Year in Review 2015: Farewell

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IN MEMORIAM: Successful Struggles of Psychiatrists, a Patient, and a Research Subject

Everyone will get sick. Everyone will die, even the doctor.¹
-Richard Gunderman, MD

Why oh why do people still remain as fearful of what is unfamiliar, strange, or, merely different?²
-Jay Neugeboren

Although there are many unique rewards, we all know that careers in psychiatry are not easy ones. There is profound stigma. There are anti-psychiatrists. There are many gaps in our knowledge. The brain is so hard to research. There is relatively low reimbursement. There is denial of recommended treatment by payers. There is necessary empathy with the worst in life.

Before and beyond all that, there is often a personal history of psychological difficulties that help propel us into the field in the first place. No wonder our burnout rate is approaching 50%.³

For many patients, the struggle to recover from psychiatric disorders can be heartbreaking. Research subjects, so important for the advancement of the field, may or may not benefit from their participation.

This year, we have had striking examples of notable clinicians and members of the public who have passed away, often after a life of major trouble. In this one of a continuing series of eulogies of psychiatrists, this is the first to include a patient and a research subject, both of whom are connected thematically to some of the psychiatrists. Because of confidentiality and the preferences of the media, we rarely hear about the deaths of psychiatric patients unless they are involved with murder-suicides.

All of these selections can provide us with lessons and are gifts of inspiration and knowledge. We often changed policies related to their contributions. Other than the referenced material and my indicated personal knowledge, much of the remainder of the information is adapted from various obituaries.

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Henry Krystal, MD

Dr Krystal was only a young adolescent when he was sent to several concentration camps by the Nazis. The only one of his immediate family to survive, he attributed his survival to his mother, who had assured him that he would live after childhood respiratory problems.

He then went on to become a psychiatrist in the United States. When Holocaust survivors applied for German reparations in the 1950s and 60s, he became a pioneer in interviewing them. The challenge was on two sides.

Many survivors at that time were reluctant to go through the process, either to avoid painful memories or to not admit that the Nazis had damaged them. On the German side, they didn't seem to want to grant reparations to those had psychological disabilities. Dr Krystal was able to convince many of the survivors to be interviewed, and over time to convince the German legislature to provide such compensation.

Through this process, as well as his recognition of his own Holocaust-related psychological problems, Dr Krystal came to lead an investigation into the direct effects of massive traumas. At first, he was again opposed, this time by his own psychoanalytic establishment, where the focus was on psychological damage done by conflict rather than trauma, a legacy of Freud's own conclusions. Eventually, Dr Krystal's groundbreaking work led to our understanding of PTSD and its inclusion as a formal DSM disorder in 1980.⁴

Despite his concern about how his Holocaust experience would affect his sons, one became the Chair of Psychiatry at Yale and the other a prominent psychiatrist at Duke. He died at the age of 90.

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Joel Elkes, MD

Dr Elkes was another renowned psychiatrist who came out of the Holocaust. His decision to study medicine in London during World War II cut him off from all family support. His immediate family, and much of his extended family, were then killed in the Holocaust. Before that happened, his father became a leader of the captured Jews, and Dr Elkes tried to model after his father's humane leadership after he learned what his father had done.

Early in his career, Dr Elkes was a leader in the first scientific trials of a new medication for schizophrenia.⁵ Chlorpromazine (Thorazine) became the first of many ensuing antipsychotics that helped end the often brutal surgical treatment by lobotomy. His theory, that such medication worked through neurotransmitters, went against the popular opinion at the time that electricity was key to treatment.

His research lab was notable for a culture in which the researchers mixed with subjects of the experiments during everyday activities, such as meals. This, like his father's leadership, humanized the endeavor.

He later assumed leadership as the Chair of Psychiatry at several medical schools. He lived until he was 101!

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Jack Yufe

Given that both Drs Krystal and Elkes came out of the Holocaust, and that both made important research contributions, it is interesting that a research subject related to the Holocaust also died recently. In contrast to the harrowing research done to other identical twins during the Holocaust, Jack Yufe and his identical twin, Oskar Stohr, took part in a humane study in the US, after the war.⁶

They were separated before they were a year old. Mr Yufe spent his childhood with his Jewish father in Trinidad, where he was born. His father had immigrated from Romania. He later served in the Navy in the fledging country of Israel. In contrast, Mr Stohr moved to Germany with his German mother, grew up there, was baptized as a Catholic, and joined the Hitler Youth.

They and their fascinating history were brought together in a pioneering study in 1979 at the University of Minnesota. What would the divergent social experiences of identical twins like them, who were raised apart, reveal about the relative importance of nature versus nurture in human  development? Their intermittent reunions seemed to be cautious and ambivalent ones.

Biologically, they remained very similar, but their values more paralleled their nurturing. Mr Yufe died at the age of 82.

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William Grier, MD

In 1968, at the height of the civil rights movement, Dr Grier and his co-author colleague, Price Cobbs, MD, published Black Rage, a book which received much professional and personal attention.⁷ Early in my medical school training, the book had a major influence on my later career involvement with cross-cultural psychiatry.

The authors argued that ever since slavery, blacks had an outward style of deference, but seethed with anger inside, anger not only toward whites, but to each other. This could produce a sort of "cultural paranoia."

Together, they ran a psychiatric clinic in San Francisco for many years. They used case studies of their patients to help make their points in the book.

It would seem that their work still has much resonance and relevance, given the rage we see regarding police killings of black men and institutionalized racism in colleges.

In addition, more black psychiatrists are still needed to help address some of the continuing problems in the psychiatric treatment of Black Americans, such as misdiagnosis and overmedication. Dr Grier died at the age of 89.

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Joel Fort, MD

Dr Fort was an outspoken psychiatrist who long ago advocated for the legalization of marijuana and to accept homosexuality as a normal variation of sexual preference (even though neither of these seemed to reflect personal desires). In this advocacy, he encountered much professional and political resistance and criticism, resulting in some lawsuits.

He called himself a "sociotrist" who tried to help by effecting social change and argued that alcohol was much more dangerous than marijuana.⁸ He viewed addiction as a symptom of deep social malaise.

To help address addiction, Dr Fort led a substance abuse clinic in San Francisco for many years. It is still open.

He also testified in court many times as an expert witness for both the prosecution and the defense. Most notably, he was a prosecution witness in the Patricia Hearst bank robbery trial, arguing that she was not brainwashed. Later, he felt that the wealthy and powerful Hearst family retaliated by trying to get his medical license revoked.

Given the increasing legalization and understanding of marijuana, his points seem to be proving correct about that. The normalization of homosexuality and legalization of gay marriage also has proven him right.

He must have known that before he died at the age of 86.

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Richard Christensen, MD

I came to know Dr Christensen when he was one of the awardees of an annual award that used to be given by the American Association of Community Psychiatry, called the Moffic Award for Ethical Practice in Public Sector Managed Care. We found out about his exemplary concern for the underserved as he fought for the adequate care of the poor despite intrusions to limit their care even further by for-profit managed care companies, about which I had written a book.⁹

He became even more well-known for his work with the homeless in Jacksonville, Florida. He was Medical Director for a federally funded initiative for chronic homeless persons suffering from mental illness. This is a population known to be frustrating to work with and often intractable, though not for Dr Christensen.

In one of life's most terrible ironies, for someone devoted to the homeless in his hometown, he died on Thanksgiving Day, of all days, in Zambia while on a Habit For Humanity building of homes. He was stuck by a car while on a morning run.

Serendipitously, we can be grateful that he left us with an illustrated article that was published just before his death.¹⁰ In it, he discusses the importance of caring for those whose illnesses contribute to what he thought was the most devastating form of suffering, human and social isolation. He continually tried to establish relationships through listening, empathy, and then talking, all of which could then be the basis for further healing.

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Robert Neugeboren

Although I am quite confident that Mr Neugeboren was never treated by either Drs Christensen or Fort, I am also quite certain that they would be the kind of psychiatrists who would have had the best chances to help him cope with a chronic and very severe mental illness, along with being homosexual.

In a memoir written by his brother, award-winning writer Jay Neugeboren, we learn of a life of struggle to achieve some degree of recovery after his first breakdown at the age of 19 in 1962 until the mid 1990s.² There were more than 100 hospitalizations, where he received trials of most every kind of psychiatric medication, as well as multivitamins, shock therapy, and lobotomy.

Near the end of the book, which illustrates the challenges faced by family members that led to the formation of the National Alliance for the Mentally Ill (NAMI), his brother concludes with the hope that 3 things could still help:

. . . committed professionals who would be a constant in his life, and who would have the skills to work with - steadily and steadfastly, through all his ups and downs; a pleasant place to live; and some regular work that drew upon his mind and capabilities.

Indeed, his brother could turn out to be grateful, and perhaps surprised, that much of that was achieved for about a decade near the end of his Robert's life.

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Life lessons

What do these struggles teach us? Despite the trauma of concentration camps, antisemitism, slavery, racism, homophobia, poverty, and stigma, recovery and resilience are still possible, and great contributions to society are still feasible. They are a testament to the best of the human spirit and the profession of psychiatry to overcome almost insurmountable challenges.

Even though trauma often causes other medical problems, other than the accidental death of Dr Christensen, all lived much longer than their life expectations, including longer than the reduced life expectations of those with schizophrenia. Sure, it's a very small sample size, yet still striking.

One of the most important factors that helps these successes and courage is a major supportive figure, whether that be a mother, father, sibling, spouse, or colleague. May we remember to honor these struggles and successes in our work and live in 2016.

References:

1. Gunderman, R. (2012). Success, professionalism, and the medical student. The Pharos, Spring; 75: 6-8.

2. Neugeboren, J. (1997). Imagining Robert: My Brother, Madness, and Survival. William Morrow and Company, Inc.

3. Shanafelt, T., Hasan, O., Dyrbye, L. et al (2015). Changes in burnout and satisfaction with work-life balance in physicians and the general working US working population between 2011 and 2014. Mayo Clinic Proceedings, December 2015; 90(12): 1600-1613.

4. Krystal, H. (ed.) (1968). Massive Psychic Trauma. International Universities Press.

5. Elkes, J. Elkes, C. (1954). Effect of Chlorpromazine on the behaviour of chronically overactive psychotic patients. British Medical Journal. September 4; 2: 560.

6. Segal, N. (2007). Indivisible by Two; Lives of Extraordinary Twins. Harvard University Press.

7. Grier, W., Cobbs, P. (1968). Black Rage. Basic Books.

8. Fort J. (1970). The Pleasure Seekers: The Drug Crisis, Youth, and Society. Grove Press.

9. Moffic, H.S. (1997). The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare. Jossey-Bass.

10.Christensen, R. (2015). Caring for the invisible and forgotten. The Pharos, Autumn; 48-50.