I just finished presenting four talks for the Pensylvania State Emergency Medical Services (EMS) conference in Harrisburg.

I spoke about

• Dealing with Emotions During Emergencies
• Dealing with the Angry Person and Preventing Escalation
• Dealing with the Confused Person
• Managing the Hysterical Patient.

Watch my site for postings on some of these topics.

 I want to share some of this great experience. First of all the people. All those who attended my workshops seemed truly interested in learning how to help their patients deal with the emotional stress of emergencies.  They were open to new ideas and had lots of experience and ideas themselves about what worked to calm people down.

We all agreed that although the major focus of a medical emergency  is to save lives and prevent worsening of trauma or illness this may not be possible unless the patient’s emotions are dealt with.  Fear and other emotions must  at least acknowledged. Communicating an understanding of a person’s feelings can go a long way to calming them.

 I spoke alot about empathy and we worked hard to practice this concept and be able to figure out how to use it in common situations.  If you haven’t read my blog on empathy  please do. It remains one of the most powerful communication techniques for dealing with distressed, frightened, and angry people.

The EMS providers I met seem to have a great sense of humor. I have come to appreciate how important this is to surviving in such a high intensity emotional line of work. The frustrations of the job are many,  misuse of services, lack of support, low pay, lack of repect and recognition for the life saving work they do. The rewards can be great.

Remember these are the first people there to help you when you need it most. We need to educate ourselves about the profession and the great job these folks do under pretty tough circumstances. My appreciation and respect to all of you.

I was pretty concerned  when I read this Time article about soldiers being medicated for burnout or compassion fatigue or stress and many other psychological concerns.

How can any thinking human being be in a battle zone, risking their life and seeing others killed not be distressed?  We are fooling outself if we think this is possible.  To  think that an antidepressant will help this kind of sadness and distress is just naive.  I am sure the prescribers know better.

My bigger concern in this article is the mention of Clonazepam (Klonopin) for anxiety and Ambien for sleep.

Prescribing these drugs is asking for trouble. Persons who take Benzodiazepines like Clonazepam  are often in a “fog”.  It’s the “new age Valium”. 

Clonazepam can cause memory loss, decreased self control, slowed thinking, poor decision making and detachment.  Rest assured these are not RARE side effects but happen routinely with these medications. Clonazepam is a particular worry because it can stay in the body and have effects for more then three days. 

The warnings on Clonazepam  tells you not to drive (due to slowed reflexes, decisions and lethergy). They do not say however not to carry a gun or fight in a war !

Ambien is a sleeping pill that is a sedative. It is less troublesome then Clonazepam because the drug usually lasts about 10 hours, but it is not uncommon to have daytime drowsiness

Some rarer side effects that are very troubling can include changes in thinking and/or behavior such as:

• more aggressive behavior than normal
• confusion
• agitation
• hallucinations
• worsening of depression

Any use of drugs or alcohol can enhance all the effects of both these medications. The other worry is that long term use can cause dependence and may result in depressive feelings.

It is  my opinion that the use of these drugs makes a dangerous situation even worse. Our boys at least need to be educated about what these drugs can do to them.

What are your thoughts?

   Buried at Work? 

Ø      Avoiding or rushing through work

Ø      Rigid rules and “by the book” approaches

Ø      Dehumanizing clients

Ø      Anger and emotional outbursts

Ø      Increasingly cynical attitudes

Ø      Boredom

Ø      Stress from work interfering in social and family relationship

Ø      Physical symptoms of stress such as headaches sleep disturbance and tiredness.

Some important reminders to prevent burnout:

 Ø      Take care of you, it will relieve some of your stress and allow you to better deal with others

Ø      Learn and use self-empathy and self-nurturing techniques

Ø      Try understanding and treating yourself with care

Ø      Allow yourself to say no, offer alternatives, or even avoid situations if you feel unable to say no

Ø      Increase your self-awareness

Ø      Plan for a routine to help ease the transition from work to home. (Do not use alcohol to unwind)

Ø      Do not expect all your feelings of self-esteem to come from your profession.

Ø      Develop outside interests that have nothing to do with your work.

Ø      Try to avoid over-identification with clients

Ø      Recognize and allow your own feelings

Ø      Develop relationships outside of work where you can talk about your feelings

Ø      Practice stress reduction techniques (exercise, relaxation, meditation, distraction)

Ø      Plan for regular breaks, conferences, and vacations

Ø      Talk with colleagues to not only complain, but also to also make plans for burnout prevention, take charge where you can

Ø      Know when to say “enough”, consider transfer if necessary

Burnout can and must be prevented. Recognition of your own level of stress and taking care of yourself are the keys to stress reduction and burnout prevention.  

Burnout can also have an unexpected positive influence in your life; it can act as a catalyst to make a much-needed change. It can be the impetus to move on to different more rewarding careers. Many entrepreneurs started off as burned out employees.

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I found an online article listing questions parents should ask before considering psychiatric hospitalization for their children.  I think there are some qood questions here, but I would like to add my 2 cents to certain questions. 

In the spirit of full disclosure I am a Psychiatric NP with many years experience including inpatient units. Psychiatric admissions and hospitalizations have changed dramatically in the last 20 years. What used to be for weeks even months is now days.

1. What type of therapies will my child have while in the hospital and how are they better than outpatient therapy? The reality is that therapies in hospitals are usually limited to medications and sometimes groups. The groups are educational and do not meet the criteria for psychotherapy (aimed at some type of change).  Of course If they are done well, they can be helpful in terms of offering information such as how to deal with feelings, anger and stress managment.

 Hospital admission is not for therapy any more but for treatment of crisis, specifically to maintain safety.  Hospitalization  is best used to prevent suicide,  self-harm,  or violence.  Remember if your child is on a unit with other more troubled kids they may  copy  worse behaviors. Due to insurance company rules and today’s model of treatment the usual process of hospitalization is to stablilize and discharge the person ASAP.  This often means use of medications quickly  with little time to evaluate theraputic effects, dosages or side effects.

  2.  Will my child receive in depth psychological testing and psychotherapy by a clinical psychologist while hospitalized? Or will the treatment mainly consist of drug therapy by a psychiatrist?

This appears to be a question written by and from a  psychologists point of view. Most units do not have psychologists as therapists (they cost more) but may use them as  consultants to do psycological testing if needed (usually determined by the Psychiatrist or Psychiatric NP ). Psychological testing CAN be helpful in determining  personality style, making diagnosis and identifing learning disabilities and IQ. It is usually only done once or twice in a lifetime as these things don’t change. It is very expensive and its use is determined by the culture. ( what is the view of the value of the testing. how many psychologists are present in the system). Psychological testing is not an exact science,  neither is psychiatry or medicine.

I request psychological testing  to determine IQ and screen for learning disability, to help with diagnosis if I am unclear (notice the word help, this is not a sure thing but an interpretation).  I also like  it for what is called a validity scale, that is it can tell if the person is exaggerating or providing inconsistent answers.

The persons who manage inpatient units are psychiatric nurses and social workers, they may see the patients for a few minutes a day (as does the psychiatrist) but that’s not therapy, it is more management. The goal is usually to discharge the person as soon as possible, especially before the insurance runs out. This is not necessarily bad, but it  does tend to increase use and dosage of medication as the time for evaluation of effects is limited.

3. Will we be attending family counseling sessions regularly?

Family meetings are often part of the hospitalization. Calling this counseling is a stretch in my opinion. They are most often used to obtain or  convey information and plan for discharge. Family counseling or therapy is often necessary when working with children but this needs to be done on an outpatient basis.

4.  When our child is discharged, will it be necessary for him or her to receive follow-up care?

In my opinion any child that needed psychiatric admission needs follow up whether they recieve medication or not. Here is where family therapy is often needed.

I would love to hear your comments or experiences with this issue.

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There is a long complicated article in the NY Times today about suicide and impulsivity that is worth a read (if you can manage it.)

“Suicide autopsy” studies can give us lots of information, but no one really knows what goes through the head of a person just before he or she dies from suicide, it may be regret as suggested by one person interviewed by the author.

There are a few comments I would like to make about the article and suicide in general that are based on my own years of experience, and thoughts. If you can’t get through the article hopefully they will still make some sense to you.

In terms of the debate about impulsivity vs planned suicide; I believe that there is always an impulsive piece of suicide. People may have a long complicated plan in their head “just in case”, but it takes a trigger to finally push them over the edge. I wonder if sometimes this can be just the opportunity as well as it be the “last straw” type event. It is not an either/or choice.

One study indicated that victims of what look like highly impulsive methods of suicide (bridge, gun) often “display few of the classic warning signs associated with suicidal behavior” ” …jumpers have a lower history of prior suicide attempts, diagnosed mental illness…” It seems to me that these persons may have not been treated or recognized as being depressed which may put them at high risk.

Also the person who is most determined to kill them self may be less likely to let others know, due to not wanting intervention. Use of an almost guaranteed to succeed method, does not seem to me to be a sure sign of impulsivity.  Some people have been planning for a while and have chosen the method they believe least likely to fail, thus the use of a gun or a bridge.

I will never forget a man I saw years ago, who had given away all his possessions. He denied suicide, did not look in the least depressed, and had no psychiatric history. I would never have thought him to be suicidal.  If it hadn’t been for a family member who was very worried about his “generosity” with lack of explanation and forced an evaluation, I have no doubt this man would have killed himself. (He later admitted his intention).

Suicide is another one of those things we will never have all the answers for. There are many different motives and types of suicide: some with depression, some with psychotic thinking where voices are telling them to kill themselves, some with existential pain, some with physical pain, some with end of life issues. Some are carefully planned while others are impulsive. It is my belief that most have components of both.

Are we trying to categorize and understand something that may not fit into a neat clean framework? Our frantic efforts to figure things out are often attempts to control something we fear.

We certainly can help to prevent suicide, and we should keep learning, but we also need to acknowledge that there are some things we may never understand completely, and may never be able to control. Life and death are not so neatly black and white.

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Question and Answer Post

From a Reader named “Mary”

Please help me! I have been in a relationship with my live in boyfriend about 3 yrs. He is like having another child around. He does not help with things and expects me to take care of everything. He has a bad temper and although he has never hit me when he gets angry he breaks things. I want to end this relationship but when I tell him that he says he can’t live without me and will kill himself if I go. I’m scared! I don’t know what to do. I cry all the time and can’t sleep well at night.

Dr. Duffy’s response.

Mary, this is a tough situation and I can under why you feel scared. First let me tell you that unfortunately this situation is not that uncommon. Men who act like your boyfriend are often very dependent on the women they are with! They try to get what they want and need with threats of all kinds. Threatening to kill himself in order to keep you is emotional blackmail! So what to do…….

First and most important: you must be very sure you want to end this relationship. The worse thing you can do is make threats to leave in hopes that he will change his behavior. When you do this it only teaches him that you do not mean what you say. If these threats do get him to change, it is usually only for a very brief time and then the behavior starts again. So you must so some serious soul searching and make sure this is what you really want. Make sure you are really ready. Once you have done this you must put a plan in place to leave. Try not to do it on the spur of the moment or during a crisis unless you are being physically threatened!

Second: Make a plan: You must decide when you want to leave and where you will go. Many women want the man to leave the home. This is much harder to make happen (although not impossible) and the easier and safer thing to do would be to leave temporarily with the expectation that living arrangements will be settled later. Certainly who leaves the home may be dependent on who ownership. Leaving may also have some legal complications for those who are married and the advice of an attorney should be sought. If there are children involved it is more difficult but that is also all the more reason to go ahead with such a plan.

If you have already discussed your desire to leave you do not need to tell him that you are leaving until you are ready to go. In the process of leaving however YOU CANNOT COUNT ON HIM TO BE REASONABLE. Once the crisis is over and he is certain this is really the end, he may become more reasonable and able to negotiate things. Mediators are available in most areas to help separating people with just this type of issue.

Third: get the help of others. Many women are embarrassed by this type of situation and try to manage it alone. This is a mistake! Secrecy is one of the things that make blackmail effective! You must let people you trust know what is going on. Tell a friend, family members, your boyfriend’s family (he needs support too) and perhaps a professional. You do not need to reveal all the details just make sure they realize you are planning to leave and he is making threats to kill himself. A strategy that often works is to have someone he trusts with him when you actually leave. If you leave and he makes threats you may need to notify the police to check on him.

Fourth: take care of yourself. This is critical. I have a few questions here. Are you depressed? You mention crying and trouble sleeping. Now a certain amount of this is to be expected in this situation, but are you seriously depressed? This is an important distinction to make. Do you have trouble with concentration and memory? Are you anxious and feeling overwhelmed by the situation? Are you feeling hopeless, helpless and immobilized? Are you having trouble machine decisions? Are you eating? Is your energy level where it should be? Do you have a history of depression? These are some questions that might help you decide the level of your depression. Please review the symptoms of depression on the following page to help you decide if you are clinically depressed. If you are significantly depressed you may find it much harder if not impossible to leave while you feel this way. If you think this is the case you should consider having an evaluation by a mental health professional. If you are depressed there are medications and some herbs that may be of help to you. Once you feel better you will be more able to deal with this situation.

The other question I would have in this area is IS THIS A PATTERN FOR YOU? Do you have a history of getting involved in the same type of relationships? Do you seem to attract needy people (men and friends.)? Do you try and take care of everyone. Do you take care of yourself? Do you feel good about yourself? These are important questions to answer for your own emotional well being and to help with future choices.

You must remember no one is responsible for the life of another person. We all must take responsibility for our own lives. Just as you cannot cause someone to take their own life if they wish to live, you also cannot prevent it if they are determined to die. Suicide is not usually the result of a single loss, but the end of a long history of depression , problems and pain. Persons like this are in desperate need of professional help and sometimes staying with them to try and help may actually prevent them from getting the professional help they really need. GOOD LUCK!

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There is a terrific article in the NY Times today that is a must read for everyone who will eventually die (that’s you & me). It talks about the “you must fight” attitude many of us think we should have and expect of other people when they are very ill.  Is this the best for them and us?

The usual statement ” I am going to fight and beat this” is the politically correct thing to do, especially in public. However, many people believe that this is the way we must react to illness; keep a stiff upper lip and fight!  This is what some people (not the writer) think is a positive attitude. The truth is that no one can be strong all the time, especially when your life is threatened. Moments of feeling weak and frightened do not mean you are going to give up. Expectations that are unrealistic make people think: What is wrong with me? Why can’t I be more like him?  I must be weak. I am ashamed of myself. I am feeling sorry for myself.

 The fear and anger that we hold inside eventually will take its toll. It will cost you and those around you. I believe the stress of hiding true feelings will make it more difficult for you to heal. The inability or unwillingness to cry or get mad can be a costly trait.

 We are very death phobic in this country and life at any cost seems to be our mantra.  Don’t get me wrong, many people fight long and hard to live, and survive against all odds. That is right for them. But even these folks have moments of feeling like giving up. That is normal, these moments pass, but the feelings should be acknowledged or they will only become more powerful. Then there are others who perhaps don’t fight as hard to live for lots of reasons; and that is ok too.

 As someone who worked for many years with people who were ill and often dying, I know there are as many ways of dying as of living. But everyone has moments (days, weeks) of fear, sadness, and anger. We do not need to share all of feelings of fear and anger with everyone at all times, but you must allow them. Hopefully  you can share them with someone who will listen.

  When I had my heart attack a few years ago, lying in the ER I thought, “Well this might be it”.  I remember being sad about leaving those I loved. I cried a little. I then turned over and peacefully went to sleep. Well as you can see, I woke up. I had three new 3 stents in my heart and more time. I am trying to enjoy that time to the max and build a legacy to leave when my time does come.

 My thoughts are with Senator Kennedy, Patrick Swayze and all those struggling for life. For them and all of us I say, enjoy live as best you can at the moment and go easy on yourself!

An article in today’s NY times about a doctor who offered to pray with a patient brought a variety of responses that covered the entire gamet from  suggestions of  taking his  license away to nominating him for sainthood.

I thought about this because the use of prayer,  religion or other spiritual practices has been a topic of many conversations by patients in my psychotherapy practice over the years.  I usually say something like “if it helps you or brings you comfort  its fine”. However,  no one has ever asked me directly to pray with them.  I can imagine this could happen especially during a crisis or emergency.  As a matter of fact, it is a wonder I have avoided it so far.  This article made me wonder what my answer would be to such a request. 

 As I have no objection to prayer  (even do it myself)  I imagine I could pray with a patient. However it goes so much against my training, it would  make me uncomfortable, so what would I say?  Well truthfully, I don’t know and I hope nobody ever asks. But just in case,  I am practicing a few responses…..  ” I would like to sit with you while you pray”,  or “Why don’t we sit quietly together and each pray in our own way”. 

I hope to avoid this issue, but if it does comes up I know I will do what feels right at the time. One thing I know for sure (this seems to be my answer to more and more  things the older I get) is there is no right answer. Darn!

Take a look at this  NY Times story  on this crisis about  a third suicide by a teenager in the last year on Nantucket Island. It is a sad story. What struck me is the fact that the “experts” don’t agree and are not always helpful.

We need to realize that we have very few answers to this and many other Mental health questions.  We also are not paying much attention or doing much research in this area.  Mental health care often has sparce coverage by insurance companies. In this country our attention is often on other things:  money, possessions, power. Our educational system training “experts” is lacking to say the least.

What we do know about teenage suicide is:

• Nearly 5,000 teenagers commit suicide each year.
• Suicide is the third leading cause of death among those aged 15-24.
• Young women attempt suicide four times more frequently.
• Young men commit suicide 4 times more often.
• White males are more at risk.
• Reports of one suicide triggering others within a school or community, have increased.

What can a parent do to prevent this tragedy?

• Talk to your teen-ager .
• Don’t be afraid to say the word “suicide.” Using the word will not “give him/her ideas” but will provide relief by saying its ok to talk about this.
• Reassure him/ her that you love him no matter what. Remind him that no matter how bad things seem you want to help and problems can be solved.
• Ask him/ her to talk about her feelings. Listen carefully. (see my blog on listening)
• Do not make light of  problems ( relationships, thinking no one likes them etc.)
• Do not give glib answers or get angry.
• Remove guns from your home.
• Seek professional help. Finding a good therapist is difficult. Ask around, school counselors may be a good source of referrals but usually can not handle this problem on their own.
• Get help yourself to deal with this. Do not be ashamed of this problem, it is not uncommon enough.
•  A variety of outpatient and hospital-based treatment programs are available that have sliding fee scales.

Not enough can be said for the powerful protection of  a loving stable family life. Suicide often runs in famlies. Unhappy, troubled  families unwittingly may pass on genetic or environmental factors to their children. If you are a parent with your own painful past, get help for yourself and your children!�

The recent story in the NY Times about a psychiatrist who was stabbed to death

and another who was critically injured brings up many fears about the mentally ill. It is a horrible very sad event, but it is important to keep in perspective the facts regarding mental illness and violence. Here are the numbers that may help to do that.

Violence in male persons with schizophrenia is 5.5% higher then in the “normal population”

Violence in women with schizophrenia is 5-9 times higher. (Women have much less violence rates to begin with)
Persons with Schizophrenia who are violent are most often off their medication and psychotic (hearing voices or delusional)

Inclusion in any group of people is not a predictor of violence.

Violence is difficult to Predict but the best predictors of violence are the following demographics (risk factors).

• Male under age of 30
• Previous history of violence
• Alcohol and drug use
• Victim or witness to violence
• Social isolation
• Low income
• Low intelligence & education
• Low assertiveness
• Impulsivity
• Unstable social situation
• Brain injury