These vignettes are based on real cases which I have  either been involved with as the therapist or as  the supervisor or I have read about them or have been told about them by a colleague. Some details may have been changed to protect confidentiality.

All the cases are at least 10 years old. Readers of this blog are welcome to express their opinion about the cases. We all recognize that in a real clinical situations, there would be much more information available about the patient which might help in making a decision.

In a future blog, I will present further discussion about these two cases.

Case #1

The   patient is a  26 year old young women who came into therapy because  she was depressed about her inability to complete things. She had started college twice and dropped out and as a adolescent she came home from sleep away camp twice. Her goal was to go to nursing school some day in the future. She had many friends but had trouble keeping a boyfriend, She was attractive but was somewhat inhibited and only on occasion would allow herself to have sexual relations which she would enjoy. Her parents  were divorced when she was 6 years old. Her father is a physician would visit her periodically as a child  and when she  was older she would visit him and  his new wife . She always felt close to them and their two children. Her own mother was an alcoholic and when she was younger her behavior was quite erratic. At time she was physically abused by being slapped around. Other times she would have to take care of mother by making food for her and sometimes would even stay home from school . Despite poor attendance she got good grades. She herself does not drink or take drugs.  She shows no evidence of a major depression or psychotic symptoms. She is often moody but doesn’t appear to have hypomania. She becomes angry when she is disappointed. As a preadolescent she saw several therapists and  she had 2 or 3 brief trials of therapy in the past 3 years  including several weeks of a trial on an SSRI which she didn’t feel made any difference. She is currently in treatment with psychodynamically  oriented psychiatrist who has decided not use medication at present.  She has been coming for 4 months 2x/week ( Tuesday and Friday).   She says this is the first time she is making progress in therapy as she feels she can talk freely and is not being judged.

During her last session on a Friday very close to the end of session, she said , Whatever we say here is completely confidential, isn’t it?” The therapist replied, “Why do you ask this question ?”  The patient then went on , “ You know that baby sitting job that I have been doing every Saturday nite for Mr. and Mrs. Woodman my neighbor’s   15 month child.?” Well last week the kid was a real problem. He was whinning all the time and wouldn’t listen to me. The final straw was that he spit on me. I lost it  and slapped him    real hard across the face. His face got really red and swollen. I put some ice on it. I will never do that again.” The therapist, was stunned and before she could say anything, the patient said , “Well, I know my time is up” and got up and left.

Should the therapist do anything with this information. Is the therapist required to notify anybody? What are the  legal  and therapeutic implications ?

Case #2

A senior therapist  is supervising the following case. The patient is a single 36 year old dental hygienist living in Manhattan who is in her second year of three times / week psychoanalysis. She entered treatment because of difficulty trusting men which has been related to an inconsistent and insensitive father who shared with the patient the fact that he was cheating on her mother. The therapy has been going well and the patient has made progress in her ability to accept interpretations, have her own insight and utilize insight through her understanding of the transference.

The patient came into a recent session a little anxious and perplexed. She related the following incident . The other day after coming home from work she  rode up in the elevator with a young man a few years younger than her  who lives across the hall from her with whom she has a causal acquaintance. She believes he has a minor position in the union and always viewed him as trying to act like a wannabe tough guy but “a nice kid.”  He was pacing back and forth and seemed scared and she asked if everything was Ok. He asked her if she had a beer or a drink. She invited him and gave him a beer. She distinctively heard him say half to himself, “ I can’t believe I helped put someone to sleep.” When she asked him what did he say, he said it was nothing. They chatted about incidental things and he thanked her for her time and left. She wondered if that were something serious like someone being killed but then became scared and changed the subject and got into talking about her family, dreams and other things that were all continuation of issues she had been recently talking about. The therapist didn’t see any direct or indirect references to this subject in the next two sessions leading up to the  supervisory session.

Does the supervisor t have any obligation to either to suggest  or urge his supervisee  to try to influence the patient to report this information to the authorities and  is the therapist or the supervisor  obligated to do so.? What are clinical and therapeutic implications for the therapist  to spontaneously bring up this incident if the patient is not talking about it ? 

8-14 million Americans suffer from depression each year. As many as two out of ten Americans will have at least one episode of major depression during their life times.

20% of ailments for which Americans seek a doctor’s care are related to anxiety disorders such as panic attack, that interfere with their ability to live normal lives.

About 12-15  million children under the age of 18 suffer from mental disorders such as autism, depression and hyperactivity.

In all 1.5 million Americans suffer from schizophrenia disorders and 300,000 new cases occur each year

13 million Americans suffer from alcohol abuse or dependency and another 12.6 million suffer form drug abuse or dependence.

Nearly 1/4 of the elderly who are labeled senile actually suffer some form of mental illness that can be effectively  treated.

The cost of work related mental health problems to businesses is very high. Almost 3  billion dollars and an estimated 50 million working days are lost each year.

What are implications of these and other similar statistics to your life? What are implications to our health care system? What is the meaning to the mental health professions?

Dr. Ricardo Dolmetsch

Stem Cell Possiblities in Autism Research

Dr. Thomas R. Insel

Dr. Ricardo Dolmetsch from Stanford University  and his colleagues have generated stem cells from children with autism allowing them to study how the brain develops in children with Autism Spectrum Disorder (ASD). The motivations for this research occurred when a child with autism spectrum was born to Dr. Dolmetsch and his wife . In a video  interview with With Dr. Thomas Insel, director of the National Institute of Mental Health, he described how this event led to change in the direction of the  research that he had previously been doing.

Stem cells can be made from skin cells or blood cells. The stem cell has the capacity to make any cell in the body including brain cells. Dr. Dometsch explained how he has been able to take skin cells from his own child with autistm and make little pieces of brain which can be analyzed as to their development and function. One of preliminary findings is that some autistic children are making too many cells that produce dopamine, a chemical that transmits signals to various cells in the brain and nervous system. This provides a potential target for future therapeutic research. To see a video clip of this interview please go to:   http://www.nimh.nih.gov/media/video/dolmetsch.shtml

Increased Incidence of Autism Spectrum in Children

In an earlier interview, Dr. Insel interviewed Dr. Peter Bearman, Professor of Sociology at Columbia University, on his research into the prevalence of autism. It is s quite remarkable that in the past several years the prevalence has increased from 1 in 1500 births to 1 in 150 births.  If one just looks at Autism Spectrum, the prevalence may be 1 in 100 births. Some of these statistics may be due to the fact that there has been a change in the diagnostic critieria which would include more children to fit into this diagnosis. This may account for ¼ of this

Dr. Peter Bearman

increase. Another important discovery which may influence these statistics is the discovery that there are certain relatively small geographic areas called  “spatial clustering” where there is an apparent very high incidence of the diagnosis of ASD. This raises the possibility of some toxic agent in this area. There also is the consideration that such an increase incidence is due person to person education and awareness which allows for cases of ASD not to be missed and therefore a higher reported rate. One other factor which may account for the increased incidence in the diagnosis of autism and ASD is the fact that people are having children at a later age. It has been postulated that increased parental age leads to mutations which are associated with this condition. To see a video clip of this interview please go to : http://www.nimh.nih.gov/media/video/bearman.shtml

Repetitive Behaviors in Adults with Autism Spectrum Disorders Significantly Lessen With Antidepressant Treatment

In News release from the American Psychiatric Assoication dated 12/2/11 it was reported that a .12-week study showed that the antidepressant fluoxetine produced a greater decrease in repetitive behaviors and more overall improvement than placebo in adults with autism spectrum disorders. The study by Eric Hollander, M.D., of the Albert Einstein College of Medicine and Montefiore Medical Center and colleagues from Mt. Sinai School of Medicine represents the first large-scale, double-blind, placebo-controlled trial of fluoxetine in adults that targeted changes in the core domain

Dr. Eric Hollander

of repetitive behaviors as well as overall functioning. Overall improvement in autistic symptoms occurred in 35% of individuals receiving fluoxetine and none of those receiving placebo. Half of the individuals in the fluoxetine group experienced substantial improvement in their repetitive behaviors (versus 8% of those receiving placebo). Previous trials of treatments for these disorders have mostly tested interventions for children. An earlier high-profile trial of another antidepressant, citalopram, did not reduce repetitive behaviors in children with autism spectrum disorders.

Although treatments for common characteristics have been studied, Dr. Hollander notes, “Research on medications for the core features of autism spectrum disorders is still in the early stages, and successful treatments could greatly improve the daily lives of patients and their families. The full study will be published in a future edition of the American Journal of Psychiatry

Dr. Thomas Kirsch **

Dr. B: Can you comment on the relationship between Freud and Jung as depicted in this movie?

Dr. Kirsch : I thought that David Cronenberg’s portrayal of the relationship between Freud and Jung was fair, showing the strengths and weaknesses of both characters. Jung’s initial enthusiasm for Freud and his theories, as well as his reservations about ubiquity of the sexual origin of neurosis, are well portrayed.  Freud is seen as sympathetic to Jung’s countertransference to Sabina Spielrein — a highly probable response, given what we know of their early relationship.  The movie shows the historical beginning of the study of the countertransference dimension of psychoanalysis as seen through the relationships between Freud, Jung and Sabina Spielrein.The scene on the boat going from Bremen to New York was an especially good rendition of the spirit of Jung’s account of the incident, if not the details. In the movie Jung tells his dreams to Freud, but Freud does not reciprocate.  Actually, according to Jung in Memories, Dreams, Reflections, Freud did tell a dream, but refused to offer his associations . Jung asked why. ‘He said, “But I cannot risk my authority!” At that moment he lost it altogether.’

Dr. B: Jung is shown to believe in premonitions, telepathy and perhaps other non scientific unprovable ideas. In what way is this a fair or unfair representation of his theories?

Dr. Kirsch: I find this question biased towards a  misinterpretation of Jung’s openness to investigating phenomena as his belief in them, rather than seeing it as a representation of his forward-thinking attitude toward of the scientific method; the latter is the way it was accurately set forth in the movie. Famous physicists like Nobel prize-winning physicist Wolfgang Pauli and other equally prestigious scientists have shown a great interest in these parapsychological phenomena. The areas of parapsychology, synchronicity, chaos theory, and subjects related to these fields have received an increasing amount of attention by scientists from a number of fields, including psychoanalysis in recent years. A recent issue of Psychiatric Annals (Vol 41, #12, December, 2011) is entirely devoted to the subject of meaningful coincidences and Jung’s concept of synchronicity, a central part of his study of the archetypal layer of the psyche. In a late scene in the movie, the meeting in Freud’s study when the loud crack resounded, was an apt portrayal of Jung’s interest in what he saw as the exteriorization of psychic tension. Freud refused to find any psychological meaning in the phenomenon. My understanding is that, historically,  Freud was not interested in such phenomena. Furthermore, Jung’s interest in parapsychology has been used by psychoanalysis to cast suspicion upon Jung’s credibility, thus demonstrating that Jung was “unscientific” and truly a “mystic”.  I think the movie portrayed the differences between Freud and Jung on that subject accurately and sympathetically.

Dr.B: Do you believe that Jung had a sexual affair with his patient Sabina Spielrein and if so, should this influence the judgment of Jung’s contributions to psychoanalysis?

Dr. Kirsch: I have no idea whether Jung had a sexual affair with Sabina Spielrein. This is a subject which has been written about extensively .   Zvi Lothane, a psychoanalyst and historian, wrote of his conviction that they had a sexual affair in his earlier papers.  In a later paper he reversed his opinion. Let me give a personal vignette from my experiences around this subject. In 1983 I attended a public lecture by Bruno Bettelheim at the Stanford University Medical School. His subject was the Mistranslation Of Freud, but instead he spoke, to an audience who had no access to documented facts, about the still unpublished correspondence between Sabina Spielrein, Freud and Jung, A Secret Symmetry by Aldo Carotenuto (published the following year.) Bettelheim was emphatic that Jung and Sabina Spielrein had had a sexual affair . In the discussion. I asked him how he could be so sure, and he became characteristically offensive toward my challenge of his view of the truth.  In fact, I was familiar with the researches of Carotenuto and knew about the correspondence he had been offered from the basement of the Psychological Institute where Sabina Spielrein had been working prior to returning to Russia..  It is interesting that Spielrein had left all of her papers behind when she returned to Russia in 1919.

Whatever the truth, it is unfair that we should judge Jung’s contributions on the basis of his relationship to Sabina Spielrein.  Jung was only 29 year old in 1904, just at the start of a long career in a still unformed field of study, depth psychology.  To the movie’s credit, it treats Jung sympathetically in this respect. If the full truth is admitted, in the early days of psychoanalysis there were many such sexual liaisons.  Ernst Falzaeder, a psychoanalytic historian, has mapped out the various sexual liaisons between early psychoanalysts and their patients.  It is a remarkably long list. Many of those patients themselves became psychoanalysts. If Jung did have a sexual relationship with Spielrein, his was one among many.

Furthermore, Jung knew about the close relationship between Freud and his sister-in –law, Minna Bernays.  I myself have seen the signature of Freud where he signed himself and Minna into the guestbook of the Hotel Schweizerhof in Majola, Switzerland as husband and wife.  This is highly suggestive, yet Freud loyalists have long protested that this proves nothing about the nature of their relationship.  Jung in an interview with Kurt Eissler for the Library of Congress to be released in 2013, does not expressly say that they had an affair, but he does report that both he and his wife Emma had observed, when they visited Freud for the first time in Vienna in 1907, that Minna  was au courant with Freud’s ideas (in contrast to her sister Martha) and that she looked at Freud adoringly.

There is no question that Jung and Sabina Spielrein had a mutually erotic transference/countertransference relationship. From this distance in time it is going to be very difficult if not impossible to ascertain to what extent it was acted upon.  But is that the most important question to ask?  This was the beginning of psychoanalysis, and we know that Breuer had left the field because of this issue.  The fact is that Sabina Spielrein was helped by Jung’s psychoanalytic treatment of her and that Jung encouraged her aspirations, demonstrating his respect for her.  That she became a physician, a psychiatrist, and an early member of Freud’s psychoanalytic group in Vienna surely demonstrates that his good influence was not misplaced.  The movie also highlights her role in broadening Freud’s libido theory. Her influence on Freud’s theory of the death instinct is documented in a seldom cited footnote in Freud’s Beyond the Pleasure Principle.

Dr. B: How will a movie such as this one or the play by Christopher Hampton, upon which it is based, influence the legacy of Jung?

Dr. Kirsch:I have heard from some of my colleagues that they are disappointed by the portrayal of Jung in the movie. On the basis of this, as well as its sensational trailers, I was prepared to not like the portrayal of Jung.  Certainly the spanking episode is over the top.  The role of Otto Gross, and the fact that Jung and Gross were engaged in a mutual analysis, was one of the strongest historical, as well as dramatically pivotal, aspects of the film.  Gottfried Heuer, a Jungian analyst in London and the president of the Otto Gross society, believes that Otto Gross influenced Jung deeply in 1908 toward greater sexual freedom.

Unfortunately, there is a glaring error at the end of the movie.  When Sabina asks if Jung is involved with another patient, Jung says yes, and furthermore tells her that Toni Wolff is half-Jewish.  That is a complete fabrication!  Toni Wolff comes from one of the oldest Christian families in Switzerland.  Her family tree can be traced back to the beginnings of the Swiss Confederation in the twelfth and thirteenth century.  Christopher Hampton was told of his error before his play The Talking Cure opened in London, but he chose to leave Toni Wolff as half Jewish, and to perpetuate the error in his film version.  Furthermore, many prominent psychoanalytic historians have taken Hampton’s  drama as a statement of fact!  Diedre Bair has documented Toni Wolff’s genealogy on page 713, note 27, in her biographical work, Jung.

I was especially taken by their rendition of Jung’s plea to Spielrein for a reciprocation of the caring patience he had shown toward her in her own state of terrible inner conflict.  This is a faithful rendering of his state of confusion, as documented in their published correspondence, as well as alluded to by Jung in MDR and demonstrated in his Red Book, although this is generally regarded in part as his emotional reaction to the ending of his relationship with Freud.

Dr. B: Did you enjoy this movie and would you recommend it to others?

Dr. Kirsch: I did enjoy the movie.    I thought that both Jung and Freud were well represented and I especially found myself liking the Jung of Michael Fassbender.  The role of Sabina Spielrien was superbly played in all its dramatic potential by Keira Knightly.  The one person who was not well represented was Emma Jung.  She was a much more earthy and powerful person than the haughty, frail creature see in the movie.  That was a real disappointment, because nothing I have heard about Emma Jung was represented, either by the role or by  the actor Sarah Gadon.

I certainly would recommend others to see this movie with the caveats I have raised.  Overall, I found myself admiring and empathizing with David Cronenberg’s portrayal of Sabina Spielrein and both Freud and Jung.  I hope that mine is a more widespread reaction.  If so, it may mark a shift in public awareness of Jung’s value as a pioneer and major contributor to our knowledge of the psyche.

The misrepresentation of Toni Wolff, though, poses a major problem, especially because of the later accusations against Jung for his alleged anti-Semitism. When portrayed as having begun yet one more intimate relationship with a (half) Jewish woman, when he is already widely seen as anti-Semitic, Jung the man comes across as a character lacking integrity.  As the repetition of Hampton’s error by prominent psychoanalytic historians proves, drama can wield a powerful influence over even the most scholarly of minds.

** Thomas Kirsch M.D. is a graduate of Yale Medical School, the residency program in psychiatry at Stanford and the CG Jung Insitute of San Francisco. He is Past President of  the Jung Institute of San Francisco, past vice-president and president of the International Association for Analytical Psychology. He has written numerous chapters in books on Analytical Psychology and is  Co-editor of the Jungian Section in the  International  Encyclopedia of Psychoanalysis, Psychology,and Neurology. He also is author of The Jungians, a social history of the Jungian movement and is co-editor of book: Initiation: The Reality of an Archetype. Dr. Kirsch has written  numerous book reviews and is a well known  lecturer on Jungian subjects. Most recently he has written the preface of a publication of the  correspondence between his father , Dr. James Kirsch who was a psychoanalyst  and Jung titled C.G. Jung/James Kirsch Correspondence, published by Routledge, London 2011. ( There are 150 letters between the two men.) Dr. Thomas Kirsch is in private practice in Palo Alto, California.

I would  would like to thank Dr. Kirsch for answering these questions for PsychiatryTalk-MB

It is reproduced below. As always your comments are invited. In two weeks my next blog will feature an interview about this movie with Dr. Thomas Kirsch a Jungian analyst.

A Dangerous Method

As people who have some some acquaintance with  psychoanalytic theory and it’s history, we were drawn to want to see this movie. The psychiatrist among the two of us found it a more enjoyable experience although we both found many deficiencies in the movie. This movie, directed by David Cronenberg, with a screenplay by Christopher Hampton which came from a book by John Kerr, of course is based on real people and highlights the break between Sigmund Freud and Carl Gustav Jung who at one time Freud had thought would be his heir apparent to the psychoanalytic movement. The movie starts off in the early 1900s as a young women, Sabina Spielrein (Keira Knightley) is involuntarily brought to the Burgholzi, a  psychiatric hospital in Zurich, Switzerland, run by the famed Eugen Bleuler. Her exaggerated mannerisms and dramatic presentation suggests the type of “hysterical” patients who were known to be hospitalized in those days. Jung (Michael Fassbender) becomes her psychiatrist at the hospital and begins to use the new psychoanalytic method which Sigmund Freud (Viggo Mortensen) in Vienna has advocated. He ultimately is shown  becoming drawn into a sadomachistic sexual romantic affair with her. Jung travels to Vienna and meets with Freud several times in which they discuss theoretical issues as well as this patient. Over time Freud is depicted as becoming disenchanted with his previously highly regarded younger colleague. The reasons for this rift would appear to be Jung’s willingness to go beyond Freud’s concept of sexuality and psychic determinism and bring in such ideas as the supernatural, premonitions, telepathy, religion and many others that were not explained in much detail in the movie. In fact, the more well known ideas of Jung about the collective unconscious , symbolism and dream analysis were not very well clarified.

Carl Gustav Jung

Freud appeared to be concerned that any significant deviation from his main thesis and what he believed was the scientific method might be a reason for his theories to fail to gain wide acceptance. As best we can determine, in reality the actual affair between Jung and Speilrein was suspected, but historically it was  not universally agreed that it had actually occurred. In this movie it is shown that  Speilrein wrote to Freud and told him of her affair after Jung rejected her. Freud did not believe her and she subsequently is depicted as convincing Jung to acknowledge the affair to Freud who then gave this as an additional reason for cutting his ties with Jung. Once again Freud is very concerned about the appearance of his analytic movement and such behavior as an affair with one’s patient  at that time as well as at present would be highly unethical. The nature of the affair and the meaning of their attraction to each other is really a key part of this movie, whether it actually happened or not. The characters in their dialogue state that Jung, who is shown being torn by the relationship, views attraction to his patient to be  on the “dark side” and that with his wife on the “loving” side.  Yet he declares his undying  love for Spelrein and is bereft by her leaving him. We are not provided with real insight inot this relationship nor any significant understanding of Jung’s conflict. The film also does not do enough to explicate Jung’s ideas and their influence on Spielrein. While we more often proclaim that a movie should have been tightened up and shortened we believe this film needed a clearer illustration of the ideas that this story was supposed to be  about.  The acting in the film was very strong. The atmosphere of Freud’s office, the streets , people’s dress, horse drawn vehicles and early motor cars made it a wonderful period piece. But alas, as much as we were interested to learn about these people, we felt we came up short in our understanding as well as in caring about them.

Coming Soon : Q & A  About This Movie with Dr. Thomas Kirsch

The next PsychiatryTalk blog will feature a  special interview with  Dr. Thomas Kirsch, a psychoanalyst  and leading expert on Dr. Jung. In it Dr. Kirsch will discuss how well it depicted the various people in the movie as well as Jung’s theories.

I have read many books about the holocaust, have seen many movies about this subject and have visited various holocaust museums throughout the world.  As a psychiatrist, I have treated a few holocaust survivors and many more children of holocaust survivors. I was therefore surprised how impacted I was by reading this book which consisted  first person stories of 52 holocaust survivors most of whom were born between 1926 and 1938.

I became aware of this book  when a good friend of mine John Glass who is one of the 52 authors, showed me a copy of the book and told me about the project behind it. Each author is a member of the Child Survivors of the Holocaust, Los Angeles Organization that was founded in 1983.  Dr. Sarah Moskovitz and Dr. Florabel Kinsler organized the largest international group of child survivors with a membership of more than five hundred people. In the introduction to this book, Marie Kaufman President of the Los Angeles child survivors group and Chair of the Editorial Committee that put together the book noted that many of the authors have given oral testimony  to museums  and to the Shoah Visual History Foundation. But in the fifteen to twenty years since they have done so, they have become aware that for many reasons they have left part of their story untold. This book gave them opportunity to disclose secrets never divulged before.

As one reads this book and digest the  narrative which is recounting horrific early childhood memories, you cannot help but consider whether these are true memories. Could they be screen memories, retrospective memories based on things they were told and learned at a later age? In the course of psychotherapy and psychoanalysis we  often help patients reconstruct early childhood memories and feelings. The accuracy of the actual memory may not be as important as the meaning. I do believe that the memories reported in this book do ring to be quite true. I also would suggest a simple exercise before you read this book. Reflect back on your three or four earliest memories. Sometimes it will be helpful to choose a key event which you can easily date such as the birth of a  sibling, a  death or tragedy or famous event such as the assassination of JFK or Martin Luther King or the  landing on the moon, a particular grade school teacher etc. Often the event that you recall will have some negative or conflictual quality. My own earliest memory is when my mother left me alone  in our apartment for a few minutes to do an errand and brought me back a chocolate bar. When I discussed this memory with her many years later, she was astounded that I exactly recalled the events and she was able to date it when I was less that three years old. I recalled being under the care of an aunt during the time that my sister was born and my disappointment that a cousin has seen her first. I was less than 5 years old .   I also recalled my first day of kindergarden , when I was a  few months older than 5. While each of these memories had some anxiety and conflict, they were minuscule compared to the intensity of experiences of being taken away from one’s parents, hiding for prolonged periods of time, starving and witnessing and being threatened with death and destruction, all of which were common place in the 53 stories of this book.

There is another important dynamic which inhibited many of the child survivors from publicly telling their story . Many were hidden children who often had to assume non Jewish identities, sometimes having  several different gentile names and personas over time,  as young children during the war . Each time it was impressed upon them that under no circumstances were they to reveal their Jewish identity as this could mean death to them and their adopted families. So even after they were liberated, reunited with any surviving families and were beginning new lives in the United States, many still would not readily talk about their Jewish identity especially with strangers

It is very difficult to understand the experience that these children had where a  normal childhood was transformed almost overnight when Kristalnacht occurred in Germany, or when the Germans took over in Poland and issued the new regulations for Jews or similar events that happened in France, Hungry, Italy, Holland  and any other places conquered by the Nazi’s. They moved from their comfortable apartments or homes to the Ghetto where they were jammed into one room with extended families and strangers. In anticipation of this situation or in response to it many of their parents who suspected even worst was to come  made a decision  to send their children into hiding with non-Jewish families. In most of the cases the parents could not be hidden with their children. Childhood separation from parents is a very meaningful experience, usually traumatic with the possibility of lasting yearning, resentment, with a wide range of fantasies. This becomes colored by the subsequent events which might include loving or rejecting the adoptive parental figures  as well as being torn away from one such family as you are moved to another one.  The fate of their own Jewish  parents was often death as was that of most of the their original  families and friends. While many of the  child survivors intellectually came to understand that the decision to try to hide them allowed them to live, the full emotional understanding of this generous act on the part of their parents did  not come to them until many years later. It was often when their own children born in a safe environment were now the age at which they had been  put into hiding by their own parents, did they appreciate the sacrifice that was made for them. For some this realization did not occur until they had grandchildren who are at the age that they were hidden .

It is important to note that the trials and tribulations for many of these child survivors did not cease with their liberation from concentration camps or from their places of hiding.In some situations there was persecution by the Russians who liberated them or continued anti-Semitism when they tried to return to their home town. There were hard times often relieved by the many  organizations and people who tried to help them reunite with any exisiting  families. There were painful discoveries of what happened to missing family members. There was also  long waits for visas to new countries , travels across the ocean, learning new languages and adapting to a new culture

As was the case of many survivors who were adults during the holocaust, these child survivors  spent many years trying to forget and not to look back.  Their parents who survived or adoptive parents and relatives often did not believe that the experiences which they had as children made a lasting impression on them. They were building a new a life and did not want their own children haunted by such terrible events. As they moved on to a “normal life” in the United States the child survivors themselves thought that their memories and experiences were quite unique and as mentioned above were not inclined to talk about them. Many report an amazingly dramatic unburdening feeling when they attended their first meeting of child survivors. The intensity of that feeling and the realization that so many other children had gone through similar events was life affirming and literally changed the course of the lives.

It is noteworthy that so many of the child survivors have gone on to have very productive lives. Perhaps because they themselves have been helped by strangers (many of whom have been recognized in Yad Vashem  as the ‘righteous gentiles”  or “righteous among nations”) they have chosen a helping profession themselves. It seems to me that a high percentage have gone on to be social workers, therapists  and teachers. Some report moving into these fields after a successful career in business. Others have become artists and poets expressing their feelings and experiences in their work. There were numerous poems  as part of the narratives.

Many of the child survivors did not talk about the past for most of their lives   and for many it has only been in their twilight years that most have  felt an obligation to tell their stories or record  a first hand account that will exist for future generations. A good number of the authors of this book   have devoted many hours to teaching about the holocaust in schools and museum  and giving lectures in various settings. These activities and the writing of the chapter for this book as well as other publications that some of them have done appears to have been therapeutic for them.

The authors  tried their best to be sincere and honest in sharing all these events and their past and present feelings about what they have been through. For  most there is a triumph for having survived and for being responsible for the presence of so many wonderful people that they have nurtured and supported in their subsequent  lives  For some of people there is still an ever present wound or bewilderment and pain which stretches from their childhood to their later years. They are still trying to figure out why and how the events of their childhood  could have happened. For all there is the satisfaction of having told the story of what really happened  so those who were deprived of their lives will not be forgotten 

This was not an easy book to read. While I read it in linear fashion over a two week period and did not intersperse with other books perhaps that might not be the best way to read it. For some it might be best to consume it in small doses .  I suspect that some readers will appreciate the value of the book but will put it aside and may not complete it.

I realize also that I may not have captured the essence of the experience of the authors in this review. I would like to give you a few random excerpts although I hope over time you will read the complete version of each of these  52 stories as they all deserve to be remembered:

Lea- Born 1938 I was placed through the Dutch underground with a Christian family. There were many other children. Suddenly the family was betrayed. The underground took all the children away to new hiding places. On of my first memories was of being on a train with other boys and girls…. I  was taken to family of farmers in the small town of Horst by two men dressed in police uniforms. My clothes were torn and I had sores all over my body.  The men said that they ha d smuggled me out of some detention center but I have never been able to find out what happened to me.

Jack- Born 1926- The ghetto was organized  into factories of every possible trade and all the  the production was for the German military…My father could not get employment…When I saw my dad for the last time he was forty one years old…In July 1944 we were transported in cattle cars to Auschwitz-Birkenau. I was with my mother…(We) went through a selection conducted by Dr. Mengele. My mother was sent to the other side. Now sixty four years later, I can still see her walking hunched over, as if she know where she was going. I’m still haunted by this picute and I know that I will for the rest of my life. How do I reconcile the fact that my children are now older than my parents were when they were murdered.?

Lya- Born 1936- When I was seven and she (sister) was four we both went into hiding with different families. The thought never occurred to me that this would be the last time I’d ever see my parents. They never knew where we ended up…In 1946 my sister and I were sent live with  Parents Number 5 in Denmark…I was a very difficult teenager. Obstinate, opinionated, aggressive. I was sent out of class many times. It was sheer anger- a way of expressing myself to the world…My husband ( also a survivor) wasn’t interested in talking about his experiences and for the longest time I didn’t think that mine really countered. …I started dealing with my past in 1993, I was fifty six…. That’s when I first shared my story ( in a group ) about  losing my parents, grandparents, being separated from my sister and being in hiding with strangers. After that night, I became more aware of my own feelings. I could justify them. They were real and they weren’t something nonexistent.

Peter- Born 1936- In 1940 when I was four years old I was no longer permitted to attend my pre-school nor to attend any other school. From my earliest memories, I had to wear a yellow star with the word “Jude” on my jackets and shirts…People looked at us in disgust and were often rude to my mother when she shopped for food…Only 32 out of the 100 Jews transported in the cattle car I was in survived the Holocaust. I lived in the children’s barracks (in Terezin)…We slept in bunk beds on straw and had only a thin blanket. There was only cold water to wash ourselves in the summer and harsh winters…There was small piece of bread in the morning with some brown water they called “coffee” and for supper a watery soup with  an occasional small potato. We were half starved yet we were expected to work…(After the war)I lived my teenage years as a laborer, farm hand truck driver across the US. …By the age of 33 I had completed high school, graduated from San Diego State University and received a graduate degree in  Global Management.   … I have seven grandchildren.

Robert- Born 1935- When I was four years old our lives changed forever, The Gestapo came to our apartment and told us to take just a little luggage and follow them. They sent us by train to the Polish border. The poles would not let us in and Germans would not take us back…We traveled around Poland living as gentiles with an assumed name….The family that hid me decided to put me in the attic in the house. Many times they forgot to take care of me and did not feed me. …After the uprising failed the Germans planned eliminate the city’s population.. Everyone was loaded upon trains, which were headed to Auschwitz. …We knew we were going to be killed…My mother noticed that one of the cars had an opening on top. The train stopped about 100 yards from the Auschwitz concentration camp. My step father Emil lifted me up over the open car and I was able to open the train car door…In February 1947 we took a boat to America and settled with our extended family in Pittsburgh. I quickly learned English and graduated from Carnegie Mellon University in 1957 with degree in electrical engineering. …Over the years I have spoken about the holocaust to thousands of middle and high school children.

Erika- Born 1928- At the time of my birth my parents (in Hungary) owned two kosher restaurants.  I went to school unitl the age of fourteen when the anti Jewish Hungarian government closed the Jewish schools. Anti-Semetism forced many Jewish owned businesses to close or be taken over by non-Jews. Most of my uncles had been taken to forced labor camps in early 1940-42…I was deported to Auschwitz with my mother. We were lucky and escaped the selection. …On the day the Soviet liberators entered our camp they raped many women and wanted us to work for them. …I was helped tremendously by breaking the silence and talking about my experiences. Confronting my losses and acknowledging the effects of the traumatic times in my life have helped me to recover psychologically. However I still have problems such as fear of authority, anxiety about the health of my family, about separation  and the fear of loss.

For more information or to order this book go to www.childsurvivorsla.org

An  American  training program for mental health professionals in China provides classes via telepsychiatry (via video conferencing ) but many of the trainees wish to have their own therapy by experienced therapists who are in quite short supply in China at this time.

There are highly functioning productive people in the United states who are in occupations and jobs which often take them out of town or have long commutes to work with irregular work hours. This situation makes it quite difficult for them to arrange  psychotherapy with experienced psychiatrists  which would require them to come for sessions at least once per week.

During the past year I have become involved with devoting part of my practice to telepsychiatry and am now offering therapy in each of these three situations.

When I agreed to provide treatment one morning per week to the above mentioned clinic I already had experience in teaching courses online with video conferencing but I had not treated patients with this modality. I knew that some of these patients might have complicated mental illnesses which would require complex medications and that some might have to be hospitalized. I was aware that certain paranoid patients could be suspicious of electronic communications and some patients might require a translator if they did not speak English. I was pleasantly surprised to find how smoothly everything was able to run. A mental health nurse is in the room with the patient and a translator was available when needed.  The patients understood the concept that they were being seen by a psychiatrist in another city via video communications. We had a clear face to face discussion and the patients seemed as comfortable as in any other setting in bringing me up to date on their symptoms. I had access to a very sophisticated confidential electronic medical  record where I could record my findings and check the observations of any other visits that the patient had at this clinic. I could refer the patient for lab tests as well as to a primary care physician. I also could make referrals to other mental health professionals connected to this clinic who could do individual, family  or group meetings  with the patient. I prescribed medication directly through a very efficient electronic prescribing system, which electronically connects to every pharmacy in the state. If needed I could alternately fax a prescription or make a telephone call directly to the pharmacy. On the few occasions where a patient needed an immediate hospitalization I could arrange that and provide the referral information needed by the admitting doctors. It has been a very gratifying experience to spend this time providing this needed service.

First CAPA Graduation in Beijingi

For the past year I had been teaching as part of  the Chinese American Psychoanalytic Alliance (CAPA),a very innovative program  founded by a friend and colleague Dr. Elise Snyder.This program uses video conferencing mostly by Americans who provides high quality training to mental health professionals in China who previously had very limited access to this type of training. The program has grown and become quite in demand by young Chinese professionals embarking  upon a career in providing mental health treatment in China. One year ago I participated in study tour to China with CAPA where I had an opportunity to give a few lectures and also witness the first graduation from this program which was held in Beijing. In conjunction with such training, it has been common for the trainees to arrange their own personal therapy. Unfortunately for a variety of reasons, there has been a lack of therapists  who could offer such treatment to the trainees in China. Many of the Americans who have been teaching in this program have offered to treat such a Chinese trainee via telepsychiatry ( video conferencing) as did I. Due to the wide disparity in income between Americans and most Chinese, such treatment has to be offered at fraction of the usual fee received by American therapists in the United States. The trainees usually speak English quite well but there are at times interesting challenges related to the nuances of the meaning of words as well as in understanding various cultural differences. The fact of there being a “ one child policy”  in China means most of the trainees have grown up as an only child which has important psychological significance. Most Americans are not familiar with the Chinese concept of “shame” which reassembles but is quite different than “depression” which can be an important part of the childhood experience of growing up in China. Participating in this program as a therapist has also been a gratifying and interesting experience which I am pleased to continue.

The third situation which I described above, reflects an anticipated  shift in the  attitudes of many Americans towards  technology and psychotherapy. This change, I believe, is taking place in both patients and therapists. I practiced psychiatry in Manhattan as well as in a suburb of New York City  and more recently now in Los Angeles. I have seen  many sophisticated patients who chose their psychiatrists by referrals from trusted physicians or friends and would rework their schedules to make regular sessions, often in the early morning or evenings. People tended not to change jobs very often and it was common to have an entire course of  therapy with one therapist. Now days people commonly choose their psychiatrists after a careful investigation of their credentials and background online. Since the Internet is used for obtaining other important information it seems natural for  so many people to rely on the Internet and feel comfortable in evaluating information available on it. It is a known fact that people are changing jobs much more frequently, even in  higher paying positions. Therefore, one can’t be confident that a therapist in one location will be convenient to see at a later date. It seems that time is even at a greater premium than it was in the past. Commuting time is longer especially in a city such as Los Angeles and work environments frequently require people to be quite flexible. This means working at home at times, traveling when needed and irregular hours. Certain occupations such as the entertainment industry in Los Angeles requires long periods of time out of town as does pilots and airline personnel to name just a few. There is  increasing comfort with modern technology illustrated by  the growth of the use of video conferencing in business and education and the personal use of texting, Skyping , Facetime etc. Therefore it is inevitable that there will be a shift in the practice of medicine to use more telemedicine and for psychiatrists to use increasing amounts of telepsychiatry.  Therefore, I was very interested when the California Telepsychiatry Group (also now American Telepsychiatry) ,who were running the services for the mental health clinic described above, asked me if I would be interested in devoting some time to seeing private patients with their group.

I spent some time talking with their Director Dr. John Schaffer and I was impressed how they have arrange their video conferencing, electronic records and electronic prescribing to be HIPPA compliant (meaning state of the art confidentiality techniques) . They had addressed the various legal, ethical and questions of malpractice insurance and were carefully vetting the psychiatrists who would work with them. In addition they set up a very novel and interesting “meet and greet system” where potential patients, at no cost, could have a preliminary 10-15 minute   telepsychiatry meeting with any of the psychiatrists available for treatment . They could therefore review the credentials and experience of potential therapists, as well as meeting them, before they decided to enter into treatment. I am very pleased to now to be connected to an entity which I believe is on the cutting edge of a system for providing quality psychotherapy with this modality.

I suspect in 10 years from now or less,  people will look back on the three examples which I described above and see them all as every day occurrences in the delivery of mental health services in this country and throughout the world.

I lived in the northern suburbs of New York City at the time and the local newspapers had photographs of cars in train station parking lots that were not picked up by commuters who had perished in the World Center attack. I did not think that I knew anyone personally who died or had a close family who was killed  in the tragedy. Several months later I found out that  a chaplain with whom I worked with from time to time at the medical center had lost his son who worked at the World Trade Center. Over the ensuing years I saw many patients whose lives were impacted significantly by this event and worked in intensive therapy with several of them.

On the morning of 9/11/01 I was at Westchester Medical Center when I heard of the unfolding events. The nearest television set was on a psychiatric inpatient service near my office. I sat with staff and patients and watched the second plane hit the tower. Although many of the patients had severe acute mental illness-schizophrenia, other psychosis, suicidal behavior etc., we all responded in the same manner. There were groans and tears and statements of  “those poor people.” There was no panic and no apparent incorporation of this reality into the patient’s delusions. It has been shown that people with decompensated mental illness often show improvement at least in their short term symptoms when they are faced with emergency or tragic events.

I was reminded of an experience I had while I was in training in New York City many years previously when there was a sudden unexpected blackout with loss of power citywide for at least several hours. I also was visiting on a psychiatric inpatient service when it occurred and most people handled it quite well. I eventually published a paper how this event did interact with the psychopathology of a two patients.

By coincidence I was scheduled to give a Grand Rounds presentation on September 21 , 10 days after 9/11 at a hospital in downtown Manhattan from which you would have been able to see the World Trade Center. Ironically the topic of my talk had been about disaster psychiatry but I changed it to specifically allow a discussion on how my colleagues had responded and what they had done to address the mental health issues related to this tragedy in their backyard. A center had been set up on Pier 92 for the survivors, families and friends  of the victims. Mental health professionals from all over the Metropolitan area donated their services to work with the Red Cross in helping these people with their physical and emotional needs.

At the time of this presentation, I walked around downtown Manhattan and the area surrounding ground zero. I noted the presence of something very interesting there and also scattered throughout Manhattan.. There were posters with pictures made by family and friends of people who had been in the World Trade Center at the time of the tragic events and did not come home. The posters, as you can see, were made from the point of view that these people were “missing.” They provided a description of the person with the request that if anybody were to see them they should call a specific telephone number. There were numerous such posters. The fact is that people were not found wondering throughout the city. The relatively few injured people who were brought to the hospital were identified and families were notified. Of course, the New York City morgue had a very sophisticated system of trying to contact any family members if they had made identification of the remains of victims. So what were these posters about?

They obviously were part of the denial phase of  the acute complicated grief that the survivors were beginning to feel as on some level they realized their  loved ones were killed. Within the next two weeks people began to make alterations in these posters which showed that they recognized that these people had died.  They crossed out the words “lost” or  “missing” and would write things like “in memory of”. The posters now would be adorned with flowers. I don’t recall this phenomena ever being reported in the psychiatric literature.

While I did not participate in the work on Pier 92, I was asked to do some “debriefing” activities for some organizations. One such group was the personnel of a major TV network. (I had done some previous work identifying the psychological trauma that members of the working press often experience in the course of their work). I was the co-leader of this group with a Professor from the Columbia School of Journalism.  Prior to this time debriefing activities would have meant trying to get the participants to express their emotional reactions to their recent experience in the disaster. More recent research had suggested that this wasn’t the best approach. In fact,  it might even make things worst. So our approach was a much more general approach in which we acknowledged the type of emotional symptoms that they might experience and made suggestions how to minimize them.

The evening before I worked with this group I had spoken with a family member of mine who told me that she had a dream that the well known television anchor from this network was having a personal conversation with her about the disaster. This dream appeared to reflect the importance that such TV personalities have in reassuring people at the time of frightening events. I was able to tell my relative that I spoke with the TV producer who worked with this anchor and she was going to tell him about her dream .

There has been a great deal written about this disaster in professional journals as well as in other media.We also will dearly hold on to our personal memories of that fateful day. Feel free to relate any of your experiences or thoughts about this day in the comment section below.

This is quite relevant to a large number of people since depression is quite prevalent in the general population. It is estimated that 5.8% of men and 9.5% of women will experience a depression e episode in a 12 month period. The lifetime incidence of depression has been estimated at more than 16% in the general population.

This research study was by Dr. An Pan  and four colleagues from the Harvard School of Public Health and Harvard Medical School. The research was a meta-analysis and a systematic review which meant that the authors studied research of many studies on this subject The ended up looking at 28 prospective cohort studies comprising 317,540 participants which reported 8478 stroke cases during a follow-up period ranging from 2-29 years.

Their scientific analysis of the data demonstrated that depression is associated with a significantly increased risk of developing stroke. They also found a positive association of depression with a fatal stroke.

The authors discussed a variety of mechanisms which depression may contribute to stroke. Depression has known neuroendocrine effects. For example t there is a dysregulation of HPA axis ( hypothalamic-pituitary-adrencortical axis which can cause high blood pressure. It has been shown that depression effects platelets and leads to  dysfunction which causes abnormalities in the clotting mechanism. There are also abnormalities in the immune and inflammation systems which could influence stroke risk..

Depression is associated with poor health behaviors such as smoking, physical inactivity, poor diet, lack of medication compliance and obesity, all of which may contribute to stroke.

Depression has already been associated with coronary heart disease, diabetes and hypertension. (See an earlier blog on depression and heart disease as well as another blog which raised the question whether people with depression should be taking aspirin to prevent heart attacks).

The data from the recent JAMA study also suggested that it is possible that antidepressant medication may be associated with stroke risk but this may be a false impression since medication use can be a marker of depression severity and many of the studies that the authors looked at lacked information on dose and duration of medication use.

There are some limitations of this study and the findings don’t prove 100% that depression causes stroke. I would imagine that it is conceivable that the genetic markers for stroke and depression could be located in close proximity leading to such impression of this effect. However even if there is no causative effect (  although I believe the research strongly suggest one ), the association of these conditions clearly calls out for great attention being paid to this association. There is an opportunity for doctors who see patients who are at a high risk for stroke to be referred for treatment of depression. Also patients who are being treated for depression should be encouraged to be seek medical attention and assistance in reducing all the other risk factors for stroke whenever possible.

Depression is a serious condition and is very treatable. Treatment works! Patients who have depression should be treated whether or not they are at a higher risk for stroke and other diseases.

Don’t Change the Subject

This is a documentary about suicide, by a film maker who lost his mother to suicide when he was twelve years old. It seems to be his attempt to understand that tragic event in his life at the same time he is making film that he hopes will save some lives. Usually we don’t review films before they are ready to be released. In fact, the final edit on this movie has just been tweaked. It hasn’t hit the film festivals yet and a distribution deal has yet to be made. We hope in a small way, the availability of this review will help the process along as well as encouraging folks in the mental health community to consider using this film as a discussion tool at professional meetings and most of all to be used for educating the public.  According to the National Institute of Mental Health suicide is 10^th leading cause of death in the U.S. and the 3^rd leading cause in the age group 15-24. There are 11.3 suicides deaths per 100,000 people in this country. An estimated 11attempted suicides occur per every suicide.

While these and other statistics are important, this film is not about numbers and risk factors. It is about real people who tell little pieces of their stories. It is about people who came very close to killing themselves but for some circumstance or reason didn’t do so. It is about the filmmaker who comes across as a very likeable guy who is trying to figure out why is mother, who he believed loved him, would leave him by her own hand. He reads her letters, listens to tapes of her talking, looks at old film clips and ponders this issue with his older brother, aunt and step mother who married his father after his mom died. His brother never understood how she could have done this when she was in the music business and knew how important was his debut as an opera director that was happening the following week. His aunt, who was a psychiatrist, knew her sister had problems but didn’t see this coming. His stepmother only recently reveals her own special connection with suicide.

Sally Stutz

While the filmmaker may not have ever completely understood why his mother ended her life, he did realize that more then how she ended her life, she should be remembered for how she lived her life which included much love and support to her children. This message alone gives the film great value.

The filmmaker, Michael Stutz is also the director, writer and producer. He does go beyond just his own story and some close up vignettes of people who struggle with depression and have come close to doing this fatal deed. He follows a talented choreographer who is preparing a group of young dancers to perform a piece about autopsies. The result is as dramatic as is the meaning to young performers who had to come to grips with what their dance was about. We are introduced to a fairly successful comedian who has a team of writers help him prepare his material that daringly enough is going to be about suicide. It is always tricky business when humor is touching a potentially raw nerve. You have to understand, as a psychiatrist I usually don’t even like it when people use the word “crazy” in stories or in every day life but I appreciated the use of humor in this film. In fact the highlight was a piece by a comedian who did a monologue as a character who was leaving a video to his family prior to his suicide. He said just about everything a loved one would dread that their family member who was ending their life might say about them and how the suicidal person felt about them. It brought me to out loud laughter and will be for me one of the most unforgettable parts of this film about a very serious subject.

I said earlier that I hope professionals will view and use this film in their efforts to prevent suicide. It is not because this film will necessarily educate my profession about suicide. It didn’t really examine the difference between suicide attempts and suicide gestures nor did it attempt to show the different psychiatric diagnosis that people who attempt suicide might have. In fact there wasn’t much of a psychiatric presence in the film. However it has the potential to be very meaningful to anyone who has struggled with suicidal thoughts, had fleeting suicidal thoughts or has been close to anyone who has had these issues. Unfortunately there are a great number of people in at least one of these categories. This film can save lives so it deserves to be seen and will be a worthwhile experience for many people. I don’t know yet when and how it will be distributed but more information about it can be obtained on the following website: http://www.dontchangethesubject.org/ (2011)

Q & A with Michael Stutz

Shortly after I viewed the movie, I spoke with Michael Stutz, the filmmaker and he agreed to answer some questions for this blog.

MB: What made you decide to make this film?

MS: I wanted to make a film that I would have wanted to see when I was a kid dealing with my own mother’s death.  At that time I was struck by the typical adult reactions when talking to a twelve year old and how incredibly awkward they were.  Everyone seemed to be walking on eggshells.  If they talked about it at all it was in vague clichés or condescending attempts at “she’s in a better place.”  My mother was in and out of mental institutions for more than two years before she died.  I watched her sob and collapse and sleep for eighteen hours a day.  I also was the one who found her after her overdose.  I didn’t need clichés.  I needed honesty and a path to help me process my feelings and move on.  For me that path turned out to be theater and comedy and dance.  You can’t really capture all of the raw emotions going on in your head after something like this.  It’s surreal.  The arts helped me to work through images, fragmented thoughts and deeply conflicted feelings better than a straight on discussion could.  With this movie I wanted to suggest different ways of communicating beyond conversation.  It’s incredibly important to talk about it but not everyone is able to talk about it in the same way.  As I sit down to write this I am remembering the one adult who really helped me the day I found my mom.  It was a friend of my grandmother’s who came over to watch me while everyone else was at the hospital.  I was crying and she sat down and instead of clucking out soft meaningless words she showed me a book of watercolors she had painted over the years.  She said she normally didn’t show it to anyone but thought I might like it.  We just looked at the trees and lakes and various images that she had created and it calmed me.  I see now that’s a part of what I wanted to do with the film.  Share something private in the hopes that it might help somebody out in their own time of need.

MB:Is there a special audience that you had in mind when you made it?

MS: I made this movie for members of the suicide community who would cringe at being identified as part of the suicide community.  Over the years I’ve taught a lot of classes to various groups, teens in particular.  I’ve taught theater, comedy, dance etc. and I always find the kids I like the best and the ones who ultimately seem to get the most out of class are the ones who were the most resistant and cynical in the beginning.  The smartasses, the awkward shy kids, the kids who think they would rather be anywhere but in that class.  I made this movie for them.  Our movie is a punky, awkward, smartass, oddball little film for everyone who feels like they’d rather be anywhere but in a theater watching a suicide movie.

MB: Was it therapeutic for you to go through the process of making this film?

MS: Absolutely.  Though I have to admit when we started out my concept of the film was very different than the film that ended up on the screen.  I thought I’d interview several well-known people in the arts who had experienced suicide in some way and then see them creating their own artistic pieces.  After being turned down by everyone that I asked, I realized first how incredibly taboo this subject still is, and second that I’d have to be willing to step up to the plate and share my own story if I was going to ask others to do the same.  So then my family got dragged into it.  At the same time we were making the film my stepmother Judith was in the end stages of cancer.  Because of this she and I had been having a lot of conversations about family, including something that I didn’t know when I was a kid; her father had killed himself too.  She had held his head after he’d shot himself just like I had cradled my mother’s head after she overdosed.  Her father killed himself just before her birthday, just like my mother had done before mine.  It was amazing that we had lived under the same roof and never talked about this.  So, as Judith was entering hospice and going through her last year of life we were also filming this movie with family as they visited.  It was an incredibly bonding experience.  Judith was very involved with the whole process and always asked about its progress and was even able to see the first full rough cut three days before she died.  The conversations we had both on camera and off were some of the most rewarding and meaningful conversations I have ever been a part of and I think she felt the same way.  I will say it’s amazing that it took a camera to help all of us in the family to talk to each other in ways we never had before.

MB: How did the comedy piece of the character making the video for his  family before he killed himself, come about?

MS: There’s a comedic monologue called “Daddy’s Last Video” in the movie that I wrote several years ago for a brilliant actor named Ron Riegler.  He’s quite simply the funniest and most subtle actor I’ve ever worked with and I knew he could pull this off.  It came from my experience as a child where people would come up and say various versions of “this wasn’t your fault.” This is of course a very kind and reasonable and I’m sure in many cases very helpful thing to say.  But then again what is the alternative?  What if someone, in this case the daddy who killed himself, said in those same low and comforting tones, ‘well actually this is your fault.  You really were a lousy little kid.  Thanks for killing me.  Love Daddy.’ Now, out of context I’m sure this reads as horrifying but you have to see it to understand that I’m simply pointing out the ridiculousness of almost anything you say to a kid after a parent has killed him or herself. The situation is so bad it becomes absurd.  I guess I just hate low, hushed-toned speaking.  As a kid I thought, “Really, this isn’t my fault?  No kidding?  I just found my mom on the bed and that’s the best you can do?  Thanks.”  But, I was a weird kid.

MB: Were you concerned that this piece or any of the other humor would be found offensive by some people?

MS: I’m sure right now someone reading the previous answer is thinking ‘seriously you want me to see a movie where children are blamed for their parent’s suicide?’  I promise, it’s funny in context.  So yes, I’m sure it’s possible that some reasonable people could be offended by this or other parts of the movie.  But what I’ve found so far is that most of the people who have seen it who have experienced suicide up close and personal have laughed right along with it.  I’ve met with more resistance from those outside that world who worry that we may offend.  Gallows humor is what I do.  I’ve done plays and sketches about all sorts of issues related to mental illness.  I promise you they aren’t done to mock these very serious issues.  I was raised on Monty Python and Woody Allen.  I blame them.

MB: What kind of responses have you had from people who have seen the film ?

MS: We’ve gotten very positive responses so far, especially from folks in the psychiatric community.  I was somewhat worried that because the film is a little more “colorful” with its language in some places and does use humor to deal with very heavy issues that some folks might not be willing to take the trip with us.  But so far I’ve been very pleasantly surprised.  It’s also been great to see a broad range of people get something out of this.  A friend of mine pointed out that even though he hadn’t experienced suicide in his immediate family the way he felt after his parents’ divorce was very similar to how I felt after my mom’s death.  In some ways you could say that the movie isn’t primarily about suicide.  It’s about communication.  Everyone has had a time in their life when they felt misunderstood or unable to communicate their feelings.  That’s what we’re talking about.

MB: Do people “change the subject” when you discuss the content of the film?

MS: When I say I did a movie about suicide people usually drop their eyes and mutter something under their breath while trying desperately to inch their way away from me.  But when I say I did a weird dance comedy performance art movie with kids performing to autopsy reports and comics flipping out on rooftops and dark little animation sequences then the eyes sort of come back.  In the end many of the loveliest parts of the movie are actually the quiet, sometimes sad, sometimes funny little moments where survivors are relating their stories in this heartbreaking but incredibly inspiring way.  But since a lot of folks can’t quite wrap their brains around that we give them some other fun things to look at in between the stories.