Steven S. Sharfstein, MD

by Lloyd Sederer, MD; New York: Austin Macauley Publishers, 2020

Editor’s Note: Dr Sharfstein was one of many preeminent psychiatrists that were reached out to in order to review this book. Quite simply,

could not find anyone who did not try and dodge writing this review by saying they were conflicted out. The number of friends that Dr Sederer has, the number of psychiatrists who have worked for him or with him and hold him in such high regard, is truly impressive. If you do not know Dr Sederer and wish to review his next book, I invite you to email me at

One of the few benefits of pandemic-driven social isolation and quarantine is time to read. Really read. Newspapers and magazines, fiction and nonfiction. It was my special enjoyment to pick up Dr Lloyd Sederer’s memoir, 

 for many years and consider myself a friend and close colleague, but I did not know the Lloyd (and I will use his first name throughout this review as the memoir is about his youthful years) that is contained within these 200-plus pages. I feel that my conflict does not prevent me from reviewing this memoir, and it also gives me the pleasure of recognition of the adult Lloyd in the context of his growing years. He is one of the preeminent psychiatrists in America today as a clinician, teacher, author, and public health leader.

The book consists of 14 chapters that are stories or vignettes from Lloyd’s New York City (the Bronx in particular) experiences in the 1950s and 1960s. Each story is paired with a companion essay on the meaning of the experience or memory, and the context at that time and place and in light of today’s social issues. His insights as a psychiatrist are shared throughout and these are the key observations that lead me to hope that practicing psychiatrists will avail themselves of this easy-to-read volume.

Lloyd’s childhood and adolescence were remarkably benign or “normal.” No major trauma or losses to overcome. It was full of love and family. He did not have to overcome poverty or discrimination. There was struggle, however: the struggle of a first-generation immigrant family and small business owner; the struggle of a rebellious, odd child who fashioned his identity against the backdrop of constraints of his family’s expectations and the larger community. His is a story about how a child with relentless curiosity forged an identity.

First of all, Lloyd was a good Jewish boy (mostly). The title of the book references his weekends at aged 8 uears, going with his dad to the small stationary store that the family owned and putting together 

 for customers that would stream in that Sunday. The ink from the papers would stain his hands, face, and clothes and the experience rubbed off on him indelibly. He often wished he were somewhere else and became determined to be someone else. In this, his family, particularly his dad, supported his journey.

Second, Lloyd was a very funny boy—with a very Jewish sense of humor (ie, Neil Simon or Mel Brooks). When it came time for him to learn an instrument, he picked the accordion. The accordion! Complicated, with bellows (“that could fan Hades”) he played it in school orchestra. His Bar Mitzvah was not a typical rite of passage. Although he went to Hebrew school and learned his Torah portion, he would have preferred shooting hoops in the playground. Mesmerized by firecrackers in the neighborhood, he bought some from older boys and resold them (can you be a firecracker pusher?) to his fellow Hebrew school students just before Hebrew school, making a tidy little profit. Busted by the Rabbi (a hilarious scene in the book), he worries less that his Bar Mitzvah would not happen and more about the dad’s reaction. His dad said nothing implying approval. As he opines; “After all, wasn’t I following my dad’s Semitic, merchant bloodline, creating a (small) business and making a profit?”

Third, Lloyd was a very lucky boy—and he knows it today. An intact family, not wealthy but with enough. A loving extended family. A safe neighborhood. A rich educational table, thanks to New York’s investment in the 50s and 60s in public education from grade school, to Bronx High School of Science to City College.

He learned life’s important lessons. Show up, work hard, and then most importantly, give back. The book is a thank you note to his parents, teachers, and friends. It is full of gratitude.

I could personally relate to this memoir, having grown up in a family of small business owners (on Long Island, not the Bronx). While the ability to relate added pleasure to the experience of reading the book, it was not the source of most of the pleasure.

Psychiatrists, and our patients in particular, will benefit by seeing how one of our most effective leaders developed. Fortunately, this development into a wise leader is documented with great humor.

is psychiatrist, former president of the American Psychiatric Association, and the 2007 recipient of the Human Rights Award from the American Psychiatric Association.

Articles

What was life like in the 1950s Bronx for a budding preeminent psychiatrist? 

Ink Stained for Life

Tina, a 35-year-old legal secretary, is admitted to the hospital hearing voices that demand she gouge out her own eyes as punishment for having lived a sinful life. She was seen in the local emergency room prior to admission, both for involuntary certification and treatment for corneal damage from having attempted to harm herself. She states to the admitting psychiatrist, "If thine eye offend thee, pluck it out!"

John, a 17-year-old gang member, is admitted to the hospital because he has threatened to murder his parents and siblings. He is sitting in a group therapy session when he stands up in the middle of the group, clenches his fists, and starts pacing the floor, screaming "I will kill you and I will kill anybody who gets in my path. I'm getting out of this hospital immediately. You can't stop me. Nobody can stop me. I need to go and do what I have to do!"

The care and treatment of the mentally ill who may become violent is both a public health and public safety issue. Untreated and undertreated mental illness predisposes some individuals-especially those with the diagnosis of paranoid schizophrenia-toward a high risk for suicide or homicide. Deinstitutionalization of the mentally ill over the last 30 years has created a public health crisis across the country as evidenced by the recent shootings in Utah as well as similar incidents in New York and Baltimore. Access to hospitalization of acutely ill and dangerous people is essential today.

At the same time, the use of seclusion and restraint in psychiatric hospitals has come under great criticism as highlighted in the "60 Minutes II" program aired April 21, 1999. Tragic and preventable deaths have led federal legislative representatives and well-intentioned advocates to call for restricting the use of seclusion and restraints in inpatient settings. Recent hearings in Congress are focusing on new legislation that would limit the use of these procedures and establish national standards with additional reporting requirements.

In this era of managed care, psychiatric patients are admitted to hospitals almost exclusively in crisis on criteria of dangerousness to themselves or others. The potential for violence is inherent in an inpatient unit. At times, it is necessary to restrain or isolate individuals to prevent them from harming themselves or others. Staff in psychiatric hospitals must feel safe in order to perform basic psychotherapeutic tasks that often prevent or avoid such violence. The safety of other patients in the inpatient unit is also a major concern. Consideration of legal and regulatory apparatus that would be implemented to monitor the misuse of seclusion and restraints in psychiatric inpatient settings must be tempered by acknowledging the need for added resources that ensure adequate staffing and training in the appropriate use of these procedures to prevent violence. The ability to stabilize patients with dangerous behavior requires the flexible use of these approaches, with the safety of patients always first and foremost.

If it becomes more difficult to provide a safe institutional environment for these patients, more psychiatric hospitals will close. What will happen to the patients then? They will be subjected to the ultimate in seclusion and restraint in the nontherapeutic environments of prisons and jails. The incarceration of the mentally ill is a public shame. Today, there are tens of thousands of individuals in jail who belong in hospitals. We could increase that jailed population with misguided, single-minded regulations on the restriction of appropriate and safe use of seclusion and restraint in hospitals.

Steven S. Sharfstein, MD

Articles

Ink Stained for Life

Seclusion and Restraint