Stream of Consciousness - The Artistic Side

 

 

I have several posts on consciousness on this blog and consider myself to be a student of the phenomenon.  That is not easy because the experts even to this day will say at some point that we don’t really have a good definition.  They do tend to agree that conscious states differ and to use a famous example: “My experience of the color red is not your experience of the color red.”  If you think about that simple statement long enough it can mean a lot of things. 

Psychiatry has had an ambivalent relationship with consciousness.  Over the decades, psychiatry has gone from attempts to study psychopathology at the gross neurological level, to classifications based on clinical course, to phenomenological studies at the individual level and back to purely biological and psychological models.  Most of these models whether they are DSM based or psychotherapy model based – leave out the individual unique conscious state.  The closest we can probably come are phenomenologically based interviews relying on self report and psychotherapies that assume varying levels of conscious awareness.

From the humanities we have stream of consciousness art that reflects the artists spontaneous thoughts, feeling, memories, associations, and perceptions and translates that into an art form.  James Joyce and Virginia Wolfe are two writers famously associated with the term, but it can be found in any medium.  The poetry of Emily Dickinson and the abstract expressionism of Hans Hoffman color block style of painting are additional examples.  In current times, stream of consciousness is most likely described in movies and I will be focusing my comments on two that I recently watched – Railroad Dreams and The Life of Chuck.      

Before getting to the movies let me list a few properties of stream of consciousness.  First and foremost is non-linearity.  There is no clear beginning, middle, and end.  They are often juxtaposed or at times completely missing. This is the way most people think.  I used to get up in the morning, get in the car for the commute, and on the drive, I would be transported somewhere forward or back in time.  At times what I was thinking about was so intense, I did not recall much of the drive. There are currently debates about time – whether it exists or what the true function of time is.  One of the explanations is to create timelines for all our conscious experiences.  Stream of consciousness thought has been described as chaotic but I would see it as semi-chaotic since most of the associations should be familiar.  Exceptions might include sleep transitions with vivid random imagery, fantasies, and other imaginations.

Internal and external monologues are another feature.  At times the thought processes are accessed through an independent narrator.  The art translates these monologues into narrations, flashbacks, and voice overs. The viewer gets access to that part of consciousness that is typically hidden in real life with all the emotion, fantasy, and association.   Highly personal memories and fragments of memories come through. What the protagonist is focused on in the environment (visions, sounds, sensations) is presented.  The most famous image and connection to me occurs in Citizen Kane when at the end we learn that Rosebud was the name of Charles Foster Kane’s childhood sled and we see it being thrown into a fire as he is saying that name.

In movies if the images need to convey asynchrony - techniques are used to indicate the surrealism of dreams, spiritual, experiences, flashbacks, or memories. Historical context is used to reorient the viewer.  For example, in the Life of Chuck – 3 different actors play him at various stages in his life and as the film progresses we jump to progressively younger ages.  In Train Dreams, the director uses a bridge and narration as an anchor point to orient the viewer to where we are in the main characters life. Memorable people from many points in life are present in both films – just like the memorable people we all tend to think about in our everyday lives. Some of those memorable people become attached to other thoughts from different points in time.  In Train Dreams one of the main character’s co-workers drops dead as they are loading a horse-drawn wagon and the narrator says: “He died of a heart condition that if he was born 25 years later would have easily been discovered and cured…”  All part of how our conscious state recalls memories and modifies them based on our current experience.

In Train Dreams, Robert Granier is the central figure (played by Joel Edgerton).  It is all about his life in Idaho.  We see glimpse of his early life arriving by train in Idaho.  We see him encounter a man who has been fatally injured and is lying in the woods.  He gets that man water by filling a boot with water in a nearby stream.  Grainer is a loner leading an isolated existence until he meets Gladys Olding in church.  They marry and have a daughter Kate.  To provide for the family, Granier needs to work at a distance from home in the dangerous occupations of railroad construction and logging.  We witness his coworkers being killed by accidents, racists and vigilantes. We see his interactions with Gladys and Kate and the plans they make for the future. During his last season as a logger he comes home to find the area engulfed in a wildfire and Gladys and Kate are gone.  He is devastated and camps on the ashes of his old cabin, hoping they will reappear.  At times he hears the voices of Gladys and Kate in the woods.  His friend Ignatius Jack comes out to visit him when he is in bad shape.  Ignatius Jack shoots an elk and helps him rebuild his cabin. 

Along the way he sees flashbacks of incidents that occurred with his family and his coworkers.  Among them is Arn Peeples (played by William H. Macy). Arn is a philosopher of sorts and is focused on the connectedness of nature and how man’s existence plays out in unpredictable ways. We also witness an incident where Grainer encounters a logger who he worked with years before.  That logger is no longer doing physical work but attending to some of the machinery.  He has obvious memory problems and has difficulty tying his bootlaces.  Grainier assists him with the bootlaces and at that time makes the decision that he is done logging.

He returns home and eventually established a hauling business with two horses and a wagon.  It increases his social contact and in a most interesting encounter he meets Claire Thompsen (played by Kerry Condon) a bright, charismatic, and attractive forestry worker.  He discloses to her that he still hears the voices of his wife and daughter and asks if this makes him crazy. She normalizes the experience and says that she also lost her husband.  The have one more encounter when she invites him up to the top of her fire tower.  

At one-point Granier thinks his daughter Kate has returned as a teenager.  He finds her outside of his cabin lying on the ground.  He takes her in, notices that she has a broken leg and sets the leg.  In the morning the cabin door is open and she is gone without a trace.  The scene is surrealistic and the viewer is left with the impression that it did not happen.  He continues to live alone in the cabin.  The narration tells us that he dies alone in the cabin at age 80 while he is sleeping.  Before that we see him take the train to Spokane.  He witnesses the first moon landing on a storefront television and takes an airplane ride in a two-seater biplane.   We are left with the impression that he has finally seen meaning in what is portrayed as an isolated, tragic life.  We don’t have to look too hard to see that there were ups and downs.  That at times he was loved and cared for despite the horrific incidents and that his life was probably not that much different from ours. 

In The Life of Chuck is a drama based on a Steven King novella about the life of  Charles “Chuck” Krantz (played by Tom Hiddleston).  The movie is in three acts – in reverse chronological order.  The early view of Chuck in Act 3 is his image placed on multiple billboards and ads that all say: "Charles Krantz: 39 Great Years! Thanks, Chuck!".  The main character in this act is Marty Anderson (played by Chiwetel Ejiofor) – a middle school teacher.  He and his students are attending to what seems to be a climate change driven apocalypse.  His ex-wife calls and they discuss the end of the universe.  He travels to her house.  Before that both the Internet and television stations have failed except for the Charles Krantz ad   Along the way he encounters a young girl roller skating and an older man who is an undertaker.  The streetlights go out and Chuck’s image is projected onto the windows of surrounding houses and they do not know what to make of it.  The predominate affect is anxiety and fear.  Anderson finally reaches his ex-wife’s house.  They both fear that the end is near.  As they are watching the sky in the backyard – stars and planets start to disappear.  The scene is interleaved with Charles Krantz sick and dying in his hospital bed.  His wife and teenage son are there.  They are both tearful and his son says: “Only 39 years.”  His mother replies: “39 Great years.  Thanks Chuck!.”  Chuck dies and we are left pondering a tremendous metaphor. 

Act 2 begins with narrator Nick Offerman introducing the major players. A busker drummer sets up her drum kit and starts playing for donations from passersby.  It is a large intersection of several roads resembling an outdoor mall.  There is only foot traffic.  We learn that she dropped out of Julliard and has not told her parents yet.  We are introduced to a young woman who just received a break-up text from her boyfriend.  Finally, we see Chuck Kranz walking.  He is dressed in business attire.  We hear all about his business background, reason for being in the city, employer, and opinion of his fellow accountants.  We learn that he does not know about his condition and that he will be dead in 9 months.  No diagnosis is mentioned but from the description of the symptoms it is a severe progressive neurological problem.  In a critical piece of narration, we learn how Chuck will eventually assess the severe pain he endures with the disorder compared to what he will do that day in the street. 

As he walks across the area where the drummer is set up – they both make eye contact.   She thinks he will just walk by – but he puts his briefcase down and slowly breaks into dance following her beats.  She modifies the tempo and he continues to follow.  He notices a girl who has just broken up with her boyfriend is moving to the music and he pulls her out to dance.  A crowd gathers and it is a joyous scene – the crowd cheers them on. It is a vigorous dance number and at one point Chuck pauses and appears to be in pain.  He brushes it off and competes the dance – but declines to continue dancing.   The busker points out they were very successful and could probably do it for a living.  As they are debriefing after the scene, the busker asks Chuck why he stopped to dance and in a narrative highlight – we learn what he could have said but decided not to.   

Act 1 begins in Chuck’s childhood and we learn he lost his parents in an automobile accident.  He is living with his grandfather Albie and grandmother Sarah. His mother was pregnant at the time of the accident. Albie is an accountant and he has a drinking problem.  The house where they live has a turret with a padlock on the door and Chuck is forbidden to go in there.  His grandfather alludes to unusual things happening in there.  Through a series of comments, it seems that Albie claims he saw some distressing incidents that happened in the future while he was in that turret.     

There are two fantastic scenes in Act 1.  In the first, Chuck notices his grandmother is dancing to rock and roll music while she cooks. She is slender, athletic, and moves like a dancer.  She invites him to join her and she teaches him a lot about dancing.  He eventually joins a dance club in high school where he is a great dancer but his partner is significantly taller than he is.   The second scene is in English class.  Everyone is talking and moving.  We learn the young teacher is “a hippy dippyish woman with no command of discipline and would probably not last long in the public education system.”  She is trying to recite Walt Whitman’s Song of Myself.  Chuck appears to be the only student who is listening.  After the class disperses, Chuck approaches the downtrodden teacher and asks her what Walt Whitman means when he says: "I contain multitudes”.  She is invigorated by the question, approaches him and places her fingers on each side of his head and asks:  “What’s between my hands.?”  In the dialogue she points outs: “All the people you know.  Everything you see. The world.” And as you age that universe gets bigger and more complex.  She encourages Chuck to “fill it.” 

In the last part of Act 1, we see glimpse of Chuck in the hospital.  We learn a glioblastoma is killing him and it is having effects on his cognition.  In this act we learn that his grandmother died suddenly in a store in her mid-60s. He inherited his grandparents’ home and eventually uses the proceeds to transition though college and then into the home where he moves after his marriage. In the final scene, he is in his late teens and has been given his grandfather’s possession.  He uses the key to go into the turret.  While there he sees an image of himself in a hospital bed on a monitor.  The narrator makes the connection between what Chuck’s grandfather had seen in the room and that the waiting he referred to was the period that elapses between current time and when the image of the person’s death occurs.   

One of the most interesting aspects of stream of consciousness art is the impact on the observer.  You realize that the author is doing more than telling a story. In many ways it is a projective test for your own conscious experience.  How many times have you thought about dying?  How many times have you seen gross injustice and not corrected it – only to be haunted by it for the rest of your life?  How many people who you have encountered in your life do you think or dream about every day?  How big is the universe in your head?  The author’s associations are also your associations and they have significant emotional impact.   

The movie presents so much information about the players that even when they do not have an answer you can speculate about what it might be.  When Chuck starts dancing in the street, his initial hand movement is identical to the one his grandmother used when he first saw her dancing to rock and roll music.

There are no easy solutions presented in either movie.  Granier does not suddenly fall in love with the forestry worker and regain his martial bliss.  Chuck does not forget about his accounting job and become a busker.  His grandparents cannot be saved.  Existence moves inexorably on.

I found both movies exhilarating – not just for the stream of consciousness approach but the stream of consciousness within the stream of consciousness.  I hope it will help people focus on the universe in our head and how it operates.

 

George Dawson, MD, DFAPA

 

1:  Train Dreams.  Santa Monica, California:  Black Bear Pictures; 2024.

2:  The Life of Chuck.  New York: FilmNation Entertainment; 2024

Graphic Credit:

Graphic:  Cosmic Calendar originally invented by Carl Sagan that maps the time of the Universe (13 billion years) onto a 12-month calendar.  Man and civilization does not appear until December 31st at 10:30 PM on this calendar.  This visualization is from physicist Emma Chapman and the Royal Society

The Royal Society, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons

Page URL: https://commons.wikimedia.org/wiki/File:Cosmic_Calendar_%E2%80%93_deep_time_and_cosmic_history_as_one_year_(time-lapse_and_annotations;_50MB_version).gif

This graphic is used twice in The Life of Chuck most importantly in scene 3 when Marty Anderson is trying to reassure his ex-wife that the end may be much longer than she expects.  

Enthusiasm Is A Plus...

 

 

I am currently writing an opinion piece on the medical skills necessary for current and future psychiatrists.  I designed a table and sent it to my favorite internist for feedback – my brother.  He was concerned about my level of intensity and wrote back:

“In an ideal world this sounds good. In my experience most psychiatrists do not have your zest for medical knowledge. Enthusiasm is hard to teach.”

His response got me thinking about the enthusiasm factor in academics and medicine.  Is it teachable or can it be transmitted some other way?  What about the issue of authenticity?  Is the observable really enthusiasm or is it something else appearing to be enthusiasm?  Competitiveness is probably a good example and it is legendary in pre-med and medical school courses.  There appear to be plenty of people who adhere to the old adage about escaping a bear attack: “I don’t have to be faster than the bear – I only have to be faster than you.”  When I was in med school these people were known as gunners because on rounds with attendings they were gunning for you.  They would attempt to elevate their status by trying to make you look bad. In some cases that took on the appearance of just trying to look more interested than you.  I never really understood the mentality because after all we were in the presence of an attending who could make all of us look bad – and typically did.

My interaction with professors and attendings was the first real sign that true enthusiasm exists.  In college at every level there were professors with vast knowledge of their subject material.  At times they would interject their personal excitement about the subject matter into the lectures.  Anecdotes about the organic chemist who famously said that God consults him about molecules, the inscription on Boltzmann’s grave, or the mathematician who discovered group theory and then died in a duel at age 20 and the implications. Some of these professors would read the room and try to inject humor to invigorate the class and create some enthusiasm. And there were the obvious sacrifices like hanging in there as a professor or adjunct at a liberal arts college for substandard pay and benefits for the love of the academic field and the ability to practice it.

In medical school, it was even more obvious.  Most of the people med students interact with are attending physicians on clinical rotations who teach but also have their own productivity demands.  Physicians rounding on patients with a teaching team have their clinics or surgeries in addition to supervising trainees. They need an academic level of expertise in their field to maintain the teacher-student hierarchy.  A pediatric endocrinologist told me: “I must know the most about any endocrine subject in the room (referring to the mix of specialties on our ward team).  It is no accident that I know all about adrenal steroidogenesis.  I have to know it cold.”

Was that still about competitiveness and one-upmanship?  Possibly but highly unlikely.  After all an attending physician is not competing against trainees or anyone else.  If there is any competitiveness it comes down to internal standards.  As an attending for me that came down to a series of questions:

1.  Am I missing anything?

2.  Am I doing an adequate job?

3.  Am I covering everything that is important to cover and am I communicating what that is?

4.  Are there any problems with the staff or trainees that need to be addressed?

Competitiveness does persist post training and it is a largely undiscussed problem.  I once witnessed a confrontation between two very high-level academics where one commented that he would never be beaten by the other.  The rejoinder was: “I think the field is big enough for both of us”.   In the current American system, it is encouraged among front line physicians using several metrics like productivity (number of patients seen not papers read) and various scapegoating techniques in the corporate employee assessment. But I think most senior physicians get to the point where they welcome collegial discussion and consultation.  If you discussed it with them – their competition is most likely against high internal standards – some of which may be unrealistically high.

The psychology of enthusiasm has several dimensions. There are behavioral approaches to improve it – not the least of which is establishing predictable routines.  Athletes routinely push past nonspecific feelings of unwellness and notice that those feelings resolve and they feel much better with their workout routine.  This helps establish a long-term pattern of enthusiasm for high levels of exercise.  There is a social component that is used in sports for both the athletes and spectators involved.  Like all psychological phenomena there are rating scales that seek to describe the enthusiasm of teachers and work engagement in general (1).  In the age of burnout several studies have suggested that enthusiasm may minimize that problem.  It would be difficult to maintain enthusiasm in the face of moral injury.

From a psychodynamic perspective, identification with teachers, professors, and attendings is a largely unspoken but in my experience powerful process. In clinical medicine there is probably no better field to observe personal attributes of teachers and consciously or unconsciously incorporate them into your personality.  I was fortunate enough to work with so many enthusiastic and high energy physicians and teams and they had a direct impact on me.  The message was be compulsive, check and recheck everything, and do the research on the fly.  I have written about the last team I worked on in medical school.  Every person on that team from the intern to the 70-year-old nephrologist was interested in kidney disease 24/7 and we covered the largest inpatient unit I have ever seen (including transplant patients) and two outpatient clinics.  We worked at it from sun up to sun down and everybody was energetic and ready to work.  That team also showed me the importance of a sense of humor.  Everybody had it but one of the Internal medicine residents was practically a stand-up comedian.  On my last day of medical school, I worked until 10 PM with that team.  They were swamped with consults and asked me to do three after the clinic.  I was happy to do it and then skipped across the golf course like county grounds to my apartment a half mile away.  Even as an old man – I feel happy every time I think about that experience. 

As I am winding down this post, there is a moral dimension to enthusiasm at least as far as medicine goes.  People have been described as doing harmful things enthusiastically.  Enthusiasm has to be a positive force.  One of the derivations from the Greek is “possessed by God or divinely inspired”.  At times in history, it has been equated with madness.  Philosophers have written about it as both a positive (promoting desirable values and politics) and a negative (zeal overtaking rationality).  In the context I am discussing – it takes the form of improved focus on difficult to solve patient problems and espirit de corps.    

Identification only gets you so far – I don’t think anybody has ever mistaken me for a comedian.       

What about in the case I started this post with?  It was my brother responding to a compulsive table about what medical problems psychiatrists should be able to recognize, diagnose, and either treat or triage. Enthusiasm may be a part of that and I will admit to being very enthusiastic about medicine and neurology in general, but there is more going on.  I made most of the diagnoses in the table not just based on enthusiasm but at least three other factors.  First, I practiced across multiple settings and was often the only psychiatrist around.  When you are asked to see people in general hospitals, nursing homes, and outpatient clinics in the same week there is a good chance that you will encounter serious but vaguely characterized problems in all these settings.   That could range from agitation due to any number of underlying neurological conditions to a mother who wants her 3-year-old son put on stimulants because of uncontrollable behavior.  Second, neurologists are in shorter supply than psychiatrists.  That doesn’t mean that psychiatrists should practice neurology but it does mean that specialists who are trained in and expected to know neurology might do a better job with certain problems than primary care physicians. At the top of that list are recognizing aphasia syndromes, presentations of acute encephalitis and meningitis, movement disorders, and functional neurological disorders.  Third, there is always a group of psychiatric patients who see their psychiatrist as the primary care physician they prefer to follow up with.  I have been able to diagnose unrecognized illnesses just based on that difference in preference and communication.  Psychiatric liaison with primary care is a useful function.     

Heading into 2026, I hope that all the professionals reading this have been exposed to the levels of enthusiasm that I have during their career.  And I hope that the doctors I end up seeing in the future all have it.

 

George Dawson, MD, DFAPA

 

Some additional thoughts/anecdotes:

1:  One of the advantages of enthusiasm is embracing just how much you need to know in order to do a good job.  A long time friend of mine who ended up being an ophthalmologist showed me his standard 3 volume ophthalmology text and put it this way:  "Every specialty is covered in 2-3,000 pages.  It is what you need to know."  That always made sense to me but as a specialist - enthusiasm changes that task from last minute cramming to knowledge that is part of your personal identity.  It is knowledge that has to stay with you and you have to keep it current.  It can mean the difference between life and death.    

2:  When I was a PGY-2, I was staffing patients in a clinic with my attending who was a brilliant psychiatrist and researcher.   He was very enthusiastic about teaching.  He asked me this question that also turned out to be a thought experiment:  "Suppose you are done with all of the training and you are out at a cocktail party somewhere.  People come up to you and start talking. Do you think you will be talking with them like a psychiatrist or like somebody who has had no training?  That question seems very easy to answer at this point in time, but back in 1984 I was drawing a blank.  This blog is probably a good example of what that answer is.

3:  Obsessional behavior can be mistaken for enthusiasm.  Ar various points in my career I have seen physicians paralyzed by it and stuck in a loop of unproductive activity.  It has happened to me a few times.  If that behavior is related to patient care - there is aways someone in your field who can tell you if you are missing something or not.   If it is a case of administrative scapegoating - you can always move on though it may not be easy.

4:  The anecdote about how my nephrology team convinced me to work late the night before my graduation is humorous, but probably not in a way that I can convey in writing.  At about 5PM that night the senior medicine residents approached me with the idea of staffing 3 more consults. It went something like this: "Look George - we know you graduate tomorrow and probably want to get out of here but we are getting killed with consults.  Do you think you could help us out by doing three?  One last thing?"

To clarify - in teaching hospitals, medical students are not physicians.  As part of the learning process on a consult service, they see the patient, get the necessary historical, physical exam, and laboratory data and record everything in the chart.   Then they present it to the attending physician.  The attending shows interviews the patient, does the indicated physical examination, adds the additional insights of an expert for both the consult team and the patient, and adds to the note and countersigns it.  The medical student and residents need to come up with their own diagnoses and treatment plan for discussion purposes - but that is the ultimate responsibility of the attending. There is a progression in medical training that the initial work by the medical student or resident becomes either a much closer approximation or identical to what the attending would say as people progress from med student -> resident -> fellow -> attending.

The residents were trying to cajole me into doing the work but they did not need to.  When I said I would they increased the flattery to absurd levels and we all had a good laugh about it.    

5:  On the issue of competitiveness - I had no idea how bad it could be until I had graduated from college.  I attended a very small college and we did not have a specific pre-med track.  I was a chemistry and biology double major.  Long before I decided to go to medical school - I heard anecdotes about sabotage in the organic chemistry lab to either contaminate the products or reduce the yield of synthetic reactions.  As a former lab assistant that is probably not the best way to evaluate lab performance.  Organic chemistry was one of the feared med school pre-requisites.  There is even palpable bitterness about the course in some people who are practicing physicians. Sabotaging somebody else's lab results seems counterproductive in so many ways and it is difficult for me to see how that would work very well.  As a lab assistant I viewed my job as making sure everyone was safe (I did prevent 2 explosions) and knew what they were doing.      

References:

1:  Schaufeli WB, Bakker AB. Utrecht work engagement scale: Preliminary manual. Occupational Health Psychology Unit, Utrecht University, Utrecht. 2003 Nov;26(1):64-100.

 

Graphic Credit: 

Teaching hospitals of the Medical College of Wisconsin taken from the path walking from my apartment on 89th street.  The black and white photo is Milwaukee County Hospital shot in 1982.  The color photo is from the same spot in December 2025.  The two most visible buildings are the Froedert and MCW Center for Advanced Care (left) and the Froedert & MCW Clinical Cancer Center.  The Froedert legacy spread from the original Froedert Hospital that was there is 1982 - where I did 2 neurosurgery, a nephrology, and a neurology rotation.  B&W is shot with a Konica 35 mm and Ektachrome.  Color is an iPhone 15.

A New Year's Resolution About Passwords? Make Them A Lot Tougher

 

Since the advent of the Internet security has been an afterthought. Passwords have been one of the most visible problems. Early on you could get away with 6 or 8 letter words that were easy to remember.  As time passed upper and lower case, numbers, special symbols, and punctuation marks were all added.  Then mandatory password reset intervals were added.  As a result, passwords became much more difficult to remember and use.  If you had to log in at work – there might be a temporary delay as you are forced to come up with another new secure password and write it down somewhere. 

Despite all these precautions – there are still people logging in with password, password123, Password123?, and so on.  Secure passwords for many accounts are still seen as a nuisance. If you routinely check whether some of your logins are on the Dark Web – every time a business is hacked your account information is bought and sold on the Dark Web.  In many cases those accounts are linked to email addresses that are no longer active.  The business entities hacked are often no longer in business or at least you no longer do business with them.  If those accounts were just used to track your activity and have no associated financial information – there is probably less to be concerned about.  That is of course unless you use the same password across multiple accounts.       

Internet crime in the US is big business for sociopaths.  In 2024 there were $16 billion in losses and the rate of this crime was increasing at a rate of 33% per year.  According to the Federal Trade Commission the 65+ crowd may be defrauded of up to $80B per year with most of it unreported.  There are an endless variety of ways that criminals can defraud people that include identity theft, hacking your accounts by stealing your passwords, creating phony technical assistance web sites, imitating relatives and people who you do business with, and creating false investment offers and invoices to get access to your account information.  They can also place malware on your computer or phone that allows them to see all your account and login information.  This essay will briefly focus on passwords.

The most basic consideration with passwords is how they are obtained.  Can somebody trick you in to using your password on a fake site imitating your financial institution or favorite internet site?  The most common phishing emails I get are from people imitating security, financial, and antivirus companies suggesting that my data has been compromised or that I owe them money and encouraging me to log in to a link they provide.  According to warning from Social Security there are also fake sites asking for your SSA account information.  If hackers know where you conduct business and they know your login they can go to that site and attempt to find the password.  The human factor is the weakest link in Internet security.  Even though hacking tools have been automated to facilitate hacking by criminals with less computer knowledge most of them would prefer that you just hand the information over to them.    

In the case where password hacking is necessary, a common type of attack is a brute force attack where hackers try every existing combination they can from stolen data.  They can also use dictionary attacks or hashing attacks that try every possible combination of words or hashes.  Hashes are basically codes for passwords stored on the server that is being attacked so they can be matched rather than the exact password.  Limited login attempts, Captchas, and external authentication can help prevent these attacks, but the best up-front protection is a good password.  

How are passwords measured in terms of security?  The current measure is Shannon entropy although they don’t seem to use that term.  Claude Shannon applied the Second Laws of Thermodynamics to information theory back in 1948 and revolutionized the field (1).  This innovation demonstrated that all forms of communication could be coded, statistically analyzed, and from there bandwidth and efficient channel capacity and coding could be determined.  I first read this paper in 1974 when I was studying thermodynamics in physical chemistry. 

During the evolution of required passwords complexity (upper case/lower case/numbers/special characters) was initially emphasized but those passwords are easily cracked by brute force attacks using current technology.  Password length is the currently the most critical factor.  Every increase in character length doubles the amount of time it would take to crack it.   The problem with length is that passwords rapidly get to the range that they are not only impossible to memorize but even to keep straight while entering them.  What follows are a few examples of the arithmetic of password length and a way to simplify the process.

The basic calculation for password entropy involves the equations:

Based on character set and length:

E = L x log₂(R)

L = Length of password in characters

R = Pool size of character set to be used

Based on passphrases and 

E = log₂(W) x N

W = Number of words in your dictionary (usually 7,776)

N = Number of words in your phrase

Note:  the 7,776 words here is based on the possible combinations of rolling a 6-side dice 5 times (65) 

Doing a couple of examples:

Using a standard 95-character keyboard – let’s say a site wants you to use a minimum of 8 characters with the standard upper and lower case, number, and special character requirement.

E = L x log₂(95) = 8 x 6.56 = 52.48 bits

Extending word length to 10 characters:

E = 10 x 6.56 = 65.6 bits

Using a 7,776 word dictionary and a 4-word pass phrase length:

E = Log₂(7,776) x 4 = 51.68 bits

Extending the phrase length to 8 words:

E = 12.92 x 8 = 103.36 bits

The general trends from these calculations are obvious.  Larger character sets and or password length leads to greater Shannon entropy and password security. What may be less obvious is how adding even one more digit to your password can greatly increase the time it takes to crack it.  If the number of a large exponent doubling the amount of time required can add decades to the amount of time required to crack it.  

An example from the graphic occurs at the 133-bit calculation. 2^133 = 1.09 x 10^40 combinations.  Assuming a computer that can make a quadrillion (1015) guesses/second it would take and correcting for seconds per year yields a total of about 172.5 quadrillion years.

That is an impressive amount of security, but it also highlights some of the unspoken aspects security recommendations.  It all comes down to available technology.  In the above example – there are very few machines capable of make that number of guesses per second.  Over time as the technology improves and gets less expensive more powerful processors will be able to crack passwords with higher combinations.  Many federal agencies suggest that the 133-bit encryption is all that is needed in the foreseeable future – but when quantum computing comes online that recommendation may be a thing of the past.  To protect yourself, you need to use the ideal passwords, eliminate human mistakes, and be aware of what the technology is doing.

I decided to present this basic information on encryption primarily because I see the destabilization of financial systems as a significant future risk. Banks and financial institutions are likely to tell you “we have the top experts on it.”  If you carefully read the boilerplate you must sign off on every year – it is not clear that you are protected in every case. If you are like me and make suggestions like blocking all wire transfers or requesting that withdrawals are made only in person with ID and biometrics you might be disappointed.  

For those reasons and the fact that I am not an Internet security expert by any means – I am encouraging everyone who reads this to do their own research and become their own expert.  When any company requires that you open an account with a username and password think about the information you are trying to protect and make that password as secure as possible.  There are many web sites out there that take you through what you can do step-by-step.  I have included an example of how to use dice generated passphrases to produce high security passwords from the Electronic Frontier Foundation word list (3).   They provide detailed information on how to produce 133- and 256-bit encryption passphrases.  There are also web sites that do the same with different character sets.  Apart for the passwords or passphrases there are addition techniques to make them even more robust.  

At this point many people have been on the Internet for 25 years or more.  Do not let that lull you into complacency.  Technology is always advancing and security is always lagging.  Make sure you can protect what is necessary.      

George Dawson, MD

References:      

1:  Shannon, C. and Weaver, W. (1948) The Mathematical Theory of Communication. Bell System Technical Journal, 27, 379-423, 623-656. http://dx.doi.org/10.1002/j.1538-7305.1948.tb00917.x

2:  Vopson MM, Lepadatu S.  Second law of information dynamics.  AIP Advances 12, 075310 (2022); doi: 10.1063/5.0100358

3:  Electronic Frontier Foundation.  EFF Dice Generated Passphrases:  https://www.eff.org/dice

The Phenomenological Suicide Assessment – The Legacy of Dr. H.

 

Warning:  This post is about suicide and the assessment of suicide.  It is intended for mental health professionals and people who not distressed by this topic.  Avoid reading this if you find the topic of suicide distressing.  

 

Suicide assessments constitute a major part of psychiatric practice.  According to standard guidelines it is a recommended part of any initial assessment.  Acute care psychiatry selects for these assessments largely because hospitalization and crisis care is focused on it and aggressive behavior.  Over the past 30 years insurance companies and governments have made it virtually impossible to treat people in a secure environment unless there is a risk of suicide or aggression. 

Most suicide assessments are taught as an exercise in risk factor analysis. Patient traits, demographics, and diagnoses correlated with suicide or suicidal ideation are collected across studies and applied to current evaluations.  Decisions about treatment are made on that basis.  The decisions may also have implications about continued risk despite what is said in the interview.  It can be a basis for court ordered involuntary treatment.

For example, let’s say I am asked to see an 80-year-old man on a surgical service.  He is there because he tried to cut his throat and underwent surgical repair of his esophagus and trachea as a result.  He describes feeling better at the time of the interview but says he has been depressed for years.  He lives alone after his wife of 45 years died last year.  At some point he noticed that there was a foul smell covering his body.  He thinks the smell comes out of his mouth at night and covers his entire body.  He is a heavy drinker and consumes 500 ml of vodka per day.  He prefers to return home without treatment as soon as the surgery team clears him for discharge.  His labs show elevated transaminases and prolonged coagulation parameters.

This is an example of a person at high risk for ongoing suicide attempts based on risk factors.  In this case depression, psychosis, alcohol use, a serious suicide attempt requiring surgical repair, age, and lack of social support all define him as high risk.  It is unlikely that any psychiatry service would discharge him untreated to go back home and potentially experience the same series of events that led to the attempt. 

That was state of the art assessment back in 1982 when I started my residency and it is not much different now.  A few months ago, I sat through a very long presentation on an artificial intelligence (AI) based approach to suicide assessment.  It consisted of analyzing the patient’s word frequency during the assessment and deciding suicide risk based on that.  The qualifier was that it was not a substitute for clinical judgment.  It reminded me a lot of the quantitative electroencephalogram (QEEG) research I started doing in 1986.  The technology claimed to be able to separate psychiatric diagnoses based on fast Fourier transformation (FFT) analyses of EEG frequency bands. The problem was the analysis also depended on clinical features that had to be added to the diagnostic algorithm.  It was not a true test without that additional input. The AI analysis of suicide was no different.    

The problems with assessments for suicide potential are essentially two-fold.  First, the conscious state of the individual changes and they go from a person who would never consider suicide to one that would.  Before that change you are talking with and gathering data from a person who is not contemplating suicide.  Second, suicide attempts are generally impulsive.  Many people interviewed after surviving a suicide attempt are glad they survived.  In many cases they regretted to committing to suicidal behavior almost immediately.  A good example are the young men who survive jumping from the Golden Gate Bridge (1).  They experienced instant regret after jumping away from the railing.  An additional complicating factor is that the person sitting in front of you may want to be released to make another suicide attempt and they either do not want to discuss it or they want to conceal that fact from you.

I had all these things on my mind when I was doing consults on medical-surgical patients at the hospital where I trained back in 1982.  I was a first-year resident and my job on this rotation was to show up and do all the preliminary evaluations on the consult requests that day and then present and discuss them with my attending Dr. H.  Dr. H had been an attending for about 6 years at that point.  She had returned to work in the county hospital from private practice.   I had worked with her for a few days and things seemed to be going well.  We generally agreed on diagnoses and treatment plans and there were no personality conflicts.  That is about as ideal as it gets for a resident.  Then one day – Dr. H showed me an interview technique that I never forgot.

I had just presented the case of a young man who had overdosed on antidepressant medications.  He seemed mildly depressed and irritated.  I ran down his history and probable diagnosis to Dr. H and we walked in his room so that she could interview him.  It went something like this:

Dr. H:  “Hi I am Dr. H and I am the staff psychiatrist here.  Dr. Dawson was just telling me a few things about what happened.  Would it be OK if I asked you some questions?”

Pt:  “Sure.”

Dr. H:  (after clarifying the demographic and medical data): “Can I ask you about the overdose”

Pt:  “Sure”

Dr. H:  “Do you remember the details?  Do you know the pills you were taking?”

Pt:  “Yes they were amoxapine.”

Dr. H:  “How did you take them? Did you take them all at once or one at a time?”

Pt:  “I was taking handfuls.  I would take a handful at a time and rinse them down with water.  It was hard to do because they are large capsules….I had to take more and more water and eventually stopped.”

Dr. H:  “And what exactly were you thinking at the time?”

Pt:  “I was thinking I wanted to die.  I was thinking that I was a loser and I wanted to die.  I could not see any future.  I did some research on this and knew that this stuff was fairly toxic and that if I took enough of it – it would kill me.  I was throwing them down as fast as I could.”

Dr. H:  “What happened next?”

Pt:  “At some point I started to feel sick and I got really drowsy and passed out. The next thing I was waking up in the Emergency Department downstairs.  They had a tube down my throat and they were giving me charcoal.”

Dr.  H:  “Looking back on what happened yesterday – what do you think?’

Pt:  “I would not do the same thing again but it would not have bothered me if I succeeded yesterday.”

Dr. H:  “Do you feel like a different person today?’ ….

 

The above exchange is a brief excerpt of the interview, but it was not like my interview.  I spent about an hour interviewing the patient about depression, anxiety, and suicidal ideation like they were all third person observable objective facts. He was clearly less engaged with me than he was with Dr. H.  When you interview someone from the perspective of third person objective facts – you invite them to see the world the same way.  They become passive observers to what happened to them.  You can’t really get to the change in conscious state or impulsivity that make suicidal states unique.  Dr. H went on another 20 minutes getting every detail of this patient’s subjective experience of the incident.  It was amazing and we discussed it when she was done.

From that point on my suicide assessments were all based on that phenomenological approach whether I was talking with people who survived attempts or were talking with me because they feared losing control.  I needed to know their emotional state and what they were thinking.  Even in those descriptions there were conscious fantasies and defenses:  “I was pointing the gun at myself but I never pulled the trigger.  It just went off in my hand.”  In the process I heard hundreds if not thousands of reasons why people attempt suicide and exactly what they were feeling and thinking at the time.  In the larger scope Dr. H helped me focus on the subjective.  That is something that you lose in medical school where there is an implicit emphasis on the objective and subjectivity seems like a bad thing.  The reality is that subjectivity dwells within every classification system.

 My memories of the past are so vivid that at times I forget I am an old man.  I recalled the above exchange with Dr. H when I was discussing phenomenologically based approaches to suicide assessments with a new generation of residents.  That happened just last week.  I decided to look her up and see what she was currently doing.  I wanted to thank her for the direction she gave my development and career.  I found out that she died 6 years ago.  Her obituary said she did not want a funeral.  The family requested memories and stories.  I hope this blog serves that function. She taught me about phenomenological suicide assessments when they are scarcely written about to this day.  I am sure she taught many more people than me. 

Passing an important technique along that you can’t find in a book or a paper and making that accessible to a young resident who thinks he is getting the job done is a great legacy. 

 Thank you Dr. H!.

 

George Dawson, MD, DFAPA

 

References:

1:  Nelson K.  ‘All I wanted to do was live’: After years of debate, a suicide safety net for the Golden Gate Bridge is nearing completion. Survivors say it’ll give many a 2nd chance at life.  CNN.  November 19, 2023  https://www.cnn.com/2023/11/19/us/golden-gate-bridge-suicide-safety-net

Psychodynamic Prescribing

 

 

I did a presentation to residents and co-teaching faculty on psychodynamic prescribing last week and decided to post something while it was on my mind.  I also read several book chapters in the process and have recommended reading that readers might find useful.  My introduction to the lecture highlighted the longstanding rhetoric within the field that when sufficiently polarized leads to absurd conclusions.

I used the relative periods of the history of psychiatry and composites from several authors to look at the main intellectual focus of the field.  In the asylum era up to about 1910 – the focus was gross neuropathology, classification, and psychopathology.  There were also clear improvements in asylum care.  From 1910 to 1960, the focus shifted to psychoanalysis and various theoretical schools.  Starting in 1960, the focus shifted to biological psychiatry that is commonly characterized as the study of neurobiology, genetics, and psychopharmacology. The figure below from the presentation was an attempt to name prominent psychiatrists during each epoch who were thought leaders.  The problem that should be evident is that these periods were not homogeneous. During the most recent era for example, there are many biological psychiatrists and at the same time some of the most significant psychotherapy theorists in Kernberg, Kohut, Beck, Klerman, Gunderson, and Yalom. 

How is it that these divisions seem to exist in the field?  In my experience it comes down to competitive environments and the associated politics.  As an example, I did my psychiatric training at two different programs.  The quality of both programs and clinical experience was excellent.  One department was headed by a psychiatrist from the Washington University (St. Louis) school of psychiatry.  That school was known as the neo-Kraepelinians and they favored biological explanations for psychiatric disorders but by no means ignored the psychosocial.  The other school was headed by a psychiatrist who was eclectic and interested in both the biological and social origins of severe anxiety.  He was also surrounded by a staff of biological psychiatrists, psychotherapists of various origins, and medical psychiatrists.  Both programs had plenty of faculty on both the psychotherapy and biological psychiatry sides. 

Both of those training settings were essentially projective tests for psychiatric residents and medical students.  Some identified with the psychotherapy staff and some with the biological staff, but everyone trained in both areas and a wide array of settings.  The real strength of psychiatry is knowing what to do about diagnoses and problems across a wide variety of settings and presentations.  As an example, I could be doing hospital consults and making aphasia diagnoses one afternoon and the next day seeing several long-term psychotherapy patients.  From there I could be doing a shift in a crisis unit and doing appropriate interventions – both therapy and medications. 

The broad training that psychiatrists get is rarely mentioned.  What is mentioned are stereotypes like psychiatrists prescribe medication and financial incentives drive this process.  They do not do “therapy”.  The caricatured biological psychiatrist states: “I am a biological psychiatrist and I don’t do therapy.  If you have a problem discuss that with your therapist.”  Why is that not possible?  And why are things just as difficult on the other side of the equation – the psychotherapist that doesn’t do medications.  There was a time when medically trained psychoanalysts only practiced psychoanalysis.  Over the past 40 years, I have seen many psychiatrists with psychoanalytical training who practice general and even hospital psychiatry.

In terms of either not prescribing medication or providing psychotherapy, the first problem is that it is not how psychiatrists are trained.  The training is focused on the necessary treatment techniques to help people who have the most severe problems.  The large markers are evidence-based treatments these days and there are plenty of them, but all fields of medicine extend into treatments that have little to no evidence.  In psychiatry that zone is broader because we are necessarily focused on subjectivity – it is not a bad thing.  It is harder to measure.  According to consciousness theorists – everyone’s conscious state is different and the same external experiences are experienced differently at the mental level. Meaning (to the individual we are seeing) is important.  Second, even stable people end up in crisis whether they are stabilized on medications or improved in psychotherapy.  The ups and downs of life can trigger a crisis and everything that involves.  That generally does not require a change in medications or psychotherapy plan – but it does involve being able to verbally intervene in a crisis.  That is typically talking and environmental interventions.  Third, there have been rigid expectations for what constitutes psychotherapy that are not realistic.  For example, hour long sessions for a new patient on a weekly basis for weeks or months.  Most psychiatrists these days see 2 to 3 new people per day.  In just a few weeks of practice that type of psychotherapy schedule would be filled. Garret (4) has detailed estimates of how many patients can be seen in a month using 30- and 45-minute visits and they vary from 15 (seen weekly) to 98 (seen less frequently).  In the CMHC settings where I have worked 30-minute appointments at varying frequencies are the norm. Fourth, in an average clinical encounter how long does it take to assess the patient’s state related to medications and make the related decisions.  All of that takes about 10-15 minutes.  Then what?  You can either have 10–15-minute appointments or discuss other areas of that person’s life that are relevant to treatment.

How does this happen across settings where in many cases psychiatrists are expected to prescribe medications in limited periods of time and have an onerous documentation burden.  The Garrett reference (1) has some clear ideas and specific diagnostic codes. I have previously written about it on this blog as supportive psychotherapy being the language of psychiatry and how pattern matching in psychotherapy is not much different than pattern matching in general medicine. In this post I will discuss some additional points in how this occurs across many appointments and within the same appointment.

In the diagram below, there are several dimensions that are operating during every appointment but are most apparent in the initial assessment.  The obvious overview is that there is a psychotherapeutic context for every encounter.  This is evident in any treatment literature that you might read.  Different authors use different terms.  For example, prescriptive therapies can include lifestyle changes (diet, exercise, smoking/alcohol cessation), medications, behavior therapy, and brief manualized psychotherapies.  They all assume that the psychiatrist can see a problem that responds to a specific intervention and no deeper level of understanding is necessary.  When I use the term top down, it means approaching problems at the surface.  To use a mechanical analogy – it is like using stop-leak for a blown engine gasket rather than taking the engine apart and fixing the gasket.  Like all analogies that breaks down at some point.  You could consider behavioral activation a prescriptive therapy but it also addresses deeper processes and patterns.  Most prescriptive therapies probably lie in a more intermediate position between purely prescriptive interventions and deeper explorative therapies.

The beauty of psychodynamics is that it operates at the level of individual human consciousness and that cuts across every domain.  The typical descriptive and classificatory levels of psychiatry give the illusion that all human mental suffering can be classified into neat categories.  Contrary to antipsychiatry rhetoric that same illusion exists in ordinary medical and surgical classifications as well.  In psychiatry, there is probably no better example than a paper last week (2) illustrating how a common DSM based depression checklist is misinterpreted.  This same scale is used on a large-scale basis and used for genomics studies suggesting a degree of phenotypic certainty that does not exist.  Psychodynamics and some other forms of psychotherapy address conscious states that are highly individualized and determine unique pathways to problems.  Psychodynamics also cuts across all treatment interventions.  If you are a consultant it also includes how other physicians are reacting to your patient.    

The interface between medication response and psychotherapy is also not typically considered.  It is known that environmental, interpersonal, and psychotherapeutic interventions can alter both the placebo and nocebo response to medications. These responses can be powerful and they are not limited to psychiatric medication or interventions.   In some cases, the physician patient relationship alone is enough to alter response patterns to illnesses and medications.  It is good practice to use psychotherapeutic interventions that affect both in the desired directions of increased placebo response and decreased nocebo response.

Beyond the placebo-nocebo effects there are also conditioning effects and the environment of the clinic may be a factor. Staff interaction and the overall quality of the environment can be important.  This is thought to be a factor in many clinical trials when patients are seen and treated in clinical settings that seem much more intensive and friendly than their usual clinical settings.  

At the psychodynamic level exploring the patient’s expectations, fears, and fantasies about the medication is an important first step before prescribing.  Was the idea to try a medication their idea or did it come from somebody else?  What does taking a medication mean to them?  Is there a fear or wish for dependence?  Is there a change in the dynamics of the relationship based on allowing the physician to make decisions for the patient?  Does that occur after an adequate informed consent discussion?  Some writers describe this regression as the sick role and suggest it may be appropriate if the patient is very ill, but there always needs to be a plan to restore baseline autonomy.

Prescribing can be seen as a hostile or caring act depending on the meaning of the medication.   Medication can be seen as soothing, calming, a way to restore baseline wellbeing, and eventually regain autonomy.  It can also be seen as a punishment, confirmation of a dreaded diagnosis, or a sign of personal weakness.  At the fantasy level – it can be seen as a magical potion that will cure everything that ails the patient. In some cases, the medicine functions as a talisman warding off symptoms if it is in the possession of the patient – even when it is not taken.

In the intersubjective field, the prescribing physician can also develop countertransference thoughts and fantasies about the medication and because of emotions that occur in the relationship.  Common among them is the healer fantasy of omnipotence that all problems can be treated into remission with medications.  That can lead to over-prescribing, premature prescribing, and other boundary violations.  Various clinical scenarios (errors, treatment resistance, projective identification) can lead to anxiety and dread in the countertransference that may affect prescribing.  There is also the practical scenario that when things are not improving any physician’s anxiety will be going up. In a prescribing scenario that can lead to dose escalation, polypharmacy, inadequate attention to side effects, and inadequate attention to discontinuing ineffective therapies.  Based on my conversations with people – they are often skeptical that a rumored combination of medications will work better than what they have tried in the past.   Prescribing can also be a defense against other factors that are difficult to address.  In the most basic case, prescribing can be seen as a form of intellectualization (these symptoms –> this medication) rather than addressing the complexity of all the emotions and conflicts in the room.

Another form of prescriber anxiety in the countertransference is the fear of harm or liability.  That is often discussed as a medico-legal problem.  I have never found this a useful dimension for analysis in clinical practice, but for many years there was the suggestion that psychotherapy alone without medical treatment may be a risk.  That came from the case of Osheroff v. Chestnut Lodge that was eventually settled and therefore is not established case law.  In this case the plaintiff was an established professional diagnosed with narcissistic personality disorder and treated with psychoanalysis at the Chestnut Lodge – a psychiatric hospital.  When he started to get worsening depression and severe agitation at the 6 month mark a consultant recommended a trial of medication – but the treatment staff decided to continue psychoanalysis.  After another month of marked decline, he was transferred to another hospital where he was treated with an antidepressant and a phenothiazine where he improved and was eventually discharged and resumed working. This case is frequently cited as evidence of the superiority of medical treatment – but from the description it seems that psychodynamic prescribing just needs to adhere to a general rule in medicine – if the treatment is not working try something else. I have not seen any countertransference related factors described that could have led to this inertia – but it is easy to speculate.       

Adherence is often discussed in very basic terms from a prescriber standpoint.  For example, fewer doses per day, long-acting injectable medications, and sustained release medications all improve adherence.  From a psychodynamic standpoint – adherence is a meaningful communication.  Does it suggest ambivalence, resentment, or a challenge to the prescriber’s authority, interpersonal style, or diagnosis?  That can all be openly discussed.   

Although I have listed several psychodynamic factors relevant to prescribing, they are by no means exhaustive.  I am certain that in any practice out there psychiatrists could create a list based on the patients they see every day.  Of those factors the most significant one in practice has been countertransference.  Every psychiatrist needs to be aware of that dynamic more than the rest because it is most likely to affect your judgment and the judgment of your coworkers. If you do team meetings like I did every day for 22 years, it is most likely to disrupt your team and the environment and in the worst case affect the safety of patients and staff.  In that scenario you need to figure it out and figure how to keep a lid on the place.  The same thing is true for consult-liaison docs who are seeing disruptive patients in medical and surgical settings. 

I seem to be stating what is obvious to most psychiatrists. That is probably because most people still do not know what we do and we don't seem to talk about it much.    After all Paul Dewald (1) wrote very well about this over 70 years ago.  Everything in that chapter still applies today.      

 

 George Dawson, MD, DFAPA

 

 

References:

 

1:  Dewald PA.  Psychotherapy a dynamic approach.  2nd ed. New York: Basic Books, 1971.

 

2:  Mintz D, Azer J.  Integrating psychoanalysis and pharmacotherapy. In: Gabbard GO, Litowitz BE, Williams P, eds.  APPI Textbook of psychoanalysis, 3rd ed.  Washington DC: American Psychiatric Association Publishing, 2025: 291-305.

 

3:  Mintz D.  Psychodynamic psychopharmacology. Washington DC: American Psychiatric Association Publishing, 2022

 

4:  Garret M.  Psychotherapy for psychosis.  New York:  The Guilford Press, 2019.

 

5:  Novalis PN, Singer V, Peele, R.  Medication-therapy interactions and medication adherence. In:  Clinical Manual of Supportive Psychotherapy, 2nd ed. Washington DC: American Psychiatric Association Publishing, 2020: 377-391.

 

6:  Wright JH, Turkington D, Kingdon DG, Basco MR.  Cognitive-behavior therapy for severe mental illness. 2nd ed. Washington DC: American Psychiatric Association Publishing, 2020.