And now, Lee

September 9th, 2011 by gelenberg No comments »

As I matured as a therapist, I started integrating elements of Buddhism into the psychodynamic approach in which I had been trained. (I believe Marsha Linehan did something similar in creating DBT, and I enjoyed Jack Kornfield’s book, A Path With Heart.) In particular, I have always been stirred by the simple wisdom in AA’s Serenity Prayer. As we stop banging our heads against the walls of things we cannot change, we have more energy to affect things we can change. I have tried to help patients find comfort and their own paths forward by accepting the many forces before which we stand helpless. I have shared that wisdom with my own children. And like Alice in Wonderland, sometimes I even try to follow my own advice.

Recently I posted a blog on my flight before the fury of Hurricane Irene on the Atlantic Coast. I didn’t know it when I wrote the blog, but soon after, the worst devastation from the storm hit not along the coast, but inland—particularly with flooding in Vermont. This week Tropical Storm Lee pounded my community in Central Pennsylvania with record floods.

When I first heard about global warming, I assumed the slow process of year-by-year temperature elevations would take many decades to affect real life. But climate scientists say the short-term effect is to increase weather volatility. When I moved from the desert southwest to Wisconsin in 2007, I expected a personal climate change—but not the record-breaking snowfall that began the day I arrived in Madison. Record-breaking snow followed me to Hershey, Pennsylvania, the week I moved here after Christmas in 2009. And this week my hospital was briefly isolated, I had to wade home through serious flooding, roads and buildings collapsed, our municipal sewage system has gone down, and I worry about weekend coverage for inpatients at our psychiatric hospital.

I can make small, personal efforts to conserve energy and reduce greenhouse gases. But I am helpless against nature’s fury when it appears. I can try to take reasonable steps to be prepared, and when disasters strike, I can work with colleagues and my community to help those in need. But truly we are small, and natural forces are immense. As doctors, we seldom cure, but usually we can attenuate symptoms and relieve suffering. I try to acknowledge what I can’t change and focus on what I can.

The pounding I saw from two back-to-back tropical storms taught me one other thing: the necessity of the social compact we call government. My state and community have good infrastructure, and today President Obama declared this a disaster area, allowing federal assistance. While some congressional representatives and presidential candidates rail against all government as evil and unnecessary, I realize that a well-functioning government is people helping people. It’s who we are, and it gives us more options and help in the face of powerful forces.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

 

Irene

August 28th, 2011 by gelenberg No comments »

After a two-decade absence from the East Coast, I decided to pay an overdue visit to an Atlantic beach. A few months back, my wife and I booked 3 nights in a B & B in Cape May, New Jersey, and I took 2 days’ vacation from my university duties. We arrived Thursday afternoon, unpacked quickly, and set out for a couple of hours to survey the lovely beach community. Coming back to the beautiful Victorian guesthouse to change for dinner, we learned of a mandatory evacuation courtesy of Hurricane Irene, bearing down on the heavily populated region from the Carolinas up to New England. Our brief holiday had been cut short. Bummer!

We dined, got to bed early, awoke at sunrise, downed a quick breakfast, and set out for an uncertain drive home. The coastal evacuation stretched from North Carolina through northern New Jersey. We knew there would be serious traffic.

My new car feeds real-time traffic updates into the GPS guidance system. As I drove, my wife sat with an iPad on her lap, receiving live route information and weather reports. We were fed and rested. And since our home in Central Pennsylvania is well inland, we had a safe, secure destination. In short, we were as fortunate as people could be in an unpredictable situation where nature shows its awesome destructive potential. And we live in a country with basically sound social and physical infrastructure. But it was unsettling, nonetheless, and we felt anxious and small in this mass movement of people before a huge storm. When we arrived home, we were drained and exhausted.

My experience, minor in the scope of our lives, and trivial in the eye of the universe, gave me renewed empathy for people dislocated, “turned upside down,” and traumatized by big events beyond their control: natural and human-caused. PTSD, a regular subject of my newsletter, BTP, is painful and disabling—affecting perhaps 20% to 25% of those with a vulnerability when they undergo severe trauma. People with PTSD have trouble restoring their equilibrium after civilian or military catastrophes. They are hurting and need help—from clinicians, social agencies, governments, and neuroscientists.

And when natural or man-made disasters strike—like wars, earthquakes, and hurricanes—the mentally ill are especially vulnerable. The assets I had—an intact marriage, access to information via expensive services, physical and mental health—are unavailable to most people with chronic psychiatric illnesses. Most often, they lack safe, secure, reliable resources. And their ability to make quick, rational decisions under stress is typically compromised. When major threats loom, let’s keep them in mind and look out for their needs.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

 

Choosing A Job

August 1st, 2011 by gelenberg No comments »

Residents frequently ask senior colleagues for guidance on choosing a job—especially their first out of training. Here are a few thoughts.

No one needs to be told the importance of location and type of practice; those speak for themselves. I always put stress on the reputation of the person and organization who will be the employer. Honesty, integrity, concern for the welfare of physicians and other employees are cardinal. Prospective employees sometimes think a written contract protects them. A contract can serve to clarify details. But ideally, after a contract is signed, it should go into a drawer and never be seen again. If one needs to pull it out and re-read it, something is going wrong, usually with trust. I would rather make 20% less from an employer I can trust than sign a “sweet deal” in writing with a less trustworthy party. If a contract dispute becomes adversarial, the employee is likely in for years of unpleasant proceedings, stress, and expense and, in the end, will be lucky to see 50 cents on the dollar—usually much less.

Everyone thinks about salary. Benefits too should be counted. Some benefits are more relevant to an individual than others—depending on family circumstances, for instance. And as important as money is, remember that it’s a vehicle to quality of life. Work type, hours, flexibility, call, the caliber and “fit” of associates also feed into job satisfaction.

Don’t forget commuting. The more time one spends on the road, the less time is available to read, enjoy recreation, and be with loved ones and friends. Some communities allow shorter commutes or public transportation that may allow work or leisure to and from work.

Do something you like, care about, feel good about. Work with people you respect and enjoy. These variables are hard to quantify but very, very important to leading a good life.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

 

 

It’s hot!

July 20th, 2011 by gelenberg No comments »

I spent a week with family in Tucson recently, where it was 114 degrees in the shade. I’m back in Pennsylvania now. Today the heat wave that has steamed the mid-west lately rolls east, with temperatures north of 100 and high humidity. My life consists of an air conditioned home, car, and hospital. I am outside in this “soup” for short walks between these cool venues and for my early-morning jog.

Many of my patients are not so lucky. They live in less optimal environments—especially in summer—and have few options to escape heat. Add to that poor judgment: patients with schizophrenia often overdress and are unable to dissipate body heat. And many psychiatric (and general) medicines impair thermoregulation. Being elderly makes things worse too. When the heat’s on, as it is here today, remember the psychiatric patient, who may need extra consideration for health and safety.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

 

 

Resilience

July 8th, 2011 by gelenberg No comments »

A few days ago my father-in-law celebrated his 100th birthday. Someday a lot of people may reach that milestone, but today few do. What impresses me is not that he made it (a testimony to his genes more than his less-than-healthy lifestyle), nor that he remains cognitively sharp. What impresses me is his amazing positive attitude. Almost always, he is “up.” He sees opportunities, even at his age. He finds reasons to laugh, celebrate, get excited.

Duane grieved deeply when his wife died. But he rebounded, set a new course (he was 90), and move forward. At his 100th birthday party, he entertained four generations of family members with witticisms that could be on his gravestone.

Presumably by the luck of the genetic “draw,” some of us run on the depressive end of a mood spectrum: seeing the dark and ominous side of every development, the glass half empty. Others, like my father-in-law, see what’s possible, visualize the positive, and make it happen. I just read a book by Dean Karnazes, who embodies this grab-life-by-the-horns approach and inspires others.

Good parents help their more anxious, depression-prone kids to modulate their darker thoughts and world view. They move these young people further to the optimistic, resilient end of the mood spectrum. Truly, it’s not immutable. People can learn to see the good possibilities. CBT and most therapies try to help in that vein.

I think my centenarian father-in-law inherited good genes. But he also made conscious choices over his long life, and he benefited from many of them and achieved joy and a sense of purpose.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

 

 

 

In Memorium

May 30th, 2011 by gelenberg No comments »

Memorial Day, originally called Decoration Day, is a day of remembrance for those who have died in our nation’s service.”

It’s the Memorial Day weekend. For most of us that means leisure, barbeques, picnics, family, friends, and fun. It represents the fruits of living in a prosperous country, even as we climb slowly out of a recession (we hope). But let’s not forget the remembrance.

I served in the U.S. Army Reserve Medical Corps for six years, during which the U.S. did away with the military draft. I had misgivings then and still do. I fear our current all-volunteer military insulates the rest of us from the costs of combat—financial and human. My kids were never at risk, and I pay proportionally so much less in taxes than before Reagan was president—despite two ongoing and very long conflicts. The scars of battle tend to be borne disproportionally by those from lower socio-economic classes.

When a nation asks its young to put their bodies and lives at risk for others, noble souls always step forward. And a proportion of these altruistic and idealistic warriors come home dead or badly damaged. At a minimum we owe them and their families care and protection. It grieves me deeply to hear of families wrecked, homes re-possessed, and veterans with PTSD and traumatic brain injury (the 2 signature injuries of today’s conflicts) receiving sub-optimal care. Whatever the financial sacrifice those of us at home must bear to remediate these hurts, we owe the veterans and their families no less and so much more.

-Alan J. Gelenberg, M.D.
Editor,
Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief,
Journal of Clinical Psychiatry

 

 

Do You Read Me?

May 27th, 2011 by gelenberg No comments »

Doctors are blessed with a broad array of ways to stay current in our field these days: so many formats, so many platforms for reading. But not reading (or at least getting new knowledge via audio) is not an option. Not staying current would be unthinkable. Or it should be.

I am not the only medical educator concerned that many medical students and residents are not reading, or not reading enough. Some medical students read the “Cliffs notes” instead of texts in Psychiatry, Medicine, Pediatrics, etc. Many residents take shortcuts or believe they can absorb enough knowledge by practice (including unsupervised moonlighting), supervision, and “osmosis” to get by. And despite recertification requirements and CME, I run into numerous practitioners who are not keeping current with their specialties.

The challenge falls on faculties—of undergraduate and graduate medical education—and on physicians who create regulations on continuing education. I don’t want my loved ones treated by doctors who aren’t up to date.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

In The Moment

May 20th, 2011 by gelenberg No comments »

I just attended the APA meeting in Honolulu. One day I got in a little pool time. Sitting in an idyllic Hawaiian setting, on a perfect day, I glanced around and noticed about half the people at the pool were talking on cell phones. I pass people on the street walking with their children but gossiping with friends on the phone. Pet owners often miss out on the joy of play with their furry companion in favor of seemingly trivial chatter. Climbing Diamondhead outside of Honolulu, I reached the top, marveled at the site (and caught my breath), and had to step around distracted people on their cell phones. Let’s not even touch the subject of distracted driving.

I love many of the advances modern technology has brought us—including the ability to keep in touch across miles, to reach out to loved ones through satellite communications and so many electronic formats. But moments of intimacy, awe, play, solitude, and quiet are vital to our souls. Let’s not drown them out with noise.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

 

 

 

 

 

 

What Do You Know?

April 27th, 2011 by gelenberg No comments »

As a physician I’ve long been struck by the observation that the best doctors are not those with the largest scope of knowledge or skills. Rather, the finest clinicians are the ones who know what they don’t know. Being comfortable with our vast areas of ignorance makes us safe for patients. We can learn the answers to clinically important questions. These days, most facts are as close as the smart phones we carry in purse or pocket. Or we can refer a patient to a colleague. Over the course of my career, acknowledging that I don’t know something has become easier as I’ve grown more self confident.

And what I’ve learned as a practitioner—knowing my limits—carries over to my role as an administrator. I am no expert in many of the areas of management: e.g., human resources, finance, accounting, legal, and more. But I have grown comfortable in saying “I don’t know” and asking others. In a world of growing complexity, it’s reassuring to be part of a team.

- Alan J. Gelenberg, M.D.
Editor,
Biological Therapies in Psychiatry
Shively-Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief,
Journal of Clinical Psychiatry

 

 

 

Therapy Is A Journey

April 15th, 2011 by gelenberg No comments »

If a patient has taken medicines, I always get as much detail as possible: dose, duration, response. If a patient has been involved in psychotherapy, I try to learn what in the patient’s life has changed and through what means. People who demean and disparage the whole concept of psychotherapy claim it’s simply rent-a-friend. It can be, but ideally it should be much more.

Our goal as parents is to render ourselves obsolete. That’s also what I aim for when I’m a therapist: helping patients achieve the competence and confidence to kick off their “training wheels.” Even supportive psychotherapy should have an “end game.” Patients who seem to require the regular advice and encouragement of a professional can be coached on other sources of support: friends, interest groups, religious organizations. Symptom-based treatments or therapies designed to achieve behavior change should move progressively toward specific goals. Progress should be measurable. Endless therapy should be the exception.

When I take a patient’s history, and the patient has been in therapy, I hope to learn that therapy has provided a vehicle, that the patient and therapist have been on a journey—toward a destination. If therapy has just been a place to go and talk, if there has been no obvious progress, I raise questions.