"Mile End Cul-de-sac" - Capital Psychiatry - Summer Issue - 2022.pdf

Summer 2022 • Volume 3, Issue 3
THE E-MAGAZINE OF THE WASHINGTON PSYCHIATRIC SOCIETY

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Photo on cover by Joseph Silvio, M.D.
Joe describes the photo: Altamira Oriole
taken in Costa Rica. It’s striking colors
next to the flower evoke summer to me.
Photo on back inside cover by Arsinée
Donoyan.
Arsinée describes the photo: At the
historic Reford Gardens on the Métis River.
Native to Japan, Astilbe was exported in
late 1800.
• Letter from the Editor of Capital Psychiatry P4
Gerald P. Perman, M.D.
• Remembering Harold Eist, M.D. P5
Thomas G. Ingersoll, Ph.D. and Brian Crowley, M.D.
City of Baltimore In Memoriam Certificate
• Managing Suicide Among People of Color P8
William B. Lawson M.D., PhD and Donna Holland Barnes, PhD
• Are We at Our Wit’s End? P10
Eric M. Plakun, M.D.
• The Gaspe Peninsula in Quebec Canada P12
Photo Spread by Arsinée Donoyan
• American Homes P16
David V. Forrest, M.D.
ARTICLES
• Hope in Psychiatry P17
H. Steven Moffic, M.D.
• Truth Versus Lie P22
Henry Zvi Lothane, M.D.
• Baby Steps: Learning Psychodynamically-oriented Psychotherapy
as a Resident P26
Lekan Olaolu, MD, MPH with Commentary by Harold P. Blum, M.D.
• Jealousy in Pets P30
David V. Forrest, M.D.
• Amplifying the Historical Lens on Latino Mental Health P33
Sheila Panez, MS-III and MPH Candidate Monica Attia, G.W. MS-IV
• Overview of Commitment Process for Children and Adolescents
Amidst a Declared National Emergency P36
Mayank Gupta, M.D. and Jeffrey Moll, M.D.
• Milton Edgerton’s Psychiatric Perspective on Cosmetic Surgery P40
John Clark, G.W. MS-IV
ESSAYS
• On Being Editor P44
Gerald P. Perman, M.D., DLFAPA, DLFAAPDPP
• On Brecht and the Risks of Muffling the Muse P46
Carlos E. Sluzki, M.D.
• Do Patients Dream of Electric Shrinks? P48
Kenneth Serrano, MS-IV
BOOK REVIEW
• Body Dysmorphic Disorder By Sony Khemlani-Patel, M.D. and
Fugen Neziroglu, M.D. P50
Reviewed by Sreenidhi Thirunagaru, MS-IV
POETRY
• Mile End Cul-de-sac P52
Vincenzo Di Nicola, M.D.
• Medication on Epiphany (1940) by Max Ernst P53
Austin Lam, MS-IV
• A Way of Experience P54
Austin Lam, MS-IV
• Stretches (A Year in Haiku) P55
Management
Next Wave Group, LLC
Newsletter Design
Betsy Earley / Director of Publications
Email: Betsy@baymed.com

4 CAPITAL PSYCHIATRY, THE E-MAGAZINE OF THE WASHINGTON PSYCHIATRIC SOCIETY
By Gerald P. Perman, M.D., DLFAPA
L E T T E R F R O M T H E E D I T O R
Gerald P. Perman, M.D.
Editor, Capital Psychiatry
Dear Colleagues,
Welcome to the summer 2022 issue of Capital
Psychiatry: the e-Magazine of the Washington Psychiatric
Society.
We begin by remembering Harold I. Eist, M.D., three-
time President of the WPS and President of the APA,
who died on December 16, 2021. I attended Harold’s
memorial service on April 24, 2022, and I received
permission from Harold’s wife, Anne, to published
two of the eulogies. In a brief report, William Lawson
and Donna Holland Barnes write about the egregious
disparity in how Black suicides are reported. Erik M.
Plakun describes the tall legal hurdles in Wit vs. UBH
in the effort to obtain mental health parity. Arsinée
Donoyan shares her spectacular summer photographs
of the Gaspe Peninsula of Quebec, Canada.
Highly esteemed writer H. Steven Moffic views “hope”
from different points of view and in various contexts.
Henry Zvi Lothane delves deeply into “truth versus
lying” from philosophical, political, and psychiatric
perspectives. Lekan Olaolu poignantly writes about his
early experiences in psychodynamic psychiatry training
with Harold P. Blum offering an invited commentary.
David V. Forrest, analyst, writer, and illustrator, applies
his psychoanalytic acumen for a humorous take
on jealousy in pets. Sheila Panez and Monica Attia
provide a brief history of some of the inequalities
in Latino mental health. Mayank Gupta and Jeffrey
Moll contribute a scholarly review of the commitment
process for children and adolescents in the U.S.. John
Clark, Associate Editor of Capital Psychiatry, reviews the
ground-breaking work of Milton Edgerton, M.D. and
psychiatric considerations of cosmetic surgery.
In the essay section, I (Gerald P. Perman) give a
description of my journey to becoming Editor of
Capital Psychiatry. Carlos Sluzki takes his cue from a
1940 Bertold Brecht poem about the importance of
speaking up. Kenneth Serrano wonders if AI (artificial
intelligence) may replace what many of us are now
doing in our practices — as if this was not already
happening!
This issue of Capital Psychiatry offers captivating poems
by Vincenzo Di Nicola, Austin Lam (two poems) and
Stephen Rojcewicz (a 52-verse haiku). We conclude
with a book review by Sreenidhi Thirunagaru on a
scholarly treatise on Body Dysmorphic Disorder. Cover
photo by Joseph Silvio and inside back cover photo by
Arsinée Donoyan.
I am grateful to my Associate Editor, John Clark,
my Editor-at-Large, William Lawson, and my
Corresponding Editor, John Fatollahi. Betsy Earley
and Patricia Troy provide invaluable assistance putting
Capital Psychiatry together.
Send YOUR submissions for Capital Psychiatry to
gpperman@gmail.com.

5
I N M E M O R I A M
HAROLD EIST, M.D. • 1937 - 2021
BY THOMAS G. INGERSOLL, Ph.D.
April 24, 2022 Memorial Service
We are here today to celebrate the amazing life of
Dr. Harold Eist, a man of science, a man of principle, a
consummate family man, and a man of passion.
When he was barely six years old, his uncle took him
of a tour of the medical building at the University of
Alberta (he had been born in Edmonton). Harold
looked at the pictures of the medical school graduates
on the walls and announced that he would become a
physician.
Eleven years later, he enrolled at the University of
Albertan to begin his studies. It was here that he met
and married Ann — his lifelong companion, best
friend, and able assistant.
Colleagues called Harold that Winston Churchill of
American Psychiatry and when he returned to the
University of Alberta in 2015 to accept its Distinguished
Alumnus Award, he said of Ann: “As Churchill said to
Clemmie, ‘We have traveled ceaselessly over endless
seas.’” Ann was, indeed, Harold’s constant companion
and helpmate through their 61 happy years of marriage.
In 1967, Harold and Ann left Canada with their two
daughters, Wink and Marla (their son, Jason, was not
born until 1971). They moved first to Minnesota for
Harold to complete his psychiatry residency and then
settled in the Washington area, where he was hired as a
therapist at and Director of Chestnut Lodge in Rockville
— a well-known psychiatric institution that pioneered
the prescription of pharmaceuticals that were then
revolutionizing the treatment of maladies such as
schizophrenia and depression.
Harold also became the Medical Director of the
fledgling D.C. Institute of Mental Health. When he took
the helm, DCIMH was a clinic with five staff serving 18
patients — a most disadvantaged and poverty-stricken
population. When he left the clinic 20 years later, it had
grown to three sites ministering to 2,500 patients per
year — and the nature of that patient population never
changed: that population remained the neediest of the
Washington Area. When he retired from the Clinic in
1986 (at the insistence of his cardiologist), the DCIMH
was renamed the “Harold I. Eist, M.D. Clinic.” And it
continued to serve the area’s disadvantaged.
Harold’s service to the disadvantaged and to his
patients was widely recognized here and around the
globe. He was selected as Washingtonian of the Year in
1979, served three separate stints as President of the
Washington Psychiatric Society, was President of the
Suburban Maryland Psychiatric Society, and served
one term as President of the American Psychiatric
Association.
In running for this last position, he traveled the country
(as always, with his wife Ann) to meet with local chapters
to explain his platform — based on his long-held
belief that managed care was destroying the practice
of medicine in general, and psychiatry in particular. As
Harold put it: “The suffering of the mentally ill is being
ignored, denied, and made invisible on the alter of
managed care’s bottom line.” Until the end of his life,
Harold continued to passionately inveigh against the
ravages of managed care.
In addition to his dedication to his patients and
his battles against managed care, Harold was also a
champion of support of patient confidentiality. He was
extremely proud of his creation of the “Patient’s Bill
of Rights” that was adopted by D.C. and by many other
states and organizations. It is supported by more than a
million healthcare professionals and to shield them from
the harmful effects of the for-profit healthcare industry.
On the global state, Harold became the U.S.
representative to the World Psychiatric Society, traveling
the world (always with Ann) to advocate for better
mental healthcare and patient rights as a distinguished
lecturer in more than a dozen countries. He was never
afraid to castigate government leaders for practices that
were destructive of patient care as he did in 2004 with
the Chinese Minister of Health for that country’s use
of psychiatric hospitalization to punish members of the
Fulan Gong for their religious and cultural beliefs.
While serving his patient, his community and his
profession, Harold remained an intense personal force in
the lives of his family and friends. When they first came
to DC, Harold and Ann lived in a small apartment in
Silver Spring, but the Eists also purchased a small farm
in Middletown, MD, where Wink and Marla could board
their horses, so the Eist children quickly learned caring
and responsibility, as there were animals to be cared for
and chores that had to be done.
Harold was so proud of his family — often regaling
us with stories of his four grandchildren (their
accomplishments and their antics). He had a huge,
booming laugh that made his stories all the more
enjoyable.In their later lives, the Eists would vacation as
a family, often in the Outer Banks of North Carolina,
where Harold found immense joy in walking on the
beach with Ann. Even here, Harold would continue his
other passions: he would read avidly, he would eat great
foods and he would enjoy fine wines. He and Ann even
hosted the chefs of the island to have wine tastings at the
house they had rented.
So, to my mind, Harold was not so much a Winston
Churchill as he was a true renaissance man.

I met Harold in the 1960s, as a member of the
Washington Psychiatric Society’s Confidentiality
Committee, which he chaired, with meetings at his
home/office. We were both psychoanalytic candidates
and local psychiatric practitioners.
I worked with Harold for many years in Washington
Psychiatric Society affairs. Harold was President and
I served for years on the Board. During his American
Psychiatric Association (APA) Campaign for President,
in the 1990s, Harold was a charismatic and impressive
speaker. His oratory warned of the rising dangers
that Managed Care presented to the doctor-patient
relationship. He also saw that Managed Care would
remove badly needed dollars from the healthcare
system to a new entity interested in its own profit.
The local group around him for his campaign included
Roger Peele, Larry Kline, Rich Epstein, me, and others,
and we were a tight-knit cabal which met frequently in
his home. Committee meetings in Harold’s home office
featured a wonderful assortment of FOOD laid out by
Ann. Later, more of a social friendship developed, with
Harold, Ann, Natalie, and me dining out as a foursome
in restaurants, some new, some old favorites. But
nobody knew the wine list better than Harold Eist.
“The Eists” became a common term in the APA. Ann
and Harold melded into a dynamic unit as a couple.
Ann was not only his office manager but his political
right hand. People knew they could talk with Ann if
Harold wasn’t available.
Harold and Ann traveled all over the U.S., as APA
candidates for President had never done before. They
visited almost every District Branch, becoming fast
friends with many psychiatrists all over the country,
as well as later, when they traveled in several foreign
countries representing the APA.
Harold Eist was a major leader in psychiatry: a
dedicated champion of the underprivileged and of our
core professional values.
I N M E M O R I A M
HAROLD EIST MEMORIAL SERVICE, APRIL 2022
EULOGY
BY BRIAN CROWLEY, M.D.

7
Dr. Harold Israel Eist
In friendship:
On behalf of the citizens of this State and the Office of
the Attorney General, in recognition of his long and
distinguished career in psychiatry, as a persistent advocate
for quality mental health care, as a champion of patient
rights, and as a fighter for the disenfranchised, we wish to
confer this certificate
In Memoriam
At the City of Baltimore
in the State of Maryland,
on this 21st day of April,
in the year Two Thousand Twenty - Two
Attorney General

William B. Lawson MD, PhD and Donna Holland Barnes, PhD
Managing Suicide Among People of Color
The Washington Psychiatric Society (WPS) is having a
Presidential Symposium that is presenting the state of
the science of suicide from a biopsychosocial issue. It
should help to put suicide in the forefront of health
issues. Suicide should be looked at as a public health
issue impacting our communities that psychiatrists have
special expertise in developing preventive measure and
treatment strategies. Moreover, consideration of this
issue is relevant across all communities in the DC areas.

9
For many years, psychiatrist had learned to treat patients
with suicidal thoughts and gestures with medication
and the problem would be solved. There was rarely any
delving into what cause the patient to think that death
was an option to solve their issues. The fact that the
WPS is embarking on suicide from a biopsychosocial
perspective is monumental. The suicide rates have
increased yearly for the past 30 years, an increase of
33%.1,2
If medication was the answer, shouldn’t we have
experienced a decrease at some point?
As a medical student, I “discovered” that African
Americans did not kill themselves. The faculty member
that made that statement was not articulating an
obscure observation. After all it was thought that
people of color rarely became depressed.3
During
slavery Africans were thought immune to most mental
disorders and especially depression since they were
thought not to have the mental apparatus or did not
need to face the societal complexities that White people
had to deal with.2
Being raised in rural Virginia in a poor heavily African
American Community, the demographics were
thought not to favor individuals killing themselves. Yet
I remember a neighbor killing herself, a schoolmate
resolving the domestic disputes in her family by killing
herself and an employee of my grandfather killing
himself because he was diagnosed with cancer. Were
these formally listed as suicides? I doubt if given the
stigma about it in a rural community in the 50’s and 60’s.
Later while at Howard University I participated in a
study involving the DC medical examiner’s office. A
young African American man was found in the street
with a gun clutched in his hand pointing at his head
which had a lethal gunshot wound. The medical
examiner noted that this obviously was a homicide
because black people did not kill themselves.
The rate of homicide in predominantly African
American communities universally have higher rates
of homicide than suicide We have higher rates of drug
induced deaths and higher rates of accidents than
suicide.4
If fully investigated, could some of these deaths
could actually have been suicide.4
Certainly, we kill ourselves in a different manner. If a
man tells another man not to look at his wife or he will
kill him…the man simply looks at his wife and is shot
and killed. Singer Marvin Gaye was warned by his father
not to come into his bedroom and bother him anymore
or he will shoot him with his rifle. Marvin nearly kicked
the bedroom door down to bother him some more.
Marvin Gaye was unfortunately shot and killed by his
Father.8
During my tenure at Howard University’s Department
of Psychiatry as Chair, I insisted that my psychiatric
References:
1
Lindsey MA, Sheftall AH, Xiao Y, Joe S. Trends of Suicidal
Behaviors Among High School Students in the United States:
1991–2017. Pediatrics. 2019;144(5):e20191187.
2
Reed DD, Stoeffler SW, Joseph R. Suicide, Race, and Social Work:
A Systematic Review of Protective Factors among African
Americans. J Evid Based Soc Work (2019). 2021 Jul-Aug;18(4):
379-393. doi: 10.1080/26408066.2020.1857317. Epub 2021 Feb
23. PMID: 33622190.Thomas A and Sillwn S: Racism and
Psychiatry. 1972 New York, Brunner and Mazel.
3
Davis, K. Blacks are immune from mental illness. Psychiatric
News. Published Online:1 May2018 https://doi.org/10.1176/
appi.pn.2018.5a18
4
Poussaint, A., and Alexander, A: Lay My Burden Down: Suicide
and the mental health crisis among African Americans, by
Alexander, Beacon: Boston, 2000.
5
Bridge JA, Horowitz LM, Fontanella CA, et al. Age-Related Racial
Disparity in Suicide Rates Among US Youths From 2001 Through
2015.JAMA Pediatrics. 2018;172(7):697.
6
Bridge JA, Asti L, Horowitz LM, et al. Suicide Trends Among
Elementary School–Aged Children in the United States From
1993 to 2012.JAMA Pediatrics. 2015;169(7):673.
7
Sheftall AH, Asti L, Horowitz LM, et al. Suicide in Elementary
School-Aged Children and Early Adolescents. Pediatrics.
2016;138(4):e20160 436-e20160436.
8
Biography https://www.biography.com/news/crime-and-scandal,
searched 4/30/2022
residents had more education on suicide and hired
a sociologist who specialized in suicidology. She
conducted seminars with the psychiatric residents on
suicide risk management and she taught managing a
suicidal patient to the 3rd year medical students when
rotating to the department of psychiatry.
It was important to me that they got the proper
education after I asked one of my psychiatrists, what
happened to one of his patients. He replied, she killed
herself. I asked, “how did that happen?” He replied, she
said she was going to kill herself and I didn’t believe her.
Furthermore, the Department was the first responders
to a suicidal patient in the ER or on campus.
Thanks in no small part to the work of Poussaint and
Alexander3
, the recognition of suicide among African
American has become more recognized. Today the
data shows that young African American boys have the
highest suicide rate of any racial or ethnic group.4, 5, 6
That was not always the case as the rate has jumped
substantially in recent years. Moreover, The coronavirus
pandemic probably is a precipitating factor increasing
suicide, homicide, and overdose deaths among African
Americans through its impact on isolation, stress,
limited access to care, and despair. It should also be
considered that some of these health-related deaths may
be suicide equivalents.

By Eric M. Plakun, MD
Medical Director/CEO, Austen Riggs Center, Stockbridge, MA
We live in interesting times when it comes to access
to treatment for mental and substance use disorders.
Both the president and surgeon general recognize
that there is a national crisis in mental health, that
shameful health disparities in access to care persist,
and a recent Department of Labor review of over 150
insurance companies’ parity compliance revealed
inadequate implementation of the Mental Health
Parity and Addiction Equity Act 14 years after it became
law (https://www.dol.gov/sites/dolgov/files/EBSA/
laws-and-regulations/laws/mental-health-parity/report-
to-congress-2022-realizing-parity-reducing-stigma-and-
raising-awareness.pdf).
Despite the clear need for improved access to care for
treatment of mental and substance use disorders, a
3-judge panel of the Ninth Circuit Court of Appeals
recently overturned the landmark verdict in Wit v.
United Behavioral Health (UBH) on an apparent
misunderstanding of the arguments in the case. As
psychiatrists, we have an interest in voicing our concern
about this outcome, which can only exacerbate the
above problems.
For those unfamiliar with the case, Wit is a federal
class action addressing the restrictive access to care
guidelines used by UBH to determine the need for
outpatient, intensive outpatient, and residential
treatment. Given my experience serving as expert in
adult psychiatric disorders in Wit, I have followed how
the case has unfolded.
In his more than 100-page penalty phase verdict,
Ninth District Court Chief Magistrate Judge Joseph
Spero laid out the details of his finding that UBH
breached its fiduciary duty to its insureds by allowing
its finance department to impose overly restrictive
Photo
created
by
www.freepik.com
AreweatourWit’send?

11
access to care guidelines that limited treatment to mere
crisis stabilization, which Judge Spero found to be
inconsistent with generally accepted standards of care
(Wit v United Behavioral Health, No 14-cv-02346-JCS,
ND Calif, March 5, 2019).
In the similarly lengthy penalty phase verdict, Judge
Spero required UBH to reprocess nearly 70,000 claims,
imposed a 10-year injunction against UBH, assigned a
Special Master to oversee training of UBH employees
in their fiduciary duty and in the use of access to care
guidelines consistent with generally accepted standards
of care that are developed by nonprofit professional
societies (https://casetext.com/case/wit-v-united-
behavioral-health-12).
Former US Congressman Patrick Kennedy called the
verdict a “game changer” in implementation of the
mental health parity law. If extended beyond UBH to
other ERISA plans, to other commercial insurance,
and to Medicare and Medicaid, the verdict would not
only advance implementation of the parity law, but also
reduce shameful health disparities. Psychiatrists, other
mental health professionals, consumer organizations,
and the general public recognize these as laudable goals
that are objectively responsive to the current crisis in
mental health.
UBH appealed the verdict to the Ninth Circuit Court
of Appeals, where a 3-judge panel issued a brief verdict
that scarcely mentioned the clinical issues involved or
the evidence at trial, found no flaws in the plaintiffs’
clinical perspective, but issued a decision overturning
the verdict in Wit based on a misunderstanding of the
case. That is, the panel concluded that, just because
a treatment is within generally accepted standards of
care, an insurance company does not have to cover
it. However, the Wit plaintiffs never argued that UBH
was required to cover all treatments consistent with
generally accepted standards of care. Rather, they
argued that UBH was bound by its plans and state laws
to make medical necessity determinations that were
consistent with generally accepted standards of care
when evaluating such indisputably covered services
as outpatient, intensive outpatient, and residential
treatment. The appellate panel essentially endorsed
corporate finances overriding generally accepted
standards of care that are defined by nonprofit
professional organizations.
This is a puzzling perspective. On the medical/surgical
side, it is comparable to an insurance company finance
department adopting treatment guidelines to cover only
non-surgical treatments for acute appendicitis as a cost
saving measure.
This decision is not only puzzling but undercuts
full implementation of the mental health parity law,
fails patients, and has the potential to aggravate
shameful health disparities. Plaintiffs’ attorneys have
filed a request for an “en banc” rehearing before the
entire 29-member Ninth Circuit Court of Appeals,
citing multiple examples of why the decision is
flawed (https://www.zuckerman.com/sites/default/
files/2022-05/Wit_Rehearing_Petition.pdf).
The APA, AMA, other professional organizations,
NAMI, California, and several other states have filed
amicus briefs supporting the request for rehearing, but
this is an uphill struggle. Requests for rehearing are
infrequently accepted. However, public awareness and
concern about the nationwide implications of a decision
like this can increase the likelihood of an en banc
review.
If the overturning of the verdict in Wit stands, a few
fortunate states, like California, Oregon, and Illinois,
already have state laws requiring that access to care
guidelines be based on generally accepted standards of
care developed by nonprofit professional societies. Most
other states are less fortunate.
While the Ninth Circuit covers California and several
other western states, including Alaska and Hawaii,
even those of us far from the Ninth Circuit can use
our professional and personal voices in civil discourse
about the importance of the original verdict in Wit in
addressing the nation’s mental health crisis, in fully
implementing the mental health parity law, and in
reducing shameful health disparities.
We can emphasize the impact of the reversal of
the verdict by noting the comparison to insurance
company exclusion of nonsurgical treatments of
acute appendicitis or myriad other examples of how
unacceptable this stance would be in treating medical
disorders. We can advocate for lawmakers in our states
to follow the lead of California, Oregon, and Illinois by
adopting into law the principles of the original verdict
in Wit.
The time to act is now.
Letters to the editor, social media posts, consciousness
raising among colleagues and consumer groups, and
other steps consistent with our professionalism, are
opportunities to create public awareness and concern
about the 3-judge panel’s decision and the importance
of an en banc review.
Reference:
Plakun EM. Improving access to psychotherapy: implications of Wit
Versus United Behavioral Health. Journal of Psychiatric Practice.
2021;27;199–202
Dr. Plakun may be contacted at Eric.plakun@austenriggs.net.

THE GASPÉ PENINSULA IN QUEBEC, CANADA
Photo Spread of Arsinée Donoyan
The National Park of the Bonaventure Island
More than 200 different species of seabirds have been recorded as living, migrating, or visiting the island.

13
Percé Rock
In the St. Lawrence River on the tip of the Gaspé Peninsula where there is evidence of approximately 150 different fossilized species
of animals and plants.

Bird Sanctuary at the Bonaventure Island
Home to the second largest colony of the Northern gannets in the world.

15
Forillon National Park
Located at the tip of the Gaspé Peninsula covering 94 square miles.

By David V. Forrest, M.D.
American Homes

17
A R T I C L E S
By H. Steven Moffic, MD
“Hope
is a gift to us
for the inability
to predict the
future.”
- Maestro Thomas Wilkins
We are about halfway through 2022. As the year began,
there was hope it would be better. Polls of the public
indicated more hope, and I had more hope for my
heart (or my heart did for me), as well as for a suicidal
family member. As is best with hope, the vision for a
better future needs to be accompanied by action to get
there.
Part of my action was to find out more about hope
in psychiatry. One of the reasons to do so is that
for Psychiatric Times I was doing a weekday daily
column on Psychiatric Views on the Daily News as
well as a weekly video on Psychiatry and Society.
These endeavors were a hopeful action to encourage
psychiatric participation in societal events.
As the future of 2022 evolved, what from the past about
hope in psychiatry could be applied? And how had
society, psychiatry, and I done in terms of what we were
hoping?
The Development of Hope
If hope is a good thing, we would want to know how
to obtain it, wouldn’t we? Not surprisingly, the genesis
of hope needs to start during childhood. Trust is an
essential component. Trust develops through positive
attachment to early caregivers. In their nurturing role,
parents are a child’s first hope provider. The role of
nature is less clear, but there does seem to be genetic
variations in innate positivity. In addition, early illness,
loss, and in particular, trauma, can decrease trust.
Hope Sings Eternal. Artwork courtesy of Barry Marcus

In Erik Erikson’s classic Stages of Psychosocial
Development, Trust vs. Mistrust is the first stage and
lasts from about birth to 18 months1
. How dependable
the parenting is matters greatly. The best caretakers
anticipate the needs of the child and respond
appropriately. So do the best psychotherapists with
patients. Parents out of sync with their infant often
results in clinginess and anxiety.
As the child develops, a hopeful inner life is enhanced
by repeated encounters with positive family rituals.
Such repetition builds hope that the future will be
predictable and positive.
Freudian Hope
I wondered if there was other attention paid to hope in
psychiatry that I had missed over my career, so I started
a historical search centering on some of the most well-
known psychiatrists. There turned out not to be much,
starting with Freud.
Where else to start but with Freud, despite all the
ensuing doubt about some of his theories and
principles? Surely Freud analyzed hope, not someone
named Hope, I assumed. However, I didn’t find
much, at least from what I reviewed, but I did find an
important conclusion that it, along with faith, actually
might be one of the essential ingredients necessary
to obtain the most benefits of psychoanalysis via the
mechanism of expectations2
.
Jungian Hope
Jung, Freud’s protege for a time, touched on hope
too, but also barely. He saw hope in the universality of
the archetypes he described, in the sense that people
were connected unconsciously to the essence of other
people in a collective unconscious. The ability to make
the unconscious conscious, as in therapy and in art, was
hopeful. Hope could also be found in synchronicity, of
being the right person thinking the right thought at the
right time and place. The Jungian hopeful approach
to physical and mental illness is to understand the
meaning of the illness3
.
Carl Menninger’s Hope
Carl Menninger took up from Freud’s limited, though
positive, view of hope. Menninger, of Menninger
Clinic fame, was particularly interested in some of the
common concerns of everyday people: sin, crime, love,
hate, conflict, and hope.
Menninger came to conclude that increasing hope
doing treatment was correlated with improvement.
However, he realized that psychiatry needed to
study and understand hope more, as he advocated
in an invited lecture for the American Psychiatric
Association’s Annual Meeting in 19594
. He started
by warning that this would not be a typical scientific
analysis of a topic, in part because he didn’t know
enough about hope to do so. He went back to Freud
and clarified that the comment that included hope
alongside faith and love was not an intended summary
conclusion, but just a footnote.
However, by 1959, there were numerous publications
on faith and love, but virtually nothing about hope, as
if it was taboo or mundane. If anything, Menninger felt
hopelessness got more attention as in young physicians
full of hope becoming “hopeless physicians presiding
passively over hopeless patients.” He thought it was
in-between hope and hopelessness that was crucial
therapeutically — the right amount, not too much to be
unrealistic and not too little to lead to despair.
As I had come to wonder myself in a video I did on
“Radical Political Hope” for Psychiatric Times on
January 5, 2022, Menninger wondered why what was
The Promise of Pandora. Artwork courtesy of Barry
Marcus

19
left in the Greek myth of Pandora’s Box was hope after
all the miseries had flown out into the world. Why keep
hope hidden? Was it viewed potentially as something
bad, as later poets like Shelly concluded:
Worse than despair, worse than the bitterness of death, is hope.
Menninger noted that he had many patients who
viewed hope as negative. We now know, however, that
a lack of hope is a common sign of increasing suicide
risk. Menninger thought that the key ingredient for
the success of The Menninger Clinic and School of
Psychiatry in Topeka, Kansas was the inculcation of
hope, even unconsciously, into the psychiatrists and
everyone in the settings and community who worked
with them, including, of course, the patients.
Other Hopefuls
There were others in the early history of psychiatry that
touched upon hope. Thomas French in his examination
of the psychoanalytic process viewed hope as the
activating force of the ego’s integrative function5
. Frank
argues that patients were generally demoralized and
that the “arousal of the patient’s hope” was necessary to
alleviate suffering5
. Yalom agreed that the installation of
hope was crucial to any psychotherapy process6
.
In the area of self-psychology, the work of Heinz Kohut
provided another connection to hope7
. Mirroring
and idealization of others can contribute to a sense of
the self, self-esteem, and realistic hope for the future.
However, when idealization and mirroring of the other
is unrealistic, profound disappointment is eventually
likely.
It is possible that the direction of hope and psychosocial
benefits go in the same direction. That is, it may be the
successful techniques of various psychotherapies and
medication that also increase hope.
Coming to the present, and as a response to the
criticisms of psychiatry, that it is more bio-bio-bio than
bio-psycho-social and more business dominated ethics
than healthcare ethics, comes a call to recover the soul
of psychiatry with hope as being central. One example
is the Paul McHugh Program for Human Flourishing
at John Hopkins. The paradox is the positive psychiatry
approach that suggests the possibility that sometimes
people and patients reach their greatest potential not
despite their illness, but because of the illness8
. How so?
Recovery from mental illness can lead to more empathy
for others and resilience of the self.
Therapeutic Hope
The concern of Carl Menninger back in the 1950s that
psychiatric patients and their psychiatrists could get
demoralized hasn’t disappeared. In particular, that can
be a challenge for recent and early career psychiatrists.
Hope is the antidote, and more structured, empirically
validated models with learning objectives and
teaching materials have been developed at the George
Washington University9
.
In discussing the mental health problem, the key
assessment question for hope is: “How did you
respond?” That can activate cortical rationality
over subcortical emotional responses. The
specific interventions, which can be part of usual
psychotherapeutic processes, includes:
1. Build on signature personal strengths.
2. Use prior strategies for overcoming obstacles.
3. Resurrect hope practices previously used.
4. Add new hope practice out of problem-solving
strategies, emotional regulation, core identity,
and relationships.
Hope is also an essential component of any
placebo effect10
. Placebos work through a complex
neurobiological action in a ritualized environment of
positive expectations11
.
Hope in Religion
From the growing recognition of the importance of
spirituality and religion in psychiatric practice, it is
useful to know how the major religions view hope.
Indeed, hope seems to be an essential component
of any religion in the expectation that following the
religious practice, whatever it is, will produce future
benefits, including for some religions, an afterlife.
Research has confirmed that religiosity is generally
positively connected to hope and hope to life
satisfaction12
.
Names of Hope
Hope can be a family surname or a given individual
first name. The Hope family name was found in 13th
century England, and actually derived from the Old
English work “hop,” which meant the side of a hill or
the low ground between hills. With hope for a better life
in the New World, among the Puritan settlers were those
with the hope family name.
Given how much hope can be put on a new baby, no
wonder that the name Hope has been used, generally
for a girl. There has actually been an update of its use in

recent decades. Personally, I have a niece named Hope,
as well as a first cousin named Faith.
The Ethical Way of Hope
Hope is not mentioned in the AMA Principles of Ethics
as adapted and annotated by psychiatry. However, a
colleague and I, when we were asked to do a chapter
on ethics for community psychiatry specifically, did
choose hope as an essential ethical principle. What is
different about community psychiatry is that it focuses
on the more severely ill in a public system with relatively
limited resources.
What my colleague and I came up with was the acronym
E.T.H.I.C.S, which combines some of our more
traditional psychiatric ethics with added principles more
specific to community psychiatry13
. The H. Is for Hope
Ethics, with an accompanying Policy & Procedure. The
Policy is to convey a realistic possibility of hope for
recovery for all who participate in the organization.
The Procedure centers on sharing success stories and
consumer feedback.
From day one, prescribe hope for recovery. Conveying
such hope can still occur even with the too brief and
too infrequent appointments that are so common
nowadays. My personal solution was to focus on what
gave the patients the most meaning in their lives, or
what they have liked to do. I said something like we’ll
gear the medication goals to that goal. This proved
to help establish a positive alliance and hope for the
future.
Yet, to be ethical in the Hippocratic sense of doing no
harm, the hope has to be as realistic and as practical
as possible. Hope can even be helpful in a hospice, not
for a cure, but to live the remaining time meaningfully.
Because hope seems to be such a good motivating
force when things are difficult, it can be overused and
misused. Hope can become obsessive. Hope can be false
or unrealistic and set people up for disappointment
and defeat. Hope can prevent adequate preparation
for negative outcomes. Hope can consist of a wish for
something but not increasing the likelihood of that
happening by working for it.
Photo
created
by
jcomp
-
www.freepik.com

21
References:
1
Erikson, E: Childhood and Society. W.W. Norton & Co; 2nd
edition; 1993
2
Freud, S: Psychical (or Mental) treatment. In The Complete
Psychological Works of Sigmund Freud. Edited by: Strachey J.
Hogarth Press; 1905/1968.
3
Harris, B: Radical Hope and the Healing Power of Illness:
A Jungian Guide to Exploring the Body, Mind, Spirit Connection
to Healing. Daphne Publications; 2017
4
Menninger, K: The Academic Lecture - Hope. American Journal
of Psychiatry, 1959. December: 481-491.
5
Frank, J: Persuasion and Healing: A Comparative Study of
Psychotherapy. Schocken Books; Revised edition; 1974.
6
Yalom, I: Theory and Practice of Group Psychotherapy. Station
Hill Press; 5th edition; 2005.
7
Kohut, J. And Wolf, E.S.: The disorders of the self and their
treatment: An outline. The International Journal of Psychoanalysis,
1978. 59(4): 413-425
8
Chisholm, M: From Survive to Thrive: Living Your Best Life with
Mental Illness. John Hopkins University Press; 2021.
9
Griffith J.: Hope modules: Brief psychotherapeutic interventions
to counter demoralization from daily stressors of chronic illness.
Academic Psychiatry, 2018. 42:135-145.
10
Pozgain, I., Pozgain Z., and Degmecic D.: Placebo and nocebo
effect: a mini-review. Psychiatr Danub, 2014. 26(2):100-107.
11
Oken, B.S. Placebo effects: clinical aspects and neurobiology.
Brain, 2008. 131(11): 2812-2823.
12
Sharif, S., et al: Attachment: the mediating role of hope,
religiosity, and life satisfaction in older adults. Health Qual Life
Outcomes, 202. 19. 57.
13
Moffic, H.S. and Bateman, H.: Ethics for community psychiatry:
In Handbook of Community Psychiatry. Edited by H.S.
McQuistion et al. Springer Science; 2012.
14
Groopman, J. The Anatomy of Hope. Random House; 2004.
15
Gallagher, M. And Lopez, S.: The Oxford Handbook of Hope.
Oxford University Press; 2018.
16
Miller, J.: Hope for the New Year. Psychiatric Times, 2022. January:
2-4.
17
Lear J: Radical Hope: Ethics in the Face of Cultural Devastation.
Harvard University Press; 2006.
The Measurement of Hope
In general psychology, much research has gone into
trying to verifying the outcomes of hope. In general,
there seems to be a correlation between the degree
of hope and functioning better in social, academic,
and work settings. In addition, though there is mixed
option, hope seems to play an important role in the
outcomes of illness14
.
The difficulty here is how to measure hope, and the
right amount and kind of hope for those improved
outcomes. At first, psychologists like C.R. Snyder
worked on developing a global construct of hope. In
more recent years multiple different scales have been
developed that are more specific to different domains,
including academics, writing, and children15
.
Unfortunately, there is no simple hope scale that can
be universally applied to indicate the right amount of
hope. Nevertheless, answering yes to two questions is
promising. Do you see a better future? And, do you
believe that actions can positively bring that better
future about?
Hope for the Future
In his opening column for the New Year, the psychiatrist
John Miller, the Editor-in-Chief of the Psychiatric
Times, titled his piece “Hope for the New Year”16
. He
concluded that “our challenge is to keep that flame of
hope and optimism burning brightly”.
When social times and personal problems are especially
worrisome, and the future seemingly pessimistic,
radical hope can be considered17
. This is out-of-the-box
thinking, letting the remaining hope out of Pandora’s
box, and being prepared for unexpected consequences.
Examples might be the classic comments of Steve Jobs
and Henry Ford about innovation.
Ford of the Ford automobile company said that if he
had asked customers what they wanted, they would have
answered “A faster horse!” Jobs of Apple computers said
that people don’t know what they want until you show
them. To make the best use of hope in psychiatry, we
may have to innovatively better convey how we can help.
Hopefully.

T
ruth and lie are among the most important
words in the individual and social life of
humankind. Animals do not think or speak
with words, they communicate with ges-
tures and vocalization. With hands homo
faber creates tools and technology. With words homo
sapiens shapes science and philosophy, medicine and
psychology, religion and ethics and politics, literature
and journalism, truth and lie. According to the Latin
adage: magna est veritas et praevalebit, truth is mighty and
will prevail. As Aristotle put it: amicus Plato sed magis
amica veritas, Plato is my friend but truth is a greater
friend than he is.
The Oxford English Dictionary defines truth as (1)
agreement with fact, (2) accuracy and correctness of
statement or thought, (3) a disposition to speak or act
with candor, honesty, sincerity, i.e., without deceit. The
third definition shows truth as the opposite of the lie.
The OED defines the lie as an act of making a false
statement with the intent to deceive, an immoral act.
It can also be an illegal i.e., criminal act, as perjury,
swearing to a false statement.
In order better to understand the argument so far
one needs to differentiate lying from erring: an error
is a person’s mistaken opinion, through ignorance or
*Reprinted with permission of the author from the Bulletin of the American Society of Psychoanalytic Physicians
By Henry Zvi Lothane, M.D.

23
inadvertence for which a correction may be accepted.
The liar deliberately and persistently denies, destroys,
negates, and rejects truth moved by an intent to ben-
efit from the destruction of truth. Furthermore, as
psychiatrists we differentiate an error from a delusion,
a person’s tenacious false belief or opinion in disor-
der. We speak and write about delusions of control,
derogation, grandeur, hostility, infidelity, influence,
persecution, and more. However, since psychiatry
and law overlap, delusions acquire an added forensic
significance. As psychiatrists, we may forget that delu-
sions are also expressions of feelings and emotions of
patients and people in interpersonal situations such as
suppressed or repressed rage and resentment, hostile
and mocking attitudes (Lothane, 2015).
Truth is conformity with facts of perception, of know-
ing the world through the five senses, which we share
with animals. The German verb to perceive, wahrnehm-
en, says it clearly: to take the perceived thing or person
as true, as it is, as real. Perception serves the survival
of animals and humans. Goethe said: the senses don’t
lie, people do. Perception is also the method of every-
day and scientific observation. The shortest distance
between two points is a straight line. The opposite of
straight is crooked. Prevarication, i.e., lying, is etymo-
logically walking crookedly. Perception is the founda-
tion of a correct judgment of causality of things and
persons in the world. On the other hand, “Oh, what a
tangled web we weave, when first we practice to de-
ceive!” (Sir Walter Scott). And we express this not only
in words but enact it with our faces, bodies, and limbs,
in paroxysms of trembling and shaking, in everyday
dramas of life and during extraordinary crises. Drama
is the subject of dramatology (Lothane, 2009). The
gist of dramatology comes to this: drama is action
and dialogue in the here-and-now, the dramatic event
becomes a historical event and remains unchangeable.
Drama is all dialogue, with some dramatis personae
telling a story, is participated in or witnessed; a story
is all description, with some persons’ dialogues in it
is either listened to or read. Subsequently, one recalls
the event and tells it to oneself or to another, and the
narrative is as changeable as the narrator, a Rashomon
effect, dramatized in Kurosawa’s film Rashomon. Nar-
ratology and dramatology complement each other
(Lothane, 2009).
My main idea is this: nobody knows the truth better
than a liar.
Let us consider some individual and social situations
involving lying in interpersonal relationships and situ-
ations. Whereas candor is cherished, blunt confronta-
tion may become disruptive or dangerous. Therefore,
tact and savoir-faire require relativizing truth in the
service of keeping interactions neighborly and polite.
“There are three kinds of lies: lies, damned lies, and
statistics,” a saying attributed by Mark Twain to Benja-
min Disraeli.
There are white lies told by doctors to ill or dying
patients, using euphemisms and circumlocution about
cancer to prevent suicide; but that remains question-
able. However, would we prohibit lying to a Jewish doc-
tor in the Auschwitz infirmary to save the patient from
the gas chamber? Lying and deception can be sus-
pected in salesmanship. Deception in advertising may
be overt or covert. A special category is using placebos
in medicine and research. On the other hand, we do
accept that defense lawyers in court appearances may
act as hired guns, i.e., liars. About diplomacy the great
Talleyrand (1754-1838) said: “Speech is given to man
to disguise his thoughts” and Erasmus of Rotterdam
averred: “A good portion of speaking well consists in
knowing how to lie.” A lady who says maybe means yes,
and if she says yes she’s no lady. A diplomat who says
maybe means no, and if he says no he’s no diplomat.
Pervasive lying has spread since the internet and the
social media revolutions.
Lying in politics was first made famous in the Nixon
Watergate scandal mentioned by Sisela Bok (1979) and
recurred in the Trump impeachment trials, and let the
reader decide for himself. Steering clear of politics, I
will examine use as an example the 1894 Affaire of cap-
tain Alfred Dreyfus falsely accused of betraying military
secrets, convicted by lies and fraud, and jailed five on
Devil’s Island. The Affaire polarized France until 1906.
Among his supporters were Emile Zola with his im-
passioned “J’Accuse” and Anatole France in his1899
novel The Amethyst Ring where the hero M. Bergeret is a
vehicle for France’s own convictions and feelings:
“Do you not think,” said M. Leterrier, “that truth
contains a power that renders her invincible,
and, sooner or later, ensures her final triumph?”
“It is precisely what I, personally, do not think,”
returned M. Bergeret. “On the contrary, I opine
that in the majority of cases truth is likely to fall
a victim to the disdain or insults of mankind
and to perish in obscurity. I could give you many
instances of this. Remember, my dear sir, that
truth has so many points of inferiority to false-
hood as practically to be doomed to extinction.
To begin with, truth stands alone; she stands
alone, for falsehood is manifold, and so truth
has numbers arrayed against her. That is not her
only shortcoming. She is inert, is not capable of
modification, is not adapted to those machina-
tions which would enable her to win her way
into the hearts and minds of men. Falsehood,

on the other hand, possesses the most wonder-
ful resources. She is pliant and tractable, and
what is more (we must not shrink from admit-
ting as much), she is natural and moral. She is
natural, as being the product of the working of
the senses, the source and fountainhead of all
illusion; she is moral, because she fits in with the
habits and customs of the human race, who, liv-
ing in common as they do, founded their ideas
of good and evil, their human and divine laws,
upon the oldest, most sacred, most irrational,
most noble, most barbarous, and most errone-
ous interpretations of natural phenomena.
Falsehood is the principle of all that is beautiful
and of good report amongst men. Do we not see
winged figures and mythical pictures adorning
their gardens, their palaces, and their temples?
They lend a willing ear only to the lies of the
poets. What makes you wish to destroy falsehood
and to seek truth? Such an enterprise can only
be inspired by decadent curiosity and culpable
intellectual temerity. It is an attempt against the
moral nature of man and the laws of society. It is
a sin against the sentiments as well as the virtues
of the nations. The growth of so great a calamity
might well be fatal; were it possible to precipi-
tate matters in that direction, everything would
go to rack and ruin. But we know quite well that,
as a matter of fact, the progress of truth is very
slight and very slow and encroaches but little
upon falsehood.
It is, unfortunately, beyond all question, that the scien-
tific verities which penetrate the average mind sink as
though in a swamp and drown. They cause no upheav-
al and are powerless to destroy error and prejudice.
Truths of the laboratory which hold sovereign sway
over you and me, Monsieur, have no authority over the
minds of the general public. Scientific truths are not
acceptable to the public. Nations live on mythology...;
from legends they draw all the ideas necessary to their
existence. They do not need many, and a few simple
fables suffice to gild millions of lives. In short, truth
has no hold on mankind, and it would be a pity if she
had, for her ways are contrary to their nature, as well as
to their interests.”
At this moment a great clamour arose from the mar-
ketplace. Some citizens, actuated by zeal for the Army,
and in conformity with their recently formed custom,
were on their way to break the windows of [Jew]
Meyer the bootmaker. Mort à Zola! Mort à Leterrier! Mort
à Bergeret! Mort aux juifs!” they shouted; and as the rec-
tor gave way to some symptoms of distress and indigna-
tion, M. Bergeret pointed out to him that he must try
and comprehend the enthusiasm of mobs such as this
one.”
These ideas about the psychology and behavior of
masses and mobs were inspired by the great French
sociologist Gustave Le Bon in his 1895 famous 1895
work The Crowd A Study of the Popular Mind: first, the in-
dividual forming part of a crowd acquires, solely from
numerical considerations, a sentiment of invincible
power which allows him to yield to instincts, which,
had he been alone, he would perforce kept under re-
straint ... a crowd being anonymous [so that ] the senti-
ment of responsibility disappears entirely. The second
cause [is] contagion ... classed among phenomena of
a hypnotic order ... A third cause is ... suggestibility.
Isolated, a person may be a cultivated individual; in a
crowd he is a barbarian — that is a creature acting by
instinct. He possesses the spontaneity, the violence, the
ferocity, and also the enthusiasm and heroism of primi-
tive beings (cited in Lothane, 2006).
Le Bon’s ideas were embraced in 1920 by William
McDougall in his book The Group Mind and in 1921 by
Freud in his 1921 Group Psychology and the Analysis of the
Ego:
in the group the individual ... throws off the re-
pressions of his unconscious impulses ... all that
is evil in the human mind, [leading to] a disap-
pearance of conscience. ... [the group] has a
sense of omnipotence, the notion of impossibility
disappears for the individual in a group (cited
in Lothane 2006).
Freud elaborated that as a result of replacing one’s
individual conscience with that of a powerful leader and
his ideals the individual gives up his ego ideal and sub-
stitutes for it the group ideal as embodied in the leader.
... The selection of the leader is very much facilitated
by this circumstance ... the need for a strong chief will
often meet him half-way and invest him with a predomi-
nance to which he would otherwise perhaps have had
no claim ... to give up its former ideals and to espouse
the ideals of the leader (cited in Lothane, 2006).
Ego ideal and group ideal are Freud’s precursors of
the super-ego, i.e., conscience. The missing link in
Freud’s analysis of the leader mass dynamics is the con-
nection to lying. For this we turn to a master manipula-
tor of truth Adolf Hitler in his Mein Kampf.
in the size of the lie there is always contained
a certain factor of credibility, since the great
masses of a people may be more corrupt in the
bottom of their hearts than they will be con-
sciously and intentionally bad, therefore with
the primitive simplicity of their minds they will
more easily fall victims to a great lie than to a

25
small one, since they themselves perhaps also lie
sometimes in little things, but would certainly
still be too much ashamed of too great lies. Thus
such an untruth will not at all enter their heads,
and therefore they will be unable to believe in
the possibility of the enormous impudence of
the most infamous distortion in others; indeed,
they may doubt and hesitate even when being
enlightened, and they accept any cause at least
as nevertheless being true; therefore, just for
this reason some part of the most impudent lie
will remain and stick; a fact which all great ly-
ing artists and societies of this world know only
too well and therefore also villainously employ.
Those who know best this truth about the possi-
bilities of the application of untruth and defa-
mation, however, were at all times the Jews; for
their entire existence is built on one single great
lie, namely, that here one had to deal with a re-
ligious brotherhood, while in fact one has to do
with a race what a race! As such they have been
nailed down forever, in an eternally correct
sentence of fundamental truth, by one of the
greatest minds of mankind; he called them ‘the
great masters of lying.’ He who does not realize
this or does not want to believe this will never be
able to help truth to victory in this world.
See the article “Big lie” in the Wikipedia. As master of
political propaganda Hitler went his precursors one
better:
The psyche of the great masses is not receptive
to half measures or weakness. Like a woman,
whose psychic feeling is influenced less by ab-
stract reasoning than by an indefinable, senti-
mental longing for complementary strength,
who will submit to the strong man rather than
dominate the weakling, thus the masses love the
ruler rather than the suppliant, and inwardly
they are far more satisfied by a doctrine which
tolerates no rival than by a grant of liberal free-
dom; they often feel at a loss what to do with it,
and even easily feel themselves deserted.
The great mass of a people consists neither of
professors nor of diplomats. The small abstract
knowledge it possesses directs its sentiments
rather to the world of feeling. In this is rooted
either its negative or positive attitude. It is more
difficult to undermine faith than knowledge,
love succumbs to change less than to respect,
hatred is more durable than aversion, and at all
times the driving force of the most important
changes in this world has been found less in a
scientific knowledge animating the masses, but
rather in a fanaticism dominating them and in
a hysteria which drove them forward. He who
would win the great masses must know the key
which opens the door to their hearts. Its name is
not objectivity, that is, weakness, but will power
and strength.
Reich cited another statement by Hitler from Mein
Kampf, that “The people in their overwhelming major-
ity are so feminine by nature and attitude that sober
reasoning determines their thoughts and actions far
less than emotion and feeling.“ (cited in Lothane,
2019).
We conclude with Freud:
To urge the patient to suppress, renounce or
sublimate her instincts the moment she has
admitted her erotic transference would be, not
the analytic way of dealing with them ... Just as
little would I advocate a middle course ... My ob-
jection to this expedient is that psycho-analytic
treatment is founded on truthfulness. Anyone
saturated who has been saturated with the ana-
lytic technique will no longer be able to make
use of the lies and pretences which a doctor
normally finds unavoidable; and if, with the best
intentions, he does attempt to do so, he is very
likely to betray himself. Since we demand strict
truthfulness from our patients, we jeopardize
our whole authority if we let ourselves be caught
out by them in a departure from the truth. (p.
164).
QED. — which was to be demonstrated.
References:
Bok, S.(1979). Lying /Moral choice in public and private life. New York:
Vantage Books.
France, A. (1899). The amethyst ring. https://www.gutenberg.org/
cache/epub/49108/pg49108-images.html
Freud, S. (1915). Observations on transference love/further
recommendations on the technique of psychoanalysis. Standard
Edition, 12:159-171.
Lothane, Z. (2006). Mass psychology of he led and the leaders.
International Forum of Psychoanalysis, 15:183-192.
Lothane, Z. (2009). Dramatology in life, disorder, and psychoana-
lytic therapy: A further contribution to interpersonal psychoanaly-
sis. International Forum of Psychoanalysis, 18:135-148.
Lothane, H.Z. (2015). Emotional reality: A further contribution to
dramatology. International Forum of Psychoanalysis, 24(4):191-203.
Lothane, H.Z.(2019). Wilhelm Reich revisited: the role of ideology
in character analysis of the individual versus character analysis of
the masses and the Holocaust. International Forum of Psychoanalysis,
28(2):104-114.

Baby Steps: Learning Psychodynamically-Oriented
Psychotherapy as a Resident
Lekan Olaolu, MD, MPH
(with commentary by Harold P. Blum, M.D.)
O
ne of the things we looked forward to the
most about residency training in psychiatry
was starting psychotherapy. Finally, we were
going to become official members of the
“couch profession.” But as the third year drew nearer,
anxiety commingled with our eager anticipation. We
had watched therapy sessions on television and learned
about giants of the discipline, but we did not know
what to do in terms of actual practice.
The first and second years of residency had consisted
mostly of acute care in the emergency and inpatient
units. We always had the keys to the inpatient units,
and we were largely comfortable and confident in our
smugness because most of the patients we worked with
had significant deficits in reality testing, but the tables
were about to turn. The new set of patients, mostly
patients with neurotic and rather than psychotic prob-
lems, would challenge our thinking in a different way.
Fortunately, we were blessed with mentors. During
third-year orientation, one of the faculty informed us
that WE are the treatment now. Not the medications,
not the psychotherapy, not the milieu, but me. Me?

27
All our mentors emphasized the therapeutic alliance
as the bedrock of response in treatment. This height-
ened our already primed anxiety, but it also gave us a
reference, a starting point, and thereafter, the readings
kicked in.
I came across Lawrence Blum1
who said that the pa-
tient tells the psychoanalyst a story and incorporates
the analyst into that story as the sessions progress. The
analyst must be malleable to allow the patient to make
him whatever kind of character the patient wants the
analyst to be in the story. A collaboration then ensues
which allows the patient to understand their story and
write-in better outcomes. Finally, I had it all figured
out. It should be easy. Or so I thought.
Then I inherited my first patient. This young woman
had been in therapy for two years with a graduating
resident. In the beginning, she started to skip sessions
and had unlimited reasons why she was not available
to meet with me. This behavior was particularly discon-
certing because she had been consistent with the previ-
ous resident. I was stuck. The patient was not telling
me her story and it appeared she had no plan to ask
me to partake in it. I felt like I was bad treatment.
Before I despaired, however, one of our supervisors
discussed resistance and acting out with me. The
supervisor recommended that I explore with the pa-
tient her experience while she was in therapy with the
previous resident: the extent of the patient’s previous
therapy, the patient’s thoughts about her previous
therapy, her expectations for the future, and perhaps
her disappointment and confusion about having to
change therapists and start a new narrative. It worked
like magic: my patient started showing up for her ap-
pointments. She began to tell me her story and cast me
as one of the characters in the new narrative.
I felt like my career as a therapist had finally started,
but then there was the little snag of COVID-19. Train-
ing during the pandemic was a special experience both
for the practitioner and the patient. For me, I was most
concerned about the power dynamics between analyst
and patient. Conventionally, before the pandemic,
residents had offices where the patients would show
up for sessions. In that setting, residents were likely to
be uncomfortable only during the sometimes-awkward
walk with the patient to and from the waiting room to
the office.
The patient on the other hand, was always a visitor
in an environment controlled by the therapist which
made them more vulnerable to being uncomfortable.
Also, before the pandemic, the initiative was with the
patient to make the visit happen, they had to demon-
strate their own agency for participating in therapy. If
they did not show up to the hospital, there was no visit,
and resistance would be explored in the usual tradi-
tional analysis of resistance.
In the new world that the pandemic created, our ses-
sions were conducted electronically using different
telehealth platforms, and most sessions were con-
ducted on video. Because the platforms were newly
introduced, we had to call patients before each ses-
sion. Now, the initiative to make the visits happen had
shifted to us as clinicians. The patients quickly became
acclimatized to the calls and even accused me of being
responsible for their missed appointments, because I
did not call them.
Meanwhile, when I did not call, I had assumed that my
patients had the ability to use the platforms and they
did not need me in the parental role of making the
calls to initiate their visits. Truly, it was hard to know if
the need for the calls had to do with genuine difficulty
with new technology or an intense level of regression
from the pandemic.
Another interesting aspect of the video calls was the
experience of being in patients’ homes virtually.
Some patients took their phones with them into the
bathroom, some smoked, others showed their homes
both intentionally and inadvertently, and some even
introduced important people in their lives before one
could get a word in to correct the frame. Ultimately,
with the traditional office visits, patients felt a mixture
of excitement and discomfort in an environment that I
controlled. With the pandemic, however, I felt uncom-
fortable with the often more chaotic and stimulating
environment of the video calls.
To some degree, by peering into patients’ lives
through their homes, we who already know so much
more about the patients than they know about us, get
to know a lot more. This imbalance in exposure did
not make me feel more powerful. Rather, it was an-
other source of discomfort for me because the clinical
field became saturated with visual detail beyond what
would have been available through the verbal, appear-
ance, or body language vehicles often in use when pa-
tients come to the office. And it was difficult to decide
whether these details should be brought into analysis
or not. For example, I had a patient who always at-
tended sessions in a darkened room. I was confused
if this was material or if addressing such constituted a
boundary violation.
Maintaining the frame and avoiding transference
gratification were also paramount on my mind in these
settings. Did calling the patient before each session
gratify the patient? In addition, did it take the initiative
away from them to dictate what they wanted me to be
in their own story?

Some patients walk around their homes showing me
items, which in many instances, they felt might make
me better understand some of the issues they had
discussed with me before. And others, as mentioned
earlier, invited me — albeit implicitly — into intimate
places like the bathroom although nothing explicit was
involved.
These interruptions made it difficult to manage the
frame appropriately. Of course, there were conversa-
tions about finding the proper settings for sessions,
nonetheless, deviations occurred intermittently. I
believed then that these issues made it difficult for me
to achieve anything with the patients in the classical
sense of having their language and free association be
the primary mode by which we explore their uncon-
scious content. Then, I remembered what Ferenczi
referred to as “professional hypocrisy”2
which hinders
treatment: a state of being polite to the patient on
the surface while internally despising the patient —
repressed criticism that is still eventually felt by the
patient despite the therapist’s efforts to hide it.
The graphic visual fields in patients’ homes filled with
unedited information made it difficult to control the
frame and holding environment. I may have developed
significant professional hypocrisy because of my frus-
trations. I also thought about Harold Blum saying, “it is
usually safe to presume that transference is present in
some way, even when it seems to be absent; the osten-
sible absence is often an eloquent expression of trans-
ference resistance or lack of perceptiveness for some
reason on the part of the therapist”3
. Perhaps, these
situations were crucial material for treatment, and I
was ignoring them while preoccupied with creating the
classical experience.
I took these concerns into supervision. I was reminded
to check and address my countertransference, to
understand that the relationship between the patient
and the therapist is more important in the time of
the pandemic especially considering the carnage that
surrounded us. My supervisor emphasized the unprec-
edented nature of the pandemic, the adjustments that
came with it, and how we were all learning while living
through it. Supervision made me realize that the neu-
trality and opaqueness of the therapist is not meant to
be cold and unfeeling but rather to serve to allow the
patient to find their way in treatment unencumbered
by the analyst’s personality and history; and above all,
that neutrality should not compromise empathy.
In supervision, I learned to enter into a “dance” with
the patient; to follow the patient and to allow the
patient to lead the dance. I learned to be patient, to
listen, and to prioritize the relationship. I learned that
every occurrence is material to be explored with objec-
tive curiosity. I learned that the period was rife with
opportunities and mundane questions like, what did
the pre-session phone calls mean to my patients? How
did they feel if the calls did not come at all? etc. may
unearth unexpected treasure. Practical suggestions like
converting some patient sessions to phone calls only
also came up. Overall, I learned that clues and indica-
tors are as perennial as sand, I just needed to look out
for them, and I would find my way.
A few weeks later, I was providing psychoeducation
to a medication management patient who wanted to
stop taking medications against medical advice. The
patient listened and tacitly agreed with me but wanted
me to say that I recommend that medication should be
stopped. I reiterated my recommendation and stated
that the patient had the final choice of taking medica-
tions or stopping them. The patient, slightly frustrated,
said to me, “you remind me of dominant male figures.
My father was a dominant male figure, and I recently
broke up with a dominant male figure.” I temporar-
ily forgot the purpose of the session because a bulb
clicked on in my brain. Excited, I blurted out “that’s
transference!”
My first year of psychodynamic psychotherapy took
me through the twists and the turns, and COVID-19
made the novel experience intriguing. Overall, I am
still learning. I am learning not to panic when I see the
silent patient or when the unexpected happens. I am
learning to follow the affect and to maintain a relation-
ship.
The pandemic is on its last legs (we hope) but one of
its legacies is the widespread adoption of tele-health.
Going forwards, many patients will remain telehealth
patients while some will be a hybrid of both telehealth
and in-person visits. Navigating the relationships with
my patients post-pandemic will be telling of what I
have learned.

29
References:
1
Blum L. Why I Love Psychoanalysis and You Might, Too |
Psychology Today [Internet]. [cited 2021 Nov 4]. Available
from: https://www.psychologytoday.com/us/blog/beyond-
freud/201405/why-i-love-psychoanalysis-and-you-might-too
2
Ferenczi S. Confusion of the Tongues Between the Adults and
the Child—(The Language of Tenderness and of Passion). Int J
Psychoanal. 1949;30:225–30.
3
Blum H. The Transference in Psychoanalysis and in
Psychotherapy. Ann Psychoanal. 1982;10:117–37.
Acknowledgements: my sincere appreciation to all my psychody-
namic psychotherapy supervisors and mentors especially Dr. Lauren
Hanson and Dr. David Salvage who reviewed this manuscript.
Commentary on Dr. Lekan Olaolu’s Paper
By Harold P. Blum, M.D.
Congratulations to Dr. Olaolu for his admirable,
deeply thoughtful discourse on his residency experi-
ence. He is fortunate to be training in a program that
teaches psychodynamic psychotherapy. An obviously
eager and dedicated student, Dr. Olaolu learns from
and applies his excellent supervision.
I would like to briefly add to his advancing knowledge
and clinical skill further consideration of the trans-
ference-counter-transference implications of virtual
versus in person therapy. In clinic treatment, transfer-
ence to the institution is very likely to be significant as
well. Dependent, erotic, and aggressive conflicts are
experienced with far more affect intensity and impact,
in person, in the same room. It is important to note
that modifications in psychodynamic psychotherapeu-
tic technique are often necessary when treating more
disturbed patients with diagnoses such as borderline
or narcissistic personality disorders. There are many
different dance steps.
We all make mistakes and hopefully share Dr. Olaolu’s
unusual ability for reflection and capacity to benefit
from supervision.
MAGAZINE OF THE WASHINGTON PSYCHIATRIC SOCIETY
Dear WPS Members:
The editorial team Capital Psychiatry:
Magazine of the Washington Psychiatric
Society is currently seeking articles for publi-
cation in the upcoming Fall 2022 issue. Articles
should be 1500-2000 words in length that are
of psychiatric topical and scientific interest
to our readership. We also welcome relevant
literary essays in the style of The New Yorker
to allow you to give free rein to your creative
muse. We encourage members to submit brief
abstracts of articles for the Fall 2022 issue and
beyond. Please email your abstracts to
gpperman@gmail.com.
Thank you and let us know if you have any
questions. Feel free to contact me for a copy
of the Capital Psychiatry Editorial Policy.
Cordially yours,
Gerald P. Perman, MD / Editor
Capital Psychiatry
1
Winter 2022 • Volume 3, Issue 1
1
Spring 2022 • Volume 3, Issue 2

By David V. Forrest, M.D.
Photo
created
by
bublikhaus
-
www.freepik.com

31
An endlessly troublesome human conceit is our
convincing ourselves that we are better than some
other fellow humans. It is the basis of the group ethos,
usually accepted and untested in fair contest. Another
self-congratulatory focus of this conceit is our taking
pride in our capacities compared to those of animals.
Indeed, we leave baboons in the dust in drawing
geometric shapes like zigzags and spirals (Roberts,
2022). But much ethological research has eroded our
convictions of uniqueness, mostly in cognitive tasks.
Perhaps the funniest recently is goldfish learning to
drive a cart on which their tank sits (Fritts, 2022).
Lobsters unfortunately suffer. And then there are those
chimps who not only use tools, but practice medicine,
applying insect carcasses to one another’s wounds
(Cassella, 2022). Did they discover leeches? Most
enduring, aside from our hard-to-contest proprietary
claim to possession of a soul (which some dog lovers
argue is more doubtful in some humans than all dogs)
is our possession of the more complex emotions, like
empathy and jealousy, as well as much of what we dwell
upon in transference-based psychotherapy.
Despite lags in science, philosophy and religion,
everyone who has pets knows they can be jealous.
An occurrence of jealousy in a pet dog led me to think
about the mental capacities it would require of the
animal, as it does in us.
In the first image of the three in the figure below, the
mom is rubbing the belly of a chihuahua-minipinscher
dog, which he greatly enjoys.. In the second, the mom
and the boy are teasing the dog who is watching and
barking in jealousy as she rubs the boy’s belly and he
expresses exaggerated delight. In the third image the
mom is consoling the dog.
Before inferring the mental processes implicit in
the dog’s response, we may note that while the dog
is loved by all in the household, he is closest to the
mom and tries to stay glued to her. At night he is kept
in the boy’s room and sleeps with him. This works

well because it frees the mom to be alone with her
husband, and because the boy and the dog share
philosophies about bathing and about being alone at
night. When other family members and the mom talk
to the dog, they refer to her as Mommy, as does the
boy, almost as if they were brothers. She is the one who
feeds and walks the dog.
The dog is most jealous of the mom’s attention, but
the other situation that arouses his jealous anger and
alarm is when anyone lavishes attention upon the family
cat who, it happens, doesn’t care much about receiving
attention and was a pet in the house for several years
before he arrived as a 3-year old rescue dog. She easily
fends off his aggressive shows.
What capacities and mental mechanisms are needed
for the dog to be jealous?
1. A clear perception of and differentiation among
the humans involved. There is no evidence of
misidentification. The dog clearly distinguishes and is
hostile to all visitors and delivery people, barking and
growling at them, but loves everyone in the household
(except the cat).
2. A projective identification with the boy in the
situation, and the ability to make a projected and
empathetic construction that the boy’s belly being
rubbed is analogous to his own belly being rubbed.
This involves perception of the similarity of a body part
across species, and the boy’s reaction across species,
and the necessary mirroring..
3. Empathic perception that the boy’s feelings on
having his belly rubbed are the same as his own. In
this he is largely mistaken, as the boy is only acting an
exaggerated delight to tease him and is not (at this
age) into having his belly rubbed.
4. Nevertheless this implies some theory of mind on
the part of the dog, who imagines what his human
brother is feeling--but cannot figure out that it is a false
show to fool him.
5. Perhaps the dog is also splitting and experiencing the
mom without object constancy as turning onto a bad
mother and then into a good mother again when she
forsakes him for the boy and then makes up with him.
6. One time the mom accidentally stepped on the
dog’s paw, and he cried loudly. Despite their dog-and-
cat show animosity (chasing, growling, hissing), the
cat came running downstairs, approached the dog
(who was being elaborately consoled by the mom),
and touched noses with him. This was interpreted
as empathetic caring, although one family member
thought she might have malevolently been checking to
see if he was going to die.
The point of this examination
of the emotional mechanisms
that can be inferred from
the dog’s behavior is that
these complex dynamic
mechanisms, such as
identification, projection,
splitting, mirroring, empathy,
and theory of mind, are the
same complex mechanisms
that are the basis and focus
of all our psychodynamic
treatments such as
transference-focused psychotherapy (TFP), found in
not just in humans but in our domesticated pets.
In addition, this is a demonstration of Oedipal
or triadic configuration in another species. This
configuration comprises more than inhibition of
sexuality between siblings, postulated by Westermarck
to result from being reared together, and includes
emotions such as jealousy.
Mark Erickson (1993), an expert on the Westermarck
hypothesis and other evolutionary bases of human
behavior, in a personal communication (29 Sep
21) reported similar observations in his pets and
recommended an article by Kujala (2017) on the
evidence for canine emotions. Kujala distinguished
primary emotions (such as happiness, sadness,
surprise, fear, disgust, and anger) that are easier to
recognize from secondary emotions (such as guilt,
empathy, and jealousy) which “require some sense of
another’s mind” and are more difficult to attribute
and establish. In particular, she felt that jealousy is not
definitively established in dogs. In my opinion, jealousy
is difficult to avoid recognizing in the above example.
References:
Cassella C (2022): Chimps use insects to Soothe each other’s
wounds in never-before-seen behavior, Nature Science Alert 7 Febru-
ary 2022.
Erickson MT (1993): Rethinking Oedipus: an evolutionary perspec-
tive of incest avoidance, American Journal of Psychiatry 150(3):411-
416, March 1993, published online 1 April 2006.
Fritts R (2022): Goldfish are good drivers, new ‘fish-operated ve-
hicle’ reveals, Science 4 Jan 2022.
Kujala, Miiamaaria V. (2017): Canine emotions as seen through
human social cognition, Animal Sentience 14(1)
DOI: 10.51291/2377-7478.1114.
Roberts S (2022): Decoding shapes: grasping geometrical concepts
may make humans special, The New York Times, Science Times 22,
2022, pp. D1, D5.

33
El Lenguaje de Nuestros
Ancestros:
Amplifying the Historical
Lens on Latino Mental Health
Sheila Panez, MSIII and MPH candidate*
*MPH Candidate, UCI Program in Public Health
MS3, UC Irvine School of Medicine
Program in Medical Education for the Latino
Community (PRIME-LC)
E: spanez@uci.edu | P: (310) 953-7740
Susto, preocupación, estres — these are common words
used in place of ansiedad among Spanish-speakers.
Many pieces of historical literature have captured the
large-scale adversity and corresponding emotional
trauma that afflict the Latino community. The health
of this patient population ensued by plight has been
examined through the lens of diverse Latin American
societies. I hypothesize that these differences in inter-
pretations and labeling of the emotional affect follow-
ing structural violence cause the conception of mental
health concern in the community to go ill-defined.
As a heterogeneous population, we have learned to
define our own mental health schema into a unique
cultural entity that contrasts with that of American bio-
medicine. This dissonance is misperceived as a stigma
against mental health. As the future caretakers for this
vulnerable population, it is imperative that we recog-
nize this public health issue that has been marginal-
ized by the medical community’s discourse. We must
understand the complexity of this concept and address
it in our practice to be able to heal the whole patient.

For decades, Latinos who immigrated to this country
have been met with overwhelming hardship. As seen
under the 1893 National Quarantine Act, “in El Paso,
and along the [Mexico] border in general, forced
nudity and totalizing disinfections continued into the
late 1920s, long after the typhus panic had subsided”
(Stern, 49). Although this law was enacted with the
pretext of safety from the typhoid epidemic, it is evi-
dent that this was an act of intentional discrimination
for “Mexicans, as well as all other immigrants seek-
ing entry through El Paso, for they found themselves
subjected to elaborate medical inspection that differed
in significant ways from procedures that were also in
effect at Ellis and Angel Islands” (Stern, 45). After
reading this, one cannot help but wonder how these
blatant acts of prejudice were supported by law and
funded by the Federal Government.
Unfortunately, this account of institutional racism,
discrimination, and injustice is only one of many
documented instances. Since the current rhetoric in
American society criminalizes immigration across the
Mexican border, the accounts of inconceivable burden
are kept silent, left at the border, or discreetly passed
on to the next generation to shoulder. I remember as a
child how my mother’s undocumented status plagued
her mind with constant fear. She was consumed with
susto — as they would call it — that one day she would
be reported, met with heinous acts from the U.S. Cus-
toms and Border Protection and ripped away from her
one and only family.
This is a pervasive norm for our people as “this fear of
being deportable can be just as devastating as deporta-
tion itself, leading to self-monitoring behavior such
as avoiding medical appointments, not seeking help
from police, or staying at home and avoiding ‘danger-
ous’ public spaces, even going to the grocery store”
(Chavez, 72). So then, one must ask how the needs of
this community are met if the very society that is sup-
posed to provide it coerces them into self-deprivation
of basic rights. Furthermore, how would living in this
constant state of tension and fear affect one’s health
and that of their family?
This is where the issue becomes further compounded.
Mainstream media has rewritten our narrative and led
us to believe that there is a mental health stigma within
our community. This could not be further from the
truth. Mental health has always been in our discourse
but expressed in its very own unique way. As a teen-
ager I remember rolling my eyes as my mother would
take out a bottle that read “Valeriana.” This was always
followed by “vas a tomar una tasa de Valeriana con tu
Aguita de Azahar para los nervios” the night before a
big exam.
Border photo by Wikipedia.

35
At the time, I believed this to be a nonsense remedy
passed down by my abuelita. Little did I know that
this was a product of cultural belief rooted in the
“enormous role that curandero(a)s [played] in the area
of treatment of psychosomatic and nervous system
problems” (Bussmann, 12). This traditional use of
medicinal plants dates back 2,000 years as a common
practice in Northern Peru. It goes on to say that my
mother never neglected mental health given some sort
of cultural stigma, but rather she did not label my test-
related anxiety as such.
In medical school we are taught that anxiety is a
product of chemical imbalance of neurotransmitters
and must be corrected in accordance with that (i.e.
SSRIs). For our community though, mental health is
not a biomedical concept but rather one intertwined
with spirituality. Given this, there are many synonyms
for anxiety in our dialect as it is considered a strong
emotion linked to the state of our soul rather than a
medical condition with a definitive diagnosis.
“Susto” has been a documented widespread phenom-
enon across Latin America as early as the 1960s. From
“a psychological perspective, susto has been linked to
loss/grief reaction, post-traumatic syndrome, or stress
and depression” (Herrera et al., 72). This has been fur-
ther explored in the field of medical anthropology in
which mental health is perceived diversely among dif-
ferent Latin American countries. “In Punata, Bolivia…
social conditions [are viewed to] produce emotional
responses that become embodied in illness” (Herrera
et al., 73).
“Among the Nahua, [susto] is related to relationships
between humans and nature or with other humans,
and with situations that escape the control of the
person, violence being a key example...Conflict be-
tween family members and neighbors, violence and
relationship experiences generate life conditions that
lead individuals to experience fear in their daily lives.”
(Herrera et al., 79). This ambiguity of the collective
concept of susto is further emphasized in Paucartambo,
Cuaco, Peru. “A prototypical account of susto is recog-
nized (lethargy, disturbed sleep/appetite, diarrhea,
one sunken eye) [but] …has no single, definitive and
universally shared set of symptoms in Paucartambo.
Many yachaqs do not diagnose based on symptoms, but
rather on reading the coca leaves or through spirit or
dream revelations; symptomatology therefore holds
only secondary importance. These accounts as a whole
give insight into “how communities may link condi-
tions such as susto to ‘social suffering’…more often
than is sometimes recognized” (Herrera et al., 75).
Thus, recognition of these affects and their varying
descriptions that reflect the social fabric of the time
References:
1
Stern, Alexandra Minna. “Buildings, Boundaries, and Blood:
Medicalization and Nation-Building on the U.S.-Mexico Border,
1910-1930.” Hispanic American Historical Review, vol. 79, no. 1,
1999, pp. 41–81. Crossref, doi:10.1215/00182168-79.1.41.
2
Chavez, Leo. “Diminished Citizenship.” Anchor Babies and the
Challenge of Birthright Citizenship (Stanford Briefs), 1st ed.,
Stanford Briefs, 2017, pp. 55–79.
3
Bussmann, Rainer W., and Douglas Sharon. “Traditional
Medicinal Plant Use in Northern Peru: Tracking Two Thousand
Years of Healing Culture.” Journal of Ethnobiology and Ethno-
medicine, vol. 2, no. 1, 2006. Crossref, doi:10.1186/1746-4269-2-47.
4
Herrera, Frida Jacobo, et al. “Susto, the Anthropology of Fear
and Critical Medical Anthropology in Mexico and Peru.” Critical
Medical Anthropology: Perspectives in and from Latin America
(Embodying Inequalities: Perspectives from Medical Anthropology),
New edition, UCL Press, 2020, pp. 69–89.
5
Hoskins, David, and Elena Padrón. “The Practice of Curanderismo:
A Qualitative Study from the Perspectives of Curandera/Os.”
Journal of Latina/o Psychology, vol. 6, no. 2, 2018, pp. 79–93.
Crossref, doi:10.1037/lat0000081.
are difficult to capture and labeled as just “anxiety” or
“depression.”
As the future healers of this community, we must
combat the mental health crisis and transgenerational
trauma with a two-fold approach. We must utilize our
agency in society to bring attention to the structural vi-
olence that discriminates against and further marginal-
izes our community and their voicing of injustice. And
furthermore, we must correctly identify and remedy
the long-standing trauma within our community with
cultural humility and an understanding that Latinos
are not a homogenous group.
All stages of medical education must adapt to this
notion as “many mental health practitioners lack the
training to address spirituality with Latina/o clients”
(Hoskins and Padrón, 80). If we want to provide the
best quality care to this vulnerable community as their
healers, we must acknowledge and learn of our history.
After all, healers and curanderos are direct transla-
tions of one another - why then do “many individuals
of Mexican descent who utilize Curandera/os in the U.S
do so in private…[and] do not share their use with
mainstream mental health practitioners” (Hoskins and
Padrón, 80)?
As the future caretakers of generations of Latinos,
let us heal years of unjustified psychological trauma
by working with the cultural beliefs of our ancestors.
Our rich Latin American history and health practices
do not need to be mutually exclusive but rather com-
bined into a synergistic effort to where we can promote
mental wellbeing in our community and uplift from
our roots.

An Overview of Commitment Process for Children and
Adolescents Amidst a Declared National Emergency:
Update on Act 65 of 2020, Pennsylvania Mental Health
Consent Law (Gabby’s Law)
Mayank Gupta MD1
; Jeffrey Moll MD1
; Mary Ann Albaugh MD2
1
Clarion Psychiatric Center, Clarion PA 16214
2
(The opinions expressed in this article are not necessarily the opinions of the Pennsylvania Psychiatric Society or its leadership)
Introduction
In the last year, the mental health crisis of children and
adolescents has been on the national headlines. Lately,
in October 2021 the American Academy of Pediatrics,
American Academy of Child and Adolescent Psychia-
try, and Children’s Hospital Association1
have declared
it’s a national emergency, and subsequently, U.S.
Surgeon General Issued an Advisory on Youth Mental
Health Crisis2
exposed by SARS-COV-2 Pandemic. The
White House has echoed similar announcements in
the February 2022 state of the union address3
, focusing
on increased funding and policies for the children and
adolescent mental health crisis.
Given the heightened need for emergency services, it’s
important to understand the current trends., and legal
standards for the civil commitment of minors. Given
the highly complex nature of these decision-making
processes, we have provided a broad overview of the
historical context and current legal standards.
Trends
The Mental Health America reports Pennsylvania
was ranked fourth with nearly 12.88 % of children
from ages 12 to 17 having a major depressive episode
(MDE) in the last year. And seventh among substance
use disorders among youth with rates as high are
3.52%4
. In 2018 suicide was already the second leading
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37
cause of death among 10- to 24-year-olds5
. According
to the Centers for Disease Control and Prevention, by
May 2020, the number of emergency visits for sus-
pected suicide attempts had increased 31% from the
previous year among adolescents ages 12–176
.
According to a metanalysis of 29 studies, the preva-
lence of depression and anxiety symptoms doubled
during the pandemic with rates increasing among
older adolescents and in girls7
. These trends point
towards multifactorial etiology and a surge among chil-
dren and adolescents requiring treatment is expected.
Given a serious workforce shortage, the increase in ER
visits is reflective of the overall burden of mental illness
and how the global pandemic may impact the need for
acute mental health services.
By 2015, almost 13% of ER stays for mental health
visits for children increased to 12 hours or more from
5% in 20058
. During the pandemics these wait times
extended for days and in some cases for weeks to find
an appropriate bed9
.
Historical Perspective on Civil Commitment
In the United States, the principles of informed con-
sent and commitment to mental health treatment have
evolved in the last two centuries. The understanding
of many overlapping concepts and variations in the
statutes is required in stages of uncertainty.
Parens patriae (Latin for “parent of the nation”) is the
main concept behind the civil commitments of the
mentally ill until 196010
. However, after the civil rights
movement, it was recognized to address the rights of
other disenfranchised groups including mental health
patients.
On July 1, 1972, California’s Lanterman-Petris-Short
Act (LPS Act) first landmark statute signed by then-
Governor Ronald Reagan was sought to, “end the inap-
propriate, indefinite, and involuntary commitment of
persons with mental health disorders”11
. It was also the
beginning of mandatory inclusion of the dangerous-
ness assessment and the need to meet the essential
threshold for civil commitments of the mentally ill.
The pendulum often drifts on two sides, the first ethi-
cal principle of nonmaleficence (not harm) where
mentally ill patients are committed for the treatment
of underlying impairments and secondly from the posi-
tion of liberty12
.
Another landmark case of Lessard v. Schmidt, 349 F.
Supp. 1078 (E.D. Wis. 1972) set the highest watermark
for involuntary commitment law. This established a
standard that requires the criterion of dangerousness
assessment and due process.
Most states refrained from implementing all the
restrictions as per this case law. But a few followed the
Wisconsin standard providing patients the” right to
remain silent” or in imposing a “beyond a reasonable
doubt” standard for commitment13
. The Lessard court
also constitutionalized the right to the “least restrictive
alternative,” taking note of Judge Bazelon’s decision in
Lake v. Cameron (364 F.2d 657 (D.C. Cir. 1966)14
.
O’Connor v. Donaldson 422 U.S. 563 (1975)15
was
another landmark decision of the US Supreme Court
in mental health law ruling that “ a state cannot con-
stitutionally confine a non-dangerous individual who
can survive safely in freedom by themselves or with the
help of a willing and responsible family members or
friends.”
These events were instrumental in the de institutional-
izations of mental health systems in the late 1970s and
1980s. Addington v. Texas, 441 U.S. 418 (1979) ruling
states16
that “ to meet due process demands in com-
mitment, proceedings, the standard of proof has to in-
form the factfinder that the proof must be greater than
the “preponderance of the evidence” standard appli-
cable to other categories of civil cases. However, use of
the term “unequivocal” in conjunction with the terms
“clear and convincing” in jury instructions (as included
in the instructions given by the Texas state court in this
case) is not constitutionally required, although states
are free to use that standard. Pp. 441 U. S. 431-433.”
The message from these landmark cases was loud and
clear: it was a legal requirement for every state to set
standards to assess the level of dangerousness when
commitment is considered for the mentally ill. The
standard of proof required must be at least clear and
convincing (substantially greater than a 50% likeli-
hood of being true) but could be even higher. And the
due process must be followed with strong consider-
ation to side on the patient’s right for a “least restric-
tive alternative.”
Civil Competencies
The right to treatment and refuse treatment in adults
have been extensive legal discourse that started during
the last century. Many landmark cases laid the founda-
tion of current statutes. Perhaps Rouse v. Cameron,
373 F.2d 451 (1966) and Rogers v. Commissioner of
Dept. of Mental Health, 390 Mass. 489, 458 N.E.2d 308
(1983) are few worthy mentions17
.
Another serious but prevailing issue is the requirement
to assess the competencies of the mentally ill who are
accepting voluntary treatment. A landmark judgment
Zinermon v. Burch, 494 U.S. 113 (1990) sets another
clear legal standard18
; which states “[T]he very nature

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