock during the epidemic rivals sales seen only during weeks between Christmas and New Year’s.

We can estimate the long-term mental and medical impact of alcohol overuse, even though many medical consequences of alcohol overuse do not surface for 20 years. The potentially lethal cardiovascular, oncological, as well as gastrointestinal consequences are not as obvious or immediate as motor vehicle accident-related deaths or fatal subdural bleeds from slip-and-fall accidents that occur while intoxicated. Yet those later sequelae are just as deadly in the long run, so much so that 

 is twice that of the better-publicized opioid-related mortality,with alcohol claiming over 95,000 lives per year,

 compared with 46,800 annual opioid overdoses.

Opiate overdoses have already exploded. If we extrapolate from data related to September 11, 2001, when 

 in Manhattan remained high long after posttraumatic stress disorder symptoms subsided,

 we can anticipate (but not guarantee) similar consequences from this epidemic.

Alarmist claims about projected increases in suicide hit the press, having borrowed data from CDC websites and embellished it with artistic license not appropriate to scientific studies. Some of the most ominous predictions have been refuted; after reading the fine print, we can see that these highly publicized numbers about suicide pertain to individuals who were contemplating suicide rather than to completed suicides. In response to those data, some British medical journals 

 readers that “supposition, however, is no replacement for evidence,” and that “the literature on the effect of COVID-19 on suicide should be interpreted with caution.”

Although reports of increased suicidal ideation since the start of the COVID-19 crisis were striking enough to enter the CDC logs, we must recall that suicidal ideation is not the same as attempted suicide, and that attempted suicide is not identical to completed suicide.

In addition, a New York City Health Department 

 “Mental Health in New York City: Impact of COVID-19 on Mental Health in New York City,” published in September 2020 and emailed widely in January 2021, offered even more 

 It dissected the data, breaking it down by race and ethnicity, and ferreted even more risk factors for anxiety and depression. It focused on the greater New York area, where most of my patients reside. Similar to the 

data, the 3 top drivers of psychological distress included “feeling cut off or distant from people,” “job loss or reduced hours,” and “overwhelming or above-average financial stress.” Interestingly, many individuals on the spectrum specifically prefer to be “distant from people,” although individuals with pure social anxiety disorder often lament their limitations in partaking in such social activities.

What do these data tell us about the socially phobic individuals who report less stress during the lockdown, but experience more stress when contemplating the possibility of a return to onsite work? Let me point out that although the data showed that 40% of the American population endorsed symptoms of depression, anxiety, or trauma during the shelter-in-place mandates and work-from-home policies, this is not the same as saying that 100% of the population is suffering similarly.

My clinical experience indicates that some individuals are benefiting from limits on social interactions; they prefer the work-at-home policies and appreciate convenient excuses to avoid after-work get-togethers and sit-down holiday dinners.

Admittedly, I cannot offer elegant statistics to rival numbers garnered from formal population-based quantitative studies. All I can share are anecdotal reports gleaned from my large private psychiatric practice, originally based in New York City, but now relocated offsite to upstate New York. Yet those anecdotal reports are impressive. Gainfully employed but socially phobic patients and those on the high end of the autism spectrum (who also tend to be debilitated by social anxiety) are doing better than baseline now that they are freed from the pressures of office politics, enforced personal interactions, and water cooler–style conversations.

In many instances, such individuals experienced an unexpected sense of relief, as well as a sense of accomplishment, after seeing that they could meet their work responsibilities even better without expending extra mental energy ruminating about social interactions, wondering if they said the right thing, and worrying about being forced to speak up in meetings. Having witnessed how much easier their lives can be without the usual social stresses, they identify a different source of anxiety: fear of forced return to the workplace.

Before proceeding, I must point out that the patients to whom I refer are actively and gainfully employed—and so they do not fall into the high-risk categories identified by the 

article. They did not experience the stressors, such as job loss or lack of savings, that predispose individuals to COVID-19–related psychological distress. Because they were working before the pandemic, they likely accrued savings that further buffer them from the financial stressors listed in the 

Recall that socially phobic individuals are unlikely to speak out for themselves. For them, confrontations with their boss or coworkers are even worse than water-cooler conversations.

And that is where we as psychiatrists can help. Selective serotonin reuptake inhibitors (SSRIs) and supportive therapy go only so far in ameliorating their symptoms and relieving their distress. Advocating for changing their external environment—while we change their internal environment through psychotropic medications and psychotherapy—can offer them so much more relief.

 accommodations that may allow them to continue to work from home even after the epidemic ends (with some caveats). Familiarizing ourselves with the Department of Labor website (

) will enable us to educate our patients and to direct them to standardized sources without offering legal advice that exceeds our clinical training or purview.

At a time when so many psychiatrists are concerned with climate change and its impact on mental health, should we not also concern ourselves with adapting workplaces to meet the needs of our patients? We can advocate for change, simply by following the laws that are already in place for such purposes.

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

1. Stamm S. Is a home office actually more productive? Some workers think so. 

https://www.wsj.com/articles/is-a-home-office-actually-more-productive-some-workers-think-so-11609563632

2. Centers for Disease Control and Prevention. Coronavirus disease 2019. Accessed February 10, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/index.html

3. Ettman CK, Abdalla SM, Cohen GH, et al. Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic. 

4. Chaudhuri S. Coronavirus closed the bars. America stocked the liquor cabinet. 

https://www.wsj.com/articles/coronavirus-closed-the-bars-america-stocked-the-liquor-cabinet-11586511001

5. Jakab S. The WHO are a bunch of party poopers. 

https://www.wsj.com/articles/the-who-are-a-bunch-of-party-poopers-11587046692

6. Chaudhuri S. Online beer sales soar at brewers of Budweiser, Miller Lite. 

https://www.wsj.com/articles/online-beer-sales-drinking-at-home-boosts-budweiser-brewer-11603968729

7. Centers for Disease Control and Prevention. Deaths from excessive alcohol use in the US. Accessed February 15, 2021. 

https://www.cdc.gov/ALCOHOL/FEATURES/EXCESSIVE-ALCOHOL-DEATHS.HTML

8. Centers for Disease Control and Prevention. Drug overdose deaths. Accessed February 15, 2021. 

https://www.cdc.gov/drugoverdose/data/statedeaths.html

9.Packer S. Tele-teatime during the quarantine. 

https://www.psychiatrictimes.com/view/tele-teatime-during-quarantine

Trends in suicide during the covid-19 pandemic

. 2020;371:m4352. doi:10.1136/bmj.m4352.

11. New York City. Mental health in New York City: Impact of COVID-19 on mental health in New York City. September 2020. 

https://www1.nyc.gov/assets/doh/downloads/pdf/covid/covid-19-mental-health-impacts-hop.pdf

Patients who are report social phobia are unlikely to speak out for themselves. For them, confrontations with their boss or coworkers are even worse than water-cooler conversations. That is where psychiatrists can help.





The Other Side of the COVID-19 Crisis: The Silent, Socially Phobic Minority 

There is always something to celebrate, even in the worst of times. In December 2020, we celebrated the 100th anniversary of the first staged production of 

” Originally written around 1914, and adapted from Eastern-European Jewish folklore, “The Dybbuk” made history in Yiddish theater. The story sheds light on the histories of the mind sciences and neurosciences, which were on fast-forward in the early decades of the 20th century, as Ansky was perfecting his play.

“The Dybbuk” has lived on in many other incarnations since its stage premiere, appearing in film, opera, ballet, and even puppetry.

 In the United States, George Gershwin was commissioned to adapt “The Dybbuk” for the Metropolitan Opera, but could not secure rights, (so he created his equally immortal “Porgy & Bess” instead).

 Ansky based his play on folktales about miracle-working 

. Apart from its entertainment value, it highlights the vast differences between folkloric versus scientific (or pseudo-scientific) explanations for behavior changes and it can aid our understanding of non-science-based attitudes toward neuropsychiatry to this day.

Let me explain the story behind “The Dybbuk,” which was originally entitled “Between Two Worlds

” The play was created by a man who himself lived between 2 worlds, if not more. Shloyme Zanvl Rappoport, better known by his pen name S. Ansky, was born into a pious but impoverished Jewish family in Russia’s Pale of Settlement, but he was born with a wandering soul that sent him in search of worldly experiences. He left his insular home in the 

 after receiving a limited religious education, but he became self-taught enough to work as a tutor. At one point, he became infatuated with the socialist movements that were sweeping Russia, and he went to work among coal and salt miners, who epitomized his downtrodden Russian compatriots. He shared his revolutionary writings with his co-workers and published extensively—but did not live to see the 1920 staging of his immortal play.

Before his death in 1920, Ansky lived even more lives. He was expelled from Russia for his revolutionary activities and moved to Paris, where he attended literary salons that were far afield from his insular upbringing. Although he had previously published political polemics and revolutionary poems, the fiction for which he is most remembered took off in earnest after a philanthropist subsidized an ethnographic expedition. Ansky collected folktales, songs, and artifacts from simple and often superstitious small-town 

 Jews, whose way of life was in danger of extinction as modernity crept into Russia. While traveling about the poverty-ridden Pale, where Jews were confined, he came upon the story of the Dybbuk.

dwelling friends meet as their wives are awaiting childbirth. The men vow that their unborn son and daughter will marry one another someday. They disregard a mysterious stranger’s ominous—yet eerily accurate—warnings against vows made for the unborn. Indeed, the wife of the first man dies while giving birth to a daughter, Leah, while the other man drowns in a storm just as his wife gives birth to a son, Chanon. The children grow up, neither knowing of their fathers’ promises and neither knowing of the other. In the interim, the surviving father grows wealthy, and seeks a more prosperous husband for his daughter, in spite of his long-forgotten vow. The surviving son of the deceased man returns to town as a penniless yeshiva scholar. His religious and scholarly pursuits are respectable enough to earn him an invitation to the wealthy man’s table, yet his financial limitations cannot satisfy the young woman’s father. 

As fate would have it, young Leah and the destitute yeshiva scholar Chanon meet, and they feel an instantaneous attraction for one another, as if their shared destiny had been decreed by an unshakable unearthly force. Despite Leah’s father’s objections, Chanon still hopes to marry Leah, even though Leah’s father already announced her betrothal to a more prosperous potential mate.

Hoping to offset these nuptial plans, the crushed Chanon immerses himself in the study of forbidden mystical Kabbalistic texts, which are off-limits to unmarried men under 40, lest they suffer psychosis, or even suicide, as happened to unprepared Kaballah students many centuries earlier. The sages’ warnings about the risk of Kaballah study prove true, and Chanon dies (possibly by suicide) after his Kabbalistic rites fail to thwart Leah’s prearranged marriage.

The wedding between Leah and the rich man’s son almost proceeds as planned—until Leah is inhabited by a disembodied 

, or the clinging spirit, of her deceased lover Chanon. Possessed by Chanon’s wandering soul, which cannot enter paradise, Leah suddenly speaks in a deep, gruff voice as she stands at the 

Her behavior is outlandish and inexplicable—until a specially qualified rabbi is called in to consult. After explaining the circumstances, the rabbi exorcises the 

 from the young woman’s body. Even though the rabbi successfully extracts Chanon’s 

 Leah is so enervated by the ordeal that she faints and falls dead. Upon her death, Chanon’s spirit reunites with Leah’s, and the lovers are together in the hereafter, in true Russian Romantic era style. Leah’s father, who failed to honor his vow to his friend, is now bereft of his daughter. Inconsolable, he agrees to the penance prescribed by the rabbi-exorcist and shares half his wealth with less fortunate individuals. 

This play premiered in 1920, when important developments in psychiatry, psychoanalysis, experimental psychology, and neuropsychiatry were percolating. At the turn of the century, Sigmund Freud, MD, had promised to override superstition, and to supplant popular supernatural theories with his scientific study of dreams, and much more.

 Psychodynamic explanations for Leah’s bizarre behavior seemed world’s away from the occultist exegesis of “The Dybbuk

In fact, there are real parallels between Freud and the play, especially when one compares Freud’s theories to other psychological theories of the day. Freud’s star was rising as Ansky was perfecting his story, even if his star does not shine so brightly today. In 1918, Freud participated in a different kind of drama: he testified at the trial of Julius Wagner-Jauregg, MD, held after the Great War. Freud’s testimony impressed the audience because he acknowledged the suffering of shell-shocked soldiers and did not dismiss their physical or psychological disabilities, even if a demonstrable medical cause could not be found for their deafness, paralysis, or muteness.

Freud was calling the Kaufmannization techniques employed by the illustrious psychiatrist Wagner-Jauregg and several other military psychiatrists into question. The Austrian doctors stood accused of torturing suffering soldiers by subjecting them to painful electric shocks (not electroconvulsive therapy), to goad them into foregoing their allegedly “feigned” symptoms and returning to the front.

Although Wagner-Jauregg was not the only psychiatrist who stood trial, his name was attached to the highly publicized trial because of his renown (he went on to win a Nobel Prize in 1927). Inviting Freud to function as an expert witness, in turn, allowed the one-time neurologist turned psychoanalyst to showcase his new talking cure and the abreaction that occurred when distressed patients verbalized their conflicts and apparently purged the psychological equivalent of clinging spirits that were responsible for hysterical symptoms that had no demonstrable biological basis.

There are clear-cut parallels between Freud’s newfound talking cure and the expulsion of the dybbuk (or demons, as the case may be), and the disinhibited vocalizations made by the dybbuk, even though the supernatural explanations of thefolk healer were worlds away from Freud’s psychological explanations. Although the credibility of many Freudian case reports has been challenged, as have his claims of cures, Freud alleged that he could relieve (mostly female) patients of their hysterical symptoms through free associations. Curiously, like Freud’s hysterical patients, dybbuk possession most commonly afflicted women, who did not have a legitimate “voice” to express themselves during daily life.

Yet even those “innovative” ideas were not so novel. A millennium before Freud formulated his theories, tales of demons and dybbuk-like creatures abounded, both in Jewish lore and in the Gospel stories, which were composed in the first century CE, when the Second Temple still stood in Jerusalem. The dramatic New Testament story of the exorcism of the Gerasene demoniac, also known as Legion, inspired many artistic depictions over the centuries, including an iconic scene in 

 where the demon is expelled from Linda Blair’s mouth.

Another influential mind science researcher of the same era—the behaviorist John B Watson, PhD—also lost stature over the decades, perhaps even more than Freud, albeit for different reasons. Watson’s conclusions about behavioral conditioning have not been disproven and were published in book form in 1920, in the same year as the premier of “The Dybbuk.” Yet the methodology that Watson used to test his theories is totally unacceptable, if not downright horrifying, today.

To demonstrate the far-reaching effects of behavioral conditioning, Watson used a human child subject, “Little Albert.” Besides the fact that the toddler could not provide informed consent as we know it today, the boy suffered permanent psychological damage (and by some reports, was already neurologically compromised). His fear response, which was originally conditioned to a white mouse, generalized to other white furry objects, including Santa Claus’ beard. Albert reportedly remained a fearful child in the aftermath of superficially successful psychological experiments, even though he had no conscious awareness of the source of his distress because behavioral conditioning bypasses higher cognitive processes and produces reflexive reactions.

In both Watson’s experiments, and in Ansky’s story, innocent children suffer for the sins of their fathers—or their father figures, as in Watson’s case, in true Old Testament fashion. Yet the past experiences that haunt Leah and Chanon are unrelated to their own memories and are solely the result of their fathers' forsaken vows, which existed, at best, as buried memories from the distant past. Perhaps a die-hard Jungian could claim that Jung’s hypothetical inheritable “racial unconscious” transmitted the father’s repressed memories to his ill-fated progeny. However, that highly contested Jungian concept is one of the many reasons why Jungian ideas carry more cache among occultists and folklorists than among neuroscientists and most contemporary psychiatrists. Still, it is curious that Ansky wrote “The Dybbuk” soon after Jung published his controversial theories of the unconscious. While we have no reason to believe that Ansky was directly influenced by Jungian ideas—and we have every reason to believe that Ansky based his ideas about “The Dybbuk” on Eastern European Jewish folklore encountered during his ethnographic expedition—we can see how these recurring mythological motifs given credibility to concepts expressed in the 1909 writings of psychoanalyst Otto Rank

So, what is left? So much of yesterday’s science becomes tomorrow’s superstition, and the scientific scruples of one generation may be repugnant to later generations, as seen in the Wagner-Jauregg trials and in Watson’s Little Albert experiments. Yet “The Dybbuk” story endures and provides testimony to the natural inclinations of the human imagination, unbridled by science or psychology. And, as atavistic as the play’s premise sounds to psychiatrists, we cannot forget that 42% of Americans believe that “people on this earth are sometimes possessed by the Devil,” as per a 2005 Gallop poll quoted in a 2014 

 Apparently, it is not accidental that dybbuk

like tales resurface for new generations.

Take “The Exorcist,” for example. “The Dybbuk” does not enjoy the name recognition of “The Exorcist” although the play and movie share superficial similarities. Both invoke the paranormal and play upon psychiatric themes. “The Exorcist,” William Friedkin’s 1973 film, based on William Peter Blatty’s best-selling 1971 novel by the same name, is among the most recognized films of all time. “The Dybbuk,” on the other hand, is among the most recognized Yiddish stage productions of all time, which attracted much smaller audiences than American movies. 

In “The Dybbuk” the rabbi functions as an exorcist of sorts and was modeled after a real life 

 who was reputed to possess such powers. He successfully expels occupying spirits that induce behavior changes in living individuals. He is a folk healer, and could conceivably be called a “baal shem

” but neither he nor his followers compare the rabbi-exorcist to a medical doctor, much less to a psychiatrist. Medical anthropologists rightfully draw parallels between shamans and Jewish “baali shem” (plural of baal shem), who employed prayers, invocations, magic words, amulets, and unidentified herbals native to the area. (The famed Baal Shem Tov who started the Chasidism movement within Judaism was just 1 of many such baali shem who worked as herbal and spiritual healers.)

There are significant points of departure between “The Exorcist” and “The Dybbuk

” Most obviously, “The Exorcist”revolves around Roman Catholic rites, whereas “The Dybbuk” is undeniably Jewish, even though its author originally wrote his story in Russian before translating it into Yiddish. Equally importantly, the priest-psychiatrist in “The Exorcist”is pivotal to the plot. “The Exorcist” includes a comprehensive and impressively accurate neuropsychiatric work-up for the troubled Regan, who was suspected of having a seizure disorder or even attention-deficit/hyperactivity disorder (which was then called minimal brain dysfunction). “The Dybbuk” does not feature any psychiatrist at all and does not attempt a psychiatric (much less a neurological) differential diagnosis. It does not even hint at the existence of psychiatrists, even though psychiatry was gaining greater recognition (and notoriety) in Central Europe when Ansky’s play premiered and even though the 1920 release of the enduring German Expressionist masterpiece about a charlatan psychiatrist, 

, testifies to the growing significance of psychiatry in the West.

The story of “The Dybbuk” and the purging of clinging spirits will undoubtedly remain a tale, told in some form or another, that lives on both in fiction and science. 

Dybbuks and Jewish Women in Social History, Mysticism and Folklore

The Myth of the Birth of the Hero: A Psychological Exploration of Myth

7. Harris J. Exorcism: the miracles of St. Ignatius of Loyola: Peter Paul Rubens

Cinema's Sinister Psychiatrists: From Caligari to Hannibal

High (and low) points in the history of mind sciences can be explored through folklore. 

Demons, Dybbuks, and Other Psychic Maladies 

When the email from “Sam” arrived asking about adding a natural weight loss product to his more mainstream prescription medications, I was not surprised. Binge eating was his bête noire. A onetime college athlete who lost his scholarship because of an ankle injury, he had since sat around eating while watching sports on TV and lamenting his lost career. He desperately wanted to shed unwanted weight, but treatments that control bingeing do not guarantee weight loss. He had tried 

 with no success. So, when he heard about a new natural weight loss concoction, he was understandably excited yet skeptical because he knew of the government’s crackdown on hoodia.

Sam forwarded me a laundry list of ingredients without hoodia but with 

 (Pausinystalia yohimbe). Years had passed since I had seen that word in print.

“Was it safe?” was all he wanted to know. Whether it worked seemed to be a secondary concern. My short answer was no, and I promised a longer explanation at his next appointment. In the interim, flashbacks of another patient from long ago popped up. Although psychopharmacology has quickly evolved in the decades since the 

, that related case was too dramatic to forget.

I remember the frantic call from the ED staff, begging me to see their patient posthaste.

“Maybe you can prescribe lithium or haloperidol or something like that. We cannot contain him here, but we have nowhere to send him,” said the pressured voice on the phone. “He saw a psychiatrist, but that is all we know.”

“Was it safe?” was all he wanted to know. Whether it worked seemed to be a secondary concern. My short answer was no, and I promised a longer explanation.

It was Sunday midmorning, late summer, when many Manhattanites escape town leaving side streets empty and opening tables at New York City’s unending array of eateries. Uninterrupted by impatient New Yorkers demanding seats, out-of-towners could enjoy unhurried brunches, fussed over by glamorous waitstaff who were patiently anticipating their Broadway debuts. The tidy townhouses lined side by side behind the hospital conveyed an extra sense of calm that contrasted with rowdy Saturday nights.

 which was nearly abandoned. I peered through the window of the make-do quiet room and could see that the doctor who called the consult was not exaggerating. A tanned, middle-aged man stood a few feet behind the door. He looked to be 50-something, but he jumped and hopped like a child, in sync to the beat of an invisible drum. His thinning silver hair swung wildly. Most strikingly, his suit jacket was draped around his waist, hiding his backside and little else. Empty sleeves looped across the front, dangling like a loincloth, albeit one with a shiny—probably pricey—silk lining. Where he left his pants, shoes, socks, and shirt was anyone’s guess. All I knew is that he wore nothing else.

Per protocol, I checked the chart before walking into the room, not just for safety’s sake but to

 by skimming the demographics. He was, in fact, middle-aged, married, and, in hindsight, possibly a vestige of the 

 had not aired yet. For that matter, sildenafil had not been invented, nor had the now-ubiquitous second-generation antipsychotics that are often used to treat bipolar disorder. Per the intake sheet, “Mr Smith” was a senior vice president at a name-brand advertising firm, even if his present posture suggested otherwise.

The history mentioned that his private psychiatrist, who had retreated to the Hamptons for the summer, referred all emergencies to the hospital, as per his answering machine message. Before leaving, said psychiatrist started him on lithium, then carbamazepine, maybe even 

, but now everything spiraled out of control. Experience told me that advertising executives with bipolar disorder tendencies are not uncommon, because advertising takes high energy, unabashed enthusiasm, and lots of chutzpah, which are abundant in 

. Yet it was also unlikely that someone with uncontrolled bipolar disorder could rise so high through the corporate ranks, even if his prescriptions screamed bipolar. It was also unlikely that this behavior represented garden-variety bipolar disorder, because the nurse noted that he was disoriented to time and place, distracted, and responding to unseen stimuli. His rapid, jerky movements put me on high alert for impending seizures, even though a cursory 

I scrolled through the medication list, checked the charted vital signs, scanned all labs listed, and looked for clues to explain this seemingly sudden deterioration. Even the toxicology screens were negative. The medications included several antihypertensives, which opened the possibility of a recent cerebrovascular accident secondary to hypertension, but he was moving all 4 limbs without restrictions, and his frenetic, dancelike activity functioned as a makeshift 

 stress test, making it unlikely (but not impossible) that his strange symptoms followed hypoperfusion. There was only 1 odd entry, a little, nearly illegible word: Yocon.

In those days, we checked prescription pharmaceuticals through big, bulky Physicians’ Desk Reference editions with thin pages and small print. And that was where I found the culprit: that little word was the trade name for 

, a reputed (but disputed) aphrodisiac used in fertility rituals in Cameroon, Central Africa, according to a memorable medical school ethnopharmacology lecture. I called the man’s internist, who had hospital privileges and even made rounds on weekends. The internist checked his chart and confirmed that a urologist had started the man on prescription yohimbine a few weeks earlier. The doctor noted that he added more antihypertensive medications soon after, which made sense, given that this herb can increase blood pressure and interfere with the efficacy of blood pressure medications.

The nurses crowded outside the room, eager for an explanation, and appreciative of the colorful story behind this mystery. Yohimbine was an α1-adrenergic agonist, a product of an East African tree with a similar name. It was marketed as an 

 and subsequently approved for this purpose, despite equivocal evidence. Whether yohimbine helped in this regard was unclear, but its psychoactive properties were apparent. I wondered whether prescriptive yohimbine (or nonmedicinal yohimbe bark) directly increased libido as advertised, or whether it simply induced 

 in susceptible individuals, with the attendant hypersexuality of mania.

That theory was within the realm of possibility, especially because recent reports confirm that the stimulant especially affects individuals who are predisposed to bipolar disorder, as well as schizophrenia, panic disorder, and 

As physicians first, psychiatrists must consider the big picture, without reflexive and thoughtless prescriptions for psychotropics—even if many, including medical professionals, assume that is all we do.