 Good afternoon, it's a pleasure to welcome you on behalf of the McLean Center, the Center for Health and Social Sciences, chess, and the Bucksbaum Institute to today's lecture in our 2019-2020 series on the present and future of the doctor-patient relationship. I'm delighted to introduce a dear old friend who will be our speaker today, Dr. Laura Roberts. For the past 10 years, Dr. Roberts has served as the chair of the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine, where she's been the Catherine and Stanley McCormick Memorial Professor at Stanford. From the beginning of the Bucksbaum Institute in 2011 here at the university, Dr. Roberts has been a distinguished member of the advisory board. An internationally recognized scholar in bioethics, psychiatry, medicine, and medical education, Dr. Roberts' work has led to advances in understanding of ethical aspects of mental health, mental illness research, societal implications for genetic innovation, the role of stigma in health disparities, the impact of medical student and physician health issues, and the optimal approach to foster professionalism in medicine. Widely published, and I mean widely published, Dr. Roberts has written hundreds of peer-reviewed articles and has also written or edited more than 25 books, including the American Psychiatric Association textbook in psychiatry in its seventh edition. Other books by Dr. Roberts are in areas of professionalism and medicine, psychiatry, medical psychiatry, and the like. In addition to being widely published, Dr. Roberts is an editorial board member and reviewer herself for many scientific and medical journals. She's the editor-in-chief of books for the American Psychiatric Association and recently in the last three or four months was appointed as the editor-in-chief of the well-known journal Academic Medicine. One of the earliest fellows here at the McLean Center, Dr. Roberts was the recipient of the 2015 McLean Center Prize in recognition of her wonderful work in clinical medical ethics and psychiatry. She's also received the Distinguished Psychiatrist Award from the American Psychiatric Association and was recognized by the University of Toronto. I'm done. I'm about done. Okay, I won't even say that. She's earned many NIH R01 awards among the many grants that she's received. Today's talk, as you can see behind me, is entitled, The Therapeutic Relationship. No, Modern Perspectives on Psychiatry and the Therapeutic Relationship. It's a pleasure to welcome Dr. Laura Roberts here back to you. Thank you. My favorite personal attribute is that I get to boss him around and say enough already, enough. And I have to tell you, it is so fun for me to be here because I spent a lot of hours in this room as a medical student. And I was saying there's magic in one of the seats back there and three that I really was a wonderful, wonderful perspective on medicine. So I know this is a series on the doctor-patient relationship. But I'm going to use the occasion just to talk... Move it up. Is that better? Thank you. I'm going to use the occasion to talk about psychiatry as a field and then we're going to move down to the specific question of the therapeutic relationship in psychiatry and whether we're a special case. Is there something unique or different about us than, say, any other area of medicine? In terms of disclosures, I work at Stanford. I've got grant funding. I do get paid from the AAMC for my editor job and I don't get paid for my other job. So we're going to talk about, first, just a really important point about making a psychiatric diagnosis. We're going to talk a little bit about the overall disease burden of psychiatry mental disorders throughout the world. Amazing things that are happening in the field, changes right now, kind of moving out of a period of a fair amount of conflict and controversy into real scientific breakthroughs in psychiatry. And then we're going to land on this question, is there something different about us than in other areas of medicine? So to make a psychiatric diagnosis, this is from the DSM-5. This is our diagnostic manual. You have to have a clinically significant disturbance in cognition, emotion, regulation, emotional regulation or behavior. Significant distress or disability. An unexpected or culturally approved response to a common experience like grief would be a typical example is not a disorder. Even if you went through the book and you could tick off different symptoms. And even if you did have a diagnosis of a mental disorder, it doesn't mean that there's an imperative for treatment. So it's a little bit different. It's certainly different than I think how people view it. What happens, they Google symptoms of depression. They say, oh my God, I've got every single one of those symptoms. I must have depression. But actually that's not the case. Really the first question, kind of the first branch in the logic is are you in distress? Are you uncomfortable losing ground in your life, not advancing in your life, in areas of social work, personal growth, as well as your physical health? So why does that matter? It matters because, again, we're going to look at a more modern view of psychiatry. A more modern view of psychiatry is much more oriented to resilience, your adaptation. You were dealt a certain hand in the card game of life, and how are you playing with that hand? How are you doing in your life? And I love this quote, although the world is full of suffering, it is full also of the overcoming of it. And I think this is a really important concept about kind of a newer view of psychiatry, which is take the skills, the strengths, the things that you have, do the best with them, and try to find a way of adapting in your life. Because we all have something. We all have something we've been dealt. We all have challenges. So the real issue is whether you can flourish in your life. Very different point of view. So this modern perspective on psychiatry is much more focused on resilience, on understanding the impact of trauma, and understanding not just nature and nurture and neighborhood, but how you put it all together and how you move through your life given those experiences and your predispositions and the exposures of your life. Let's remember that mental disorders affect everybody, touch all of us directly or indirectly. Both genders, all ages, every family, every community, every nation. A profound cause of suffering, disability, and death throughout the world and immense societal costs. And I'm going to work us through those specific claims. So about 800 million people throughout the world are 10, almost 11 percent of the world's population have a mental disorder. And the average age of onset is 14. Now take a minute. Average age of onset is 14. So what it means is that it hits hard, it hits early, and if it is not addressed, it becomes a threat to your health and well-being through the decades to come. So these are very significant conditions, but that's part of why it has such significant disability throughout the world is that it hits hard and it hits early. And as you can see, so the mental disorders are like the deeper purple color, and they progress and peak in start early, but peak are in the working years, but they're carried all the way through end of life. And substance use disorders similarly go up kind of through the productive, the optimal years of your life, making attachments, building your life as an independent adult and doing the work of your life. And if you look at the world, mental disorders are the fifth leading cause of disability-adjusted life years globally, so that's a year of life lost due to premature mortality or disability, and mental disorders are the fifth leading cause of disease burden throughout the world. So very underappreciated, very under-recognized phenomenon, and also behavioral factors often contribute like tobacco use, substance use, obesity, things that have behavioral contributors or determinants are also a huge influence on the main causes of disability throughout the world. And it's getting worse. If you can look in the upper right, left-hand corner is 1990 and now 2017. And so you see that it goes from lighter to darker. The only country I can figure out that did a little bit better in all of that is Canada. But in general, the world, it's progressing to where there's greater trauma, mental health issues, threats to mental well-being throughout the world. And then if you specifically look just at disability, not premature mortality, depression is increasing. It's ascending in terms of its impact. And by 2020, depression will be the single diagnosis biggest cause. So that's this year of disability through the world. We think by year-end statistics. 2030, the number of mentally ill elders is expected to quadruple, and so it may outpace late life depression versus cognitive deterioration associated with mental disorders, Alzheimer's disease, et cetera, in the next decade. Tobacco is huge. And the use of substances that leads to other kinds of unintentional injuries, to axe car accidents, these are very significant contributors to worldwide mortality. And in the United States, about one person dies every 15 minutes due to direct consequences of alcohol use. 60 million binge drinkers in our country of 330 million people, half of whom are adults. So very, very significant contributor. And of course, we're all chilled to the bone by unintentional deaths associated with opioid use. 128 people in the U.S. die every day from opioid overdoses, most of which are unintended. 68% of all drug overdose deaths involve opioids, and so we really have a crisis. And if you can just look at the trend, it's just fairly dramatic in the number of these deaths. And vaping, we got a new problem on our hands. Vaping is a very significant issue. 37% of 12th graders in a very large, very rigorous study conducted by the CDC with partners showed that graduating high school seniors are using vape products, and there's been a dramatic increase, two and a half times increase in just the last few years in vaping. Eighth graders, so going early on, is doubling over just the last few years. And of course, we're concerned about how this lays in circuitry, I'll get to this, but it kind of lays in addictive circuitry, remodels the existing motivation, circuitry of the brain, commandeers it into an addiction platform for life. About 800,000 people commit suicide throughout the world, and it's not evenly distributed. The darker colors are where this is more serious threat to the health and well-being of the population. But we think it's underreported, so maybe a million is a more accurate number or more. And it's now emerged as a second leading cause of death in young people, so it outpaced other causes just in this last few years. One person dies every 11 minutes from suicide in this country, but there are about 1.4 million suicide attempts each year in this country. So, parasuicidal behavior, in addition to suicide, is a huge driver of use of resources, emotional distress, devastation of families. Very, very common, let's see, it's kind of hard to read, but 10 million adults had serious thoughts of committing suicide in the last year in the US, and 2.8 million made suicide attempts in this one study in 2018 as an estimate, and then 1.3 had formal actual attempts. So, yeah, suicide plans, rather, and the overall suicide rates are increasing. Now, if you look at specific subpopulations, I've already talked about young people, but veterans, members of the military, and other subpopulations like the last Native American Indian youth, elders who are widowed alone and are living with severe physical disorders, they're another subgroup that's very serious. So, if you look, the number of members of the armed forces who have committed suicide is more than the number who've been killed in combat. Suicide is ending life more than who are killed in combat. And, right now, the youth suicide rates are the highest level in 20 years, and high school students about one in five have seriously contemplated suicide. If you look at physicians, this was a very important study, published in the Archives of General Surgery in the lower left-hand corner of surgeons. Practicing surgeons should be feeling great about their lives, privileged, educated, opportunity, meaningful work, and yet more than a third had been reluctant to seek help because of fear of stigma or some kind of consequence for their medical license. Seven percent had thoughts of killing themselves in the prior 12 months in this very large study, 8,000 surgeons. So, and if you look in academic medicine, if you're interested, this appears to be an area especially for medical students who feel marginalized, who feel non-majority, that there's a significant threat of suicidal ideation and of suicide, approximately one to two physicians commit suicide every day. Stigma is a huge problem for these kind of medical populations, health populations, and it really brings up some important history, which is that, this is Creedmore, this was an old psychiatric hospital that was shut down, kind of attitudes toward people with severe and persistent mental illness versus other kinds of mental disorders that are almost ubiquitous in society. So if you look at need, though, the number of psychiatric beds in the United States has dramatically decreased over the last 30 years. So even though the rate of severe and persistent mental illnesses like schizophrenia is still one percent of the population, that hasn't gone down. But the ability to provide long-term care for individuals has gone down. And if you can see, it's a little bit hard to see, but basically as the number of beds went down, hospital beds, the number of people with mental disorders in the prison has gone up. So it isn't that we have had a great success of deinstitutionalization. In fact, we now just institutionalize in the criminal justice system, which is really devastating for people. So mental health issues are huge concerns, especially for people with severe and persistent mental illness in our jails and prisons. And it's estimated that 45 percent of individuals in federal prisons have a diagnosable mental disorder. Unbelievable. The Los Angeles County Jail is now the biggest provider of psychiatric services of any institution in the country. Homelessness. I can only imagine that it's very difficult here in Chicago, but it's just absolutely devastating in San Francisco in the Bay Area. And this is probably an underestimate of 700,000 Americans being homeless, but a very, very large, obviously disproportionate number of these homeless individuals have mental disorders and don't have the ability to receive care. So we've got this imbalance. We've got billions of people in the world, a very significant disease burden estimated to be about 13 percent, if you add in neuropsychiatric and some neurological disorders, as well as psychiatric and mental disorders. But less than 2 percent of the world's resources are expended to try and serve people with mental disorders. And in our country, we have really insufficient resources, insufficient expertise in rural communities and urban communities and significant shortages of psychiatrists. The good news is there is an increasing trend in child and adolescent psychiatrists, so we're happy that it seems like those efforts have improved. But addiction specialists, we're now totally threadbare in terms of the resources that we have. So the cost of the world is immense. It's estimated that by 2030, the annual cost to the global economy of mental disorders because they're untreated and the loss, you know, the loss of productivity, the loss of life is about 16 trillion annually. You can't even conceptualize 16 trillion. It's such a big number. But it's mostly because it hits early and hits hard. So please try to remember that piece of what we're trying to tackle as we're in this field of psychiatry. And of course, we know that the emotional cost, the devastation intergenerationally to families with an untreated member of the family with mental disorders, is really immense. So I've talked about how making a diagnosis isn't just like a checklisty thing. It's really an assessment. It's a formal judgment of how someone's doing overall in their life, whether they're doing well in their personal, emotional attachment connection, their social role, their ability to be productive and fulfill their own dreams in their lives. We've talked about how that's a huge threat for many, many, many people throughout our world. And so now where is psychiatry in all this? Well, this modern perspective in psychiatry gets us out of the old models. So for years we were divided. Is it biological? Is it psychosocial? Is it environmental? Is it this? What's the treatment? Only biological. That's the only correct way versus psychotherapy. And basically we're kind of like so over that. All right? We're just kind of over it. We're a little bit pragmatic. Like if it works, doesn't matter kind of whether it's mindfulness to medication to ECT. We want to try to understand when it will work, when it will work well, when it will restore people to a full and complete life. And we want new ways to go after treatments. So we're kind of beyond the biological and psychosocial divide. The idea that psychiatrists are just pill pushers kind of passed that too. We're not just people coming to us. In fact, the people who are much more likely to provide psychotropic medications are individuals in primary care. We're frankly, they're in settings where they don't actually have other tools. So the idea that psychiatrists just give out pills, that's kind of in the past. DSM-5, DSM-5 has been this intentional effort to take epidemiological data, phenomenological data about what the clinical presentations are of different mental disorders and put it into some kind of a logic. And we went with long before me, but now I really support it. It's more of a logic around reliability. So the idea that if you saw someone or you saw someone or you saw someone and you observe certain behaviors, you observe certain symptoms and experiences that the patient would share with you, that all of you would kind of arrive at the same diagnosis. And that was a challenge early on. We haven't been able to get at what are the causes of conditions. We haven't been able to say, oh, here's a blood test and this proves that you have a certain diagnosis. It's a strategy to create greater reliability in the field. And we're still struggling to find a logic that's a validity logic, like where we know the specific cause. But controversy is about DSM-5. Frankly, they'll come, they'll go. But there was a kind of a priori assumption that we were going to go after reliability as what we could achieve in this decade. And then there's the problem that we don't, as three psychiatrists, you get four answers. I have to say this is still true. I won't deny that. And that's partly because we pick up on different pieces. We take a holistic view of people and so different individuals will emphasize different things. But in general, when it comes to diagnosis, we are trying to have the same answer across all of us. I also want to acknowledge that our field has been somewhat tainted. We do have problems with stigma in the large part more recently because of being connected with the pharmaceutical industry. The good news and bad news about that is no pharmaceutical company is investing in CNS drugs anymore, so we think this will be history too. And then I don't know what to do with this problem. Here's a quote from Tom Cruise. Psychiatry is a pseudoscience. You don't know the history of psychiatry. I do. And so it is a challenge in popular culture. And I'm going to come back to this in a little bit. No matter how psychiatrists may feel like we're breaking through into a more modern era, so social attitudes, societal attitudes are really pretty retro. And very rigorous studies, it's not something I can talk about today, but very rigorous studies where they've done analyses of narratives of different media reports. Essentially, if there's ever an opportunity in the media to show psychiatry, mental disorders, in a negative light, they will at a much greater than average or predicted rate, certainly in comparison with other physical disorders. So we haven't enjoyed a surplus of public trust. And it does a challenge. But what is exciting for me in my career is to see this change. I like this either cheer up or take off the hat. So we're going to cheer up now and we're going to move forward because there really are amazing things happening in our field. Actually, a lot of it is here at University of Chicago and in the Midwest. I would say Stanford is kind of a wonderful place where we're doing a lot of this very innovative work. But there really are new understanding of causes and biomarkers of neuropsychiatric conditions. Great studies of brain circuitry, structure, function, really beautiful kind of big data, computer science applications to look at patterns of behavior, and really the new understanding between physical conditions and mental disorders and addiction. We're kind of making some headway. So we're integrating biological and psychosocial therapies, trying to do much more in terms of early intervention, prevention, and developing really, really different targets for treatment. And if we have time in the Q&A, I can talk a little bit more about that. So this is just to whiz through this. Schizophrenia, we're understanding much more not about schizophrenia itself, but about psychosis and the genetic predisposition to having psychotic symptoms. A big question has always been you meet a person who's depressed and then they become anxious or first they're anxious and then they become depressed. Are these the same? Are these different? We're now developing and understanding the biology to discern yes they are different and that matters because then the therapeutic strategies themselves are different. Looking at dopamine in the dopamine system to try and understand more about addiction. Looking at very interesting genetic models of neurodevelopmental disorders, in this case autism and fragile X, that's giving us not only the key to these neurodevelopmental disorders, but other genetically based conditions. Looking at bipolar disorder and the preconditions for the development of bipolar disorder as early as age three. Psychosocial treatments for eating disorders. So eating disorders, anorexia nervosa in particular has a 15% mortality rate and we have no biological treatment for it yet. So huge, huge challenges that we have developed evidence-based psychosocial family treatments that save lives of these young people. New approaches for anxiety disorders that don't involve medications and relate to for example cognitive behavioral therapies. And then some very exciting work where working in group therapy psychosocial interventions to try and improve outcomes in other conditions such as cancer. The last one I'll just talk with you about is amazing work that relates to HIV prevention and co-occurring disorders that is reversing very significant trends in the spread of HIV and other conditions. And these are strategies that are using psychological and psychosocial interventions. So a whirlwind, I know, but the point is that we've got really dramatic improvements and many of the conditions that have a mental disorder diagnosis have far better health outcomes being restored to full recovery in comparison with many physical disorders. And so the sense of kind of rational optimism, I want to try to inspire in you that there's a lot that's going on and it's not really the old Freudian model anymore. We do do individual treatment and we do sit with people. We help them bear their suffering. We stand with them. We show compassion. But it's really different in terms of what the modern practice of psychiatry is at this time. The roles themselves have changed. We have psychiatrists in schools. We have psychiatrists in public health settings. They're consulting in the hospital. There's telehealth. There's asynchronous digital care delivery. So things are really, really changing in terms of the psychiatrist's role. And so if you get to the question that I was asked to address about the psychotherapeutic relationship and the therapeutic relationship and kind of the ethical boundaries around that, it's really different if you meet someone one time, if you see them in a school setting sitting next to your teacher and the parent. It's very, very different than the old model of kind of the psychoanalytic couch. There are lots of different psychiatry subspecialties. Addiction, brain injury medicine, child and adolescent psychiatry, consult liaison psychiatry, forensic psychiatry, geriatric psychiatry, hospice and palliative care, pain medicine and sleep medicine. All are subspecialties beyond the general psychiatry training. So lots of different contexts, jails to hospitals to community-based settings. Ambulatory collaborative care, a lot in integrative care. We have many of my psychiatrists serve in primary care settings or consultants, my psychologist too. We do evaluations. We do inpatient care. We use all kinds of precision health approaches. We have people who just do procedures. They come to work. In their scrubs 10 minutes after they're at the office, and that's what they do all day, totally different from in the past. So let's think then about with this evolving role, evolving appreciation of mental disorders in the world, evolving roles and opportunities for the work as a psychiatrist. Let's think together about whether psychiatry is a special case in the therapeutic relationship. So we've talked about how mental illness affects aspects of life that are fundamental to being human. So it is our brain. It is our relationships. It's our ability to do things in the world. Things that make us individual, right? Our ability to read. So for example, a symptom can be alexithymia. Some people must know what alexithymia is. It's their inability to read your own mood and inability to read your own feelings. That's hard when you've got a mental disorder that causes you to be essentially disconnected or out of touch with your own authentic sense of self. This is the kind of condition that we're working with. So I think this kind of argues a little bit for how there's something special and distinct about what we do, that we work with the things that hold people as an individual, self-governance, self-understanding, sense of being related, sense of understanding your own maturity, insight, those kinds of things. And we deal with people who are vulnerable. They're victims of stigma, discrimination. Often, our victims of violence have often been themselves abused. There are restrictions in their ability to exercise their civil and political rights, especially the more and more that we use the judicial system to handle people with mental disorders instead of therapeutic settings, exclusion from participating fully in society, reduced access to health and social services. We have really inadequate resources, relief services, reduced educational opportunities. And almost by definition, as I said, part of the definition of mental disorder is your inability often to serve and fulfill work roles. So we work with a special population. We work with conditions that are special. But ultimately, psychiatrists are physicians. And along with other mental health professionals, we really try to understand the role of the therapeutic relationship in human healing. So probably one thing that is very distinct about us is we understand what it means to sit with someone who's suffering. I would argue that's not unique. You show me a palliative doctor. I'll show you someone who can sit with others who are bearing unbearable pain and making it through the day somehow. So I don't know that this makes us different, but it is a centerpiece of the work that we do. And we highly value and understand how relationships, connection, sense of belonging really influences health, well-being, resilience, living in the world. So that might be a little bit different. Our principles, our values and our approaches in training and in practice relate to this deep understanding of the role of trust and vulnerability in the therapeutic relationship. So I'm sure people know, but then in psychiatry, when you're going through your training, you work closely with supervisors. And part of what you do is you talk about what the patient needs, but also what happened in the interaction with the patient and the ability to pull back and observe that, observe that for its therapeutic value, observe it for your own identity as a physician are all pieces that we are very, very intentional about in training. So I think that could be somewhat different from other fields. And I have a wonderful, special person in my department whose name is Irvi Alam. He's a very remarkable psychiatrist. He served on our inpatient units at Stanford for many, many years, but he's written probably the best-selling books that relate to psychotherapy in the world. And he says that life as a therapist is a life of service in which we daily transcend our personal wishes and turn our gaze toward the needs and growth of the other. It's pretty beautiful. And it is what psychotherapy, the task of psychotherapy is, is that in real time, it's not like sacrificing, I don't know, your income so you do this versus that, it's like being in the moment very sacrificing of your needs for the well-being of your patient. And I think that is different and distinct at work. So these are the kinds of things we're juggling. We're physicians, we've got the same ethical obligations as everybody else. It's very much congruent with what it's like to be just a physician in general. And yet we are working with intimate, inner life, the interior life of others. That is unique and distinct. And we are taught in a very intentional way to be attentive to that dimension of the therapeutic work. And so I wanted to talk about three examples where there have been discussions where psychiatrists should be held to a different standard than others. So the first is sexual relationships with patients. In psychiatry, this is an absolute taboo, absolutely unacceptable. We are required to ensure that we never take advantage of the patient, we don't gratify our own needs going back to the Ravialan quote. We're supposed to set aside our needs. We would not exploit, gratify, or have an interaction where we're influencing someone else for our own personal benefit. So at the psychiatry, this is an absolute taboo. In medicine, it has the Sija AMA code of ethics. It's been a little bit softer about it. It's more like, well, you might have an intimate relationship with a patient, but it's not advised. At least that's been a historical position. If you look at... This is just saying that sexual behavior is unethical. And if you look at physicians disciplined for sex-related offenses, so reported offenses, there are fields, OBGYN, psychiatry, also family medicine. There'll be a higher incidence or higher rate of these kinds of sexual violations. These will be areas where there'll be complaints about this. And I want to be clear, the AMA does not encourage this, but it is a little bit softer and in psychiatry it's an absolute thing. But just to get back to my media point, did anybody here see in treatment? Did you guys see in treatment? In treatment, if you're interested in HBO series, if you want to understand how psychotherapy works, you should totally watch in treatment. It is the most beautiful illustration of these moments of shifting. Why sitting with someone and talking one week after week would make a difference, but it beautifully depicts it. But what, of course, happens, he has an affair with one of his patients. It just drives me nuts. They always happen. So they can't skip an opportunity to stick it to psychiatry, unfortunately. Once you're sensitized to that, you'll see it everywhere. Okay, so let's just say, all right, sex with patients, that doesn't sound so great. Nobody really wants to do that. But now you live in a small town. I'm going to come back to this. You live in a small town or you're in a small community where everybody knows everybody. There isn't a lot of, there's not a lot of people moving in. So now, yeah, maybe you don't have sex with a current patient, got that. You don't want to have sex with somebody who's maybe saw once in the emergency room in a rural hospital. Okay, we won't do that. But now, you can't see anybody. You can't have any relationship because somebody might become a patient, and that is a challenge that many rural and frontier doctors have and psychiatrists have because it isn't just that they are a patient or they were a patient. They will inevitably become your patient. And it's a really interesting question. So it introduces a lot around social isolation. Okay, so that's the sex with patients example. Now, I just told you about how the ethics code says you're not supposed to take anything that would gratify your needs, right? How do you deal with philanthropy, right? How do you deal with a patient who comes and says I've really valued our work together. I've gotten, my life is so much better. I make a lot of money. I don't need all this money. I want to give you an endowed chair. How do you deal with that? Any ideas? Should we absolutely say no? Okay, let's do the argument. Let's say absolutely not. Can't accept a gift. Your psychiatrist can't accept a gift. Now, how am I different from the cancer physician, right? Cancer physician, patients, highly vulnerable, families in distress. Is it really significantly different from that scenario? I don't know. So what my approach to it has been that even though gifts are and some codes of ethics absolutely forbidden and others, it might be an accommodation because it helps you build rapport so maybe an inexpensive gift might be an okay thing to accept. But with philanthropy, the whole strategy is you build in safeguards. So you as the psychiatrist or you as the psychotherapist can't accept the gift directly. But what you say, and this is what I train my faculty to say, is I have this wonderful chairman. She would be delighted to talk with you about a gift to the department of psychiatry. But it is an interesting issue. Is it so intimate? Is it so different? And aren't we kind of infantilizing people with mental disorders if we say that you can't give a gift? So there are scenarios where I think it really is not acceptable. Patient with bipolar disorder where part of the symptom of their condition is that they're spending money. They're buying cars. They're putting themselves in debt. That's so obvious, right? So if it's driven by symptoms, I think the answer is no. You don't do it. And you don't even say, I've got this wonderful chairman you can talk to, right? You bring that back into the psychiatric treatment and work with that as a sign of a condition that needs greater care, right? Other situations, you've got a patient who's been living with depression, is doing really well, has a lot of money, is desperate to help other people with this condition. And it wouldn't be too great of a sacrifice for them. Probably with safeguards, it might be okay, right? So I'm not sure that that's really different. But the historical view has been that psychiatrists can't accept gifts. And so I think there's another potential special case. I'm going to look forward. I talked a little bit about the small community. So Mark mentioned that I'm an editor of a book series for American Psychiatric Association. We just had a book submitted where it was an author who was talking about really different trends in the gay culture where it's a very, very small community. He realized, and he takes care of a lot of patients with HIV, he realized that a patient he was taking care of was actually a person he had a personal relationship with before. And so I think I just want to elevate this as an example where in small communities, it might not be a rural community, but in small communities that are distinct by identity, by ethnicity, culture, that these small community ethics kinds of questions come up quite a lot. So I think in the end, it's not a special case. I think we work with the interior intimate life, but you tell me that it's really any different if you're a transplant surgeon working with someone who has got a new life because of a transplant or nearly died because of the need for a transplant. You work in that intimate space. You may not call it, use the same narrative that psychiatrists do, but to me, these are moments of tremendous vulnerability, and I'm not sure it's really indifferent for psychiatrists than other kinds of physicians. We still live with the principles of respect for persons and beneficence, justice, and like all other fields, when we're in a situation of risk, we have to apply greater safeguards toward these care practices. So that's what I wanted to say about the larger field of psychiatry, how it's changing. It's not your mom's blue jeans. It's not the couch anymore. We have many public health kinds of roles. We have roles that are really different. Some are strictly procedural interventional to traditional psychotherapy and lots of different kinds of settings and ways of delivering care. But I don't think we can quite make the argument, in this modern conceptualization, that psychiatry is a special case that really requires really different ethics rules in other areas of medicine. But I'd be delighted to see what you think and if you answer any questions. Thank you. The safeguards in your future, something that functions as a mentor or supervisor, do you talk about those relationships? Yeah, so when I went to get my medical, my first medical license in New Mexico, there was this woman, Joanne Levitt, who met with every single candidate for a medical license. And she'd sit you down and she'd say, have you ever been sued? And you'd say, no. And she'd say, not yet. And then she'd click the box. And then she'd say, you know, have you ever been in psychiatric treatment or psychotherapy? And you'd say, no. And she'd say, not yet. And it wasn't just for psychiatrists. She would do it for every person who was applying to be a physician in the state of New Mexico. And I like that because it's a great reminder that actually psychiatrists end up informally or formally doing a lot of mental health treatment with colleagues. And we all are responsible for identifying colleagues who are in trouble or in distress or may be impaired. So I think whether we ever intended it or not, psychiatrists end up being a safeguard within systems, hospitals, hospital committees, physician review committees, state licensing boards, et cetera. We end up being in these roles where we have to help evaluate our colleagues. I think that's part of why I'm happy about this newer model of resilience, recovery, you know, not having a diagnosis be almost like a life sentence. We're kind of thinking very, very differently about how people can live with addiction, be in monitored treatment and do very, very well, serve very well as professionals. So there are lots and lots. We end up being safeguards. When we're dealing with others, we do have more confidentiality safeguards. And I will say I do think this is really important, for example, with the electronic health record. Psychotherapy notes. You don't have to go into so much detail in the actual record. And, you know, some people have different practices. Maybe they keep process notes that they keep aside. But I have a really interesting problem that just came to my desk about two weeks ago, where a faculty member's wife was brought to the emergency room with altered mental status. And a member of the team, I won't say who, wrote down on the problem list, as I was taught by my physical diagnosis professor, to think of every reason why a person might have altered mental status. So it could be substance intoxication. It could be substance withdrawal. It could be head injury. It could be psychosis. It could be whatever. So this very conscientious person put that into the problem list. And now we can't get rid of it. So it ended up that this woman had a metabolic reason for having it. But what does her chart say? Her chart says that she potentially uses drugs, overuses drugs, withdraws from drugs, has a psychotic condition. And she noticed within one week, when she went for follow-up care, that she was starting to be treated differently by people. And this is my world, and this is a reality. The stigma is profound. So I would say we do have some safeguards in the electronic health record for, say, the psychotherapy note being more protected than signals and whistles being blown when the wrong people are inquiring about those aspects of the medical record. But the more shared parts of the medical record where people list these diagnoses, I'm not sure we have enough safeguards because stigma is so profound for these conditions. Especially right now with addiction. The population difficulties in these disorders is that it is almost unethical to screen or ask questions for stuff if there's no treatment. And in Illinois, we have horrific wait lists and totally inadequate stuff. And is there a way that medicine should be proactive demanding equity for behavioral and substance conditions? Because historically, it was always assumed that we would send these difficult individuals somewhere else. Okay, so everybody has to help me remember. I have to talk about the difficult patient. I have to talk about parity. And I have to talk about... Population approaches if you don't have equity. Yeah, but help me remember all these things. So I learned something really amazing at a big meeting just recently about, you know, we've had parity for like a long time. How come we don't actually have parity? It's kind of what's the disconnect there? It turns out that part of it is that the legislation for parity stated that you only had to have parity around emergency stabilization or crisis stabilization. So there was never in the legislation any mandate for parity for longitudinal or chronic care. And there's a very large lawsuit right now that's looking at that, that that deviates from the true intent. So that's a way that everyone in this room can become more knowledgeable about parity or things that are driven by good ideas but actually the execution really is lacking from that. That's point number one. Point number two. There are so many low-cost, therapeutic interventions that work, that I think that the premise that there's too many, we're never going to be able to... There's such a big shortage, we're never going to be able to connect those together. I think we have to at least try to remain optimistic about that because there are so many low-cost interventions that can be delivered by trained individuals but without medical degrees and doctoral degrees. So I think over time through team-based strategies we would be able to do much more. The last thing I would say is in terms of overall kind of the difficult patient is to remember what we, I think, really, really appreciate here at University of Chicago is that when a patient is being difficult, that's a clinical sign. I'm going to say it again. When a patient is being difficult, it's a clinical sign and that means that that is something that we as physicians are responsible for responding to and addressing. It's really fascinating at Stanford. They just came out with a big task force report about essentially about naughty patients, about patients who are misbehaving and who are expressing racist thoughts and stuff like that. And there's this idea that we're going to now get rid of those patients, that we're going to not permit them to receive care, this sort of thing. And thankfully this isn't operationalized. It's just a report that kind of... My view is being a physician, we take care of difficult patients. We take care of the hard ones. We take care of the easy ones. We take care of the ones that don't say nice things to us and we view that as a clinical sign. That either it's something about their life experience that makes them very untrusting in that situation and we're going to have to intervene to figure out that. It could be that they've got a psychotic symptom that's driving their malignant behavior in the moment. But it doesn't absolve us of our responsibility as physicians. So two sides to it. One is we have to kind of buck up and take responsibility for the care of difficult patients. Secondly, there are lots of things we can do in real time that are helpful, even in a very short interaction with us, but also to try and advocate for team-based strategies in our hospitals, which are a little bit lower costs than it might be in other ways. And then looking for things like this parity thing. Here we all were feeling so great. Oh my gosh, our country has parity. Turns out it's parity for one element, not the whole thing. And it's not sufficient. So that's where our shared collective voice to advocate for these patients matters. The only ones who have a good parity insurance plan are members of Congress. You know, if the military had the same parity in the VA that members of Congress, we would not be seeing all those statistics you put up on the military. Yeah, I agree. Other questions? Yes? I was intrigued by you talking about rural areas. A former faculty member here who was a friend of mine grew up in a small town where his father was the only doctor. And he delivered this person's, his wife, this patient's mother. And I thought it was, you know, on one hand it was, it's like being not in war, but you do what you have to do. On the other hand, it was such an intimacy. You know who writes about this? It's Michael Lacombe. Is that his name? He often writes about how he is the only doctor for such a large area. And winds up doing these things that are kind of at the margins of what people in a well-resourced situation are. I just was interested in that. And the other thing I want to say is about, I think we as doctors have to own the electronic medical record because we absolutely have to be able to be honest, but we also can punish patients when there are diagnoses that are evocative with emotional value, you know what I mean? Like at the beginning of the AIDS epidemic, when you wrote that on the chart, it was like you could lose your insurance. Now it's a non-issue, but it feels analogous. Yeah, I did a, for seven years I did a study in rural Alaska and rural New Mexico. And we encountered unbelievable situations like the psychologist who was court ordered to provide the treatment for the person who killed her father because the judge had absolutely no other options in Alaska. Of course that didn't work and they figured out something, but that was the court order. Or the psychiatrist who would fly into different frontier communities who the custom in the town would be to barter for your fuel and who's he bartering for his fuel with by his own patient. And even if it wasn't his own patient, that person would inevitably become his patient over time. So the ethical principle here is that overlapping roles always produce ethical risk, right? Overlapping roles mean that the obligations of the two different roles, when they overlap, it's perfect. When they differ, then there's threats to the judgment. And so that's when you bring in safeguards, right? So you bring in a peer colleague in the lower 48 who you talk to about these hard cases. You bring in another neighbor to negotiate the fuel. You find somebody who's a nurse who can actually do the psychotherapy with the person who actually heard a member of your family, even though the nurse doesn't have that skill set, and it's an expanded role, which was what you're talking about. And you try to work on safeguards given that circumstance. So much to hear you again. Thank you. You mentioned something. If you ask a three psychiatrists, you hear four answers. I just wonder if psychiatry hasn't really defined itself, that there are so many things that they are not really psychiatric problems. Your adaptive response, reaction to the atmosphere, that, yes, you go to the psychiatrists, but another person could help you. A good novel could help you. A traveling could. And so much of it. A student who flanks a course because of every reason, all of a sudden commits suicide, or a stockbroker who really didn't have very much money and may become millions and all of a sudden crash, and then he commits his suicide. So somehow it is like the time that everything was included in philosophy. And so people had various answers. And then there came the astronomy separated, physics separated, chemistry. And so there are certain classical things, schizophrenia, bipolar and all these things that they are... And it somehow crystallized and become limited to that area as they call psychiatrists, work on it and trying to find out. And so, for example, Alzheimer no longer is a psychiatric... Of course, psychiatrists could help a lot, but no longer have done. And so everybody goes to psychiatry, everybody calls everybody crazy because of the fact that you don't agree with them. So what do you think about this? It's a great question. I've had five different answers depending on where you were in your question. So let's see. So the first thing I would say... First of all, I totally agree. If we had crisper boundaries, really sharp boundaries, it would be an easier field, easier to defend, easier to understand itself. So that's point number one. Point number two is, it turns out like reading a good book and especially exercise is good for everybody. It's good for everybody. It's good if you have Alzheimer disease. It's good at preventing Alzheimer disease manifestations. It's excellent in the care of people living with even severe and persistent mental illness and psychosis. So kind of common sense. Now we're developing a nice evidence base around a bit. Common sense, strategies around well-being are true for everybody, whether you have a psychiatric disorder or not. I think we have a huge societal problem when certain conditions that relate to lack of conscience are called psychiatric disorders because then it really blurs a lot. And to get back to your point, sometimes we don't have treatments. So for many conditions and especially the conditions where people lack conscience, there's not really a treatment. There's consequences and you can try to contain it. But we don't have answers. So the fact that it's a psychiatric disorder and it puts it in kind of my world and my domain doesn't actually mean there's anything I can really do about it. My guess is 50 years from now, we'll have a different boundary around that and a different like astronomy and other things. We'll have a different way of managing that societally and in medicine. But I would still say that just because reasonable common sense things work, I would say the same thing is true in other areas of medicine, right? And so I don't know that that makes us in any way different. I just think that it makes it harder for people to understand our field. My field's changed a lot since I was sitting in N3 in this room. And I think the biggest changes have related to circuit-based appreciation and now these big data strategies for understanding patterns that will allow precision health strategies for care of individuals. So we may see a fairly large change in the next 20 years as we triangulate genetic information, social determinants of health, and environmental exposures to understand specific phenotypes. There's a lot of progress on that in depression right now, like specific circuits that at least are correlated with the manifestation of certain kinds of depressive disorders, anxiety disorders, et cetera. So I think we're going to see something happen that will get at your point developing boundaries that are tighter. Yeah. So the unique role of psychiatry and physician well-being. So we were, in fact, we were just talking about one piece of this last night. So I do think psychiatrists have been sensitive to this forever, thoughtful, very, very appreciative of the phenomenon of secondary trauma, which is if you are empathic and you connect with your patients and they're going through very difficult things, that there's an impact on you as well and how to manage that constructively. The piece of it that I have been struggling with myself in terms of how to advise people is I just don't think medicine's ever going to be easy and I don't even want it to be easy. I mean, part of why I was drawn to it and part of why I like psychiatry is it's so hard. It's so great and so hard and pulls and causes you to be your best self and encounter your limitations and then go and try to work hard using every tool at your disposal. So I really worry about the current narrative around well-being, like somehow, oh, if we worked fewer hours, which would be better, especially me, I work long hours, but I mean, if we worked fewer hours, yeah, that might address a piece of it. If we're more mindful, yeah, that might address a piece of it. If we identify people who are having emotional regulation problems on the issue of suicide, I should come back to that. Only half of people who commit suicide actually have a pre-existing mental disorder. The other half, it's this acute moment, rupture, emotional regulation event. So figuring out the people, we as psychiatrists, figuring out which of our colleagues, of our students, who will be put in an inevitable position and they themselves have difficulties with emotional regulation. I think that would be another great thing that we could do for the field. But I haven't personally bought into this idea that medicine's going to get easier. And I think there was a moment when the duty hours thing became so obvious. Obviously, we shouldn't be working 80, 100 hours a week. But when the patient became service as opposed to learning, and we started splitting the world and not seeing the patient as the person who's our best teacher and most moving teacher and most illustrative teacher, there was something wrong with that conceptualization, that divide that made us start thinking that the patient is an object of service to that patient was not the ends of medical education. Give me a break. So I think I just struggle with how we're, how we've been working in this space. Now, there's beautiful work by Tate Shanafelt and others on institutional culture, a culture of support and acceptance, a culture where you accept your own limitations and try to put in safeguards to address those things. That's the whole piece. Oh, yeah, Tate's great. You'll enjoy his talk. He's a really good guy. And he's, what he has done, I think, well, he did that surgeon study that I referenced earlier. His more recent work has been looking at essentially how institutions set people up for those moments of crisis and distress and emotional regulation challenges. The new theory around suicide, which maybe you all know, is to look beyond these pre-existing traits, like certain age, gender, ethnicity, attributes that put you at risk, instead to look at the moment in which a person is feeling suicidal and impulsive. And it is a combination of pre-existing distress, which may or may not be related to a mental disorder, access to means, and then thwarted belongingness, so this rupture in the feeling of belonging. So an example would be a student who fails step one. You know, your whole life for years, your family's sacrificed, you've worked day and night, and then you have this catastrophic thing that you feel like is unsurvivable, it's not survivable. You know, that is an emotional regulation challenge for anybody. But for some people, they're gonna have more vulnerability in that moment. That's a role that we in psychiatry I think can really, really embrace and help with. But anyways, I'm big into well-being. I want everybody to be well, but I just think we wouldn't have come here to do this work. We don't want to change the fundamental nature of, you know, our work, I don't think. Human suffering is gonna be with us and it teaches us so much. So I don't know, I think we need to work on our narrative around the well-being challenge and medicine. So, yeah. So, instead of just calling it some kind of heroine, it really stands out to me. Yeah. So, unless I call it that, it really is what it is. Yeah. I can change that in my slides. And I also want to own the fact that we had difficulties with my slides and I have changed from both genders to all genders, but it wasn't in this version. So we all can grow and use more precise language to honor the real phenomena. So, thanks for raising that point. Appreciate that. Good. Yeah, thank you.