THOUGHTS FROM AFAR

I know almost noting about he American health system. But I am an Israeli, UK educated physician working in management dealing with mental health care reform.

So here is my twopenneth of thoughts.

I do know that no one buys a pig in the poke. Today’s medicine is expensive, incoherent and economically unsound. These conditions make a ‘tax led’ expansion nigh on impossible. 

I think that we should consider what can be done and how?

The driving force for change may be political. But change has to encompass both delivery and payment.

I will develop a theme that states basically that costs and delivery can and must be altered before payment can be tackled.

Payment is pivotal in the making of universality.

REFORM:

There is no such thing as reform in medicine. There are far too many vested interests, preconceived ideas and established practices.

To make life easy lets call the involved parties shareholders.

Shareholders must want change. The change has to be as a constructive evolution and not a threatening revolution.

There can only be small, graduated and, hopefully coordinated incremental changes.

All reform has to have both a strategy and tactics.

Each change must be seen as being beneficial to most and detrimental to none.

In other words every shareholder must see some befit before he will take some risk. The benefit must be tangible and the risk less than such. It cannot be the opposite.

DESIRES:

What do we want to do?

Most encouragingly all the shareholders agree about what they want and do not want.

They want comprehensive, coherent professional care.

They do not want to have their economic status threatened. The user does want affordable health care. The industry member wants to maintain their income level. 

So far so good.

So let’s take the first step that is accepted by all.

Lets just save money.

FISCAL PRUUDENCE:

 We’ll examine but two issues.

1. Litigation:

   The cost of insurance coverage is enormous.

   We could offer an alternative coverage. The choice would be of the individual but the premium would be affected accordingly.

   We would need to set up a State Quality Monitoring Board[SQMB]. The SQMB initially would have the following powers:

   1. Arbitrate in all litigation concerning mal-praxis.
   2. Set maximum sums to be paid according to misdemeanor.
   3. Set and monitor accepted practices in utilization of ancillary medical diagnostic services.

2. Reduced expenses:

   On signing to being in a program that is under the aegis’s of the SQMB the premium could be reduced if the patient also agrees to:

   1. Wherever possible, as the treatment of choice, use generic medications.
   2. That all laboratory services would be done in accordance with absolute, medical needs. Put bluntly, not because I may get sued or it would be nice to have the tests but because I need this test to do good medicine.

If we get this far, and we can, we will see savings.

So we can move to the next step.

EFFICIENCY:

Medicine is a system of services. More often than not the patient is not doing what he should. Quite often he is doing what he should not be doing, or could be doing it somewhere else cheaper.

As a rule of thumb the patient:

1. Should know what he is to do.
2. Be followed up to ensure that he is doing, as he should.

This means evolving a system of care that has a case manager.

This involves profound conceptually and structural changes in the delivery of medicine. 

As the patient is liable to have many needs his medical needs are holistic and should be dealt with at the community or primary care level.

The care manager should know:

1. What is needed?
2. Where is it best done?
3. Has it indeed been done?

This means several things:

1. We resort to the idea of the centrality of the Family Doctor.
2. A nurse does the case working.
3. Case management is a ‘medically based decision’. It is not fiscal. It is an essential part of an efficient delivery.

4. Cases are managed at the level of the family Doctor.

   1. Referrals and recommendations are from and to him alone.
   2. The ‘specialist’ is redesignated  as a ‘consultant’.   

For this stage to work effectively the Family Doctor Practice should be reasonably large so that it can negotiate with experts and providers in the field. THE FAMILY DOCTOR IS THE TEAM LEADER .

The enlarged family practice should subscribe to the SQMB.

The setting up of the family practices would be the corner stone of health reform

I would consider favorably:

1. That subscription to a practice would be:

   1. Per annum at a fixed fee with a basic health basket [Number of visits, hospitalization days, lab costs] per family.
   2. FFS above the basic basket. This aspect would be monitored and authorized by the SQMB.
2. That the SQMB would offer assistance in negotiating between the Family Practices and between both insurers and other health providers [hospitals, labs and etc.]

IN THE FULLNESS OF TIME THE ENLARGED FAMILY PRACTICE WOULD BECOME THE CORDINATING BODY IN CHARGE OF THE PATIENTS COMPRHENSIVE NEEDS.

In other words we now have three well-delineated bodies:

1. The professional hub – based firmly on the Enlarged Family Practice
2. The administrative hub- based firmly on the state based SQMB.
3. Payments – Private and non-private insurers.

UNIVERSALITY:

Only when medicine has been rationalized can it become universal. We cannot expect the State to foot the bill when the medicine is neither rational nor cheap. Medicine has to become professionally and fiscally rational. Only then can further decisions be made.

This decision is UNVERSALITY OF SERVICE.

The decision is twofold:

1. Political.

2. Fiscal:

   1. What is the State paying for?

      By my proposals the Sate would know what are the expenses involved.

   2. How does the State pay?

      This decision is purely fiscal. Medicine, as such, has no part in this discussion.

   3. How will the State know that I got what it paid for?

      By setting up and developing the SQMB we have the basis for an answer.

Universality has a temporal dimension. The SQMB should also be placed in charge of evaluating, developing and training professional man power so that future needs will be met.

In summary:

I suggest series of changes none of which threaten any one. A clear distinction should be made between means of payment and means of service. Limiting expenses in medicines, procedures and insurance coverage should initially reduce costs.  Service should be rationalized by developing in tandem the ‘Enlarged Family Practice’ and the ‘State Quality Monitoring Board’ [SQMB].

When costs and services have become coherent and rationalized the cost of universality of care and the political implications can begin.

Imagine a flock of birds. Imagine them migrating a cross a clear blue sky.

The flock flies as a unit. They are led. But the leadership and the formation change. The direction in general is clear. At any one time it might not be so.

Our flock is called Medicine. The birds are the patients, the Doctors, the health providers and the pharmaceutical companies.

There is an ever-changing flux. But they same as one flock.

Their aims are but one. A healthy society with healthy individuals. Their secondary goals and limitations are different. But they have more binding them together as a flock than anything else.

But today’s flock is leaderless. There are tensions, a lessening of cohesion. The flock is not really getting to where it wants to go.

Let us look why? Maybe we can find a way to re-instate cohesion.

The patient understands health as an absence of overt illness. When he is not ill he is well. The Doctor understands things a little differently. A person may not be overtly ill and yet not healthy. The pharmaceutical company understands that he has to back the Doctor but is suspected by both as having ulterior motives. So who is to lead? Who can regenerate cohesion?

We have to now discuss two new terms. The first is attrition and the second compliance. Attrition simply means that the patient stopped doing what the Doctor said. Compliance means that he does what the Doctor says but not as he was told. For example e takes his tablets but not every day. Not as often as he should.

Life would be so easy if there was a linear relationship between the words that leave the Doctor’s mouth and the tablets that enter the patients. But there is not.

Why is this so?

Let’s take a look at the Doctor. He hasn’t the the time to explain. He hasn’t the skills of presentation or indeed communication. He even sometimes does not have sufficient knowledge to answer questions. Now for our patient. He is more erudite or at least so he believes. He has to hand many facts. He has not the power to integrate them. If before he was ignorant then now he is confused. It is harder for him to get to his Doctor. He has to pass a myriad of barriers: Automatic answering services, cumbersome switchboards, services that he does not feel intimate with; changing Doctors schedules. For him the medicine has become mechanistic. There is an all pervading feeling of distance if not alienation from his Doctor. When he does get to see him his Doctor is hidden in part at least by a computer terminal screen. His eyes riveted either on the screen or on the key board. His Doctor is no longer the soothing parental figure of the past. He is a harassed bullied technocrat. The Doctor – Patient relationship is not dead. But it is certainly moribund.

As medicine has progressed so has it’s basic goals. In day’s gone by Doctors either prevented death or witnessed it. The patient either died or got well. Today they do nether. Today we are into the age of either preventing illnesses or preventing them from becoming worse.

Now we can see where the difference in expectations about health arise and why it is so important.

The patient has to both avoid attrition and comply to the Doctors instructions.

And this is where the flock is faltering.

The flock as a whole has to realise that there are six stages:

1.      Understanding: A simple but efficient way of explaining to the patient what he can understand.

2.      Knowing: The patient not only understands but accepts fully the explanation.

3.      Applying: Doing as he should but not ‘automatically”.

4.      Using: Doing as he should as part of an accepted routine

5.      Stopping:The inevitable stage. It will always happen in any chronic treatment.

6.      Restarting: Easy to do if there is someone to tell him

In short we need good explanations and good follow up. Ideally this should be the Doctor. Unfortunately we know that he is incapable. He has neither the time or training. The patient as we have stated has not the inclination. So we are left with the health providers and the pharmaceutical companies. Of the two it is the companies who have a true vested incentive to undertake the task. There is but one pitfall. There is a natural suspicion about motives. This suspicion is ill founded but certainly present . It is just as certainly circumvented. Unfortunately it is not enough to state, correctly and succinctly that although drug companies have a vested interest this in no ways diminishes from the need to supply information and follow up.

So what is needed?

1.      A vehicle that promotes understanding and the acquisition of knowledge.

2.      A vehicle that detects drop out. It detects the inevitable stage five and shorten stage six to a minimum.

This vehicle is the Internet.

In order to overcome the hesitancy about the pharmaceutical companies the vehicle should be sponsored by but be autonomous from the Companies.

I am suggesting adding a gosling to the flock.

A gosling sired the pharmaceutical companies.

A gosling that is autonomous.

The gosling will promote compliance and prevent attrition.

The patient and Doctor benefit by the improved health. The health authority benefits by increased efficiency and less recidivism. The companies by increased sales.

A gosling who can cause cohesions and increased well being to the whole flock.

In the fullness of time the gosling can grow. The goslings functionality can increase.

It can facilitate easier contact with the Doctor by anticipating when he should visit to say renew his prescription batch. At a later stage he can anticipate possible problems with possible solutions.

As an example a stressed 35 year old woman receiving anti-depressants can be screened for possible learning dysfunction in her children or maybe an otherwise non-discussed male sexual dysfunction. Suggestions can be made. Appointments may be made.

As the system beds down confidence in it will grow. The Doctor, seeing his patient attaining the results he so desired will openly and gladly cooperate with it.

The flock is short of one member. The gosling as a case worker. As in all case working the case load should deepen and become intricate and complex.

But in every situation the flock as a whole benefits. As in all flocks the increased well being of the flock is represented by the increased well being of each and every individual member of the flock.

Can we migrate to this system?

ASHDOD UNDER FIRE:
In retrospect:
A child of the ‘60’s has a curse and blessing. We have musical ADHD. We think in terms of either song or film titles. Or at least that is my excuse.
Let me encompass my recollection my way. They are mine to encompass. They are personal. So, selfishly, I will present them to assuming that you too have my presentational preferences.

MOON RIVER: A song about a man and his river.

“Two drifters off to see the world. There is such a lot of world to see….
… But we are after the same, Rainbows end — it’s waiting round the bend —

Moon River and me”

Like a river we flow with our experiences.. Rocks like experiences become part of that river. We flow with it. Sometimes our river is placid. Sometimes it is a surging torrent casting all before it. Sometimes it breaks its banks. Experiences are forever entering the river. The river carries them along. Sometimes it does so with ease. Sometimes they cause eddies and turbulence. Sometimes the experience dams the stream. The dam causes flooding mud and devastation. Afterwards the stream is reduced in its vigour and richness.

But all in all the quality and richness of our river is the sum of our experiences and how we flow with them.

As we navigate the river of our life we are aware that we may hit a rock. That brings me to my next point of departure:

A ROSE BY ANY OTHER NAME: A Shakespearean quote used as a book and film title. It means so many things. But the bottom line concerns conceptualisation and reality.

At time of extreme stress we tend to a few things to cope.

1. In acute danger we survive. We do so by either running, freezing so as to avoid attention or crying for help. They are highly efficient mechanism. We survived the jungle with these gambits. They do not need changing. They are certainly not a cause of remorse, shame or self-rebuke. When your life is at threat that is what you do. We secrete massive amounts of adrenalin. The adrenalin turns off everything that is superfluous. This includes thinking. At this moment we react. Adrenalin turns on everything that we need. I speeds our heart, it cools us with sweat, and it prepares our muscles to run. It causes us to cry, literally for help. Crying is a highly efficient way of gaining attention and help. Screaming is even more so. Most important it changes our sense of time. Past and future al virtually erased. The present is as if slowed down.
   At that moment our stream has stopped.. This stage is called fear. It is a distinct, well-coordinated reaction to a highly defined cause. Our life is in real danger.

2. Immediately after the danger there is a stage of recuperation. The danger has passed. The adrenalin is still highly active. Time is still slowed down. It is still hard to think in our usual logical way. We are still in a state of arousal. It takes adrenalin a good few hours to burn off. Afterwards there is a feeling similar to a hangover or ‘crash’. We feel tired and listless. We may feel sad. It is the adrenalin. That is all. Our appreciation of time is still not as it was. We can drift back to the event. But now it is a memory. We remember the event as a memory. The memory can be vivid. The memory of our pain and fear can be almost as if they were re-happening. But they are not. The sadness and pain diminish slowly but surely. We all remember when we lost someone dear. Maybe through death. Maybe someone you loved very much loved you less. But we have all experienced the first day. As if there will never be another day. But there is. This is a real pain. The sense of sadness and tiredness is real.

3. The recuperation becomes in the days to come a memory. It is an unpleasant memory. You have learned the hard way that your experience could have ended your life. A lesson learned the very hard way. You will be reluctant to remember. But you will be equally reluctant to endanger yourself in ant similar way. This is how we have not only coped but learned how to avoid danger.

Now what has this to do with “A rose by any other name”? Because these stages are blandly called ‘anxiety’, ‘depression’ or ‘adjustment disorders’. They most certainly are not. They are normal healthy reactions.

So what is anxiety? Anxiety is the fear of something unknown. Now I will say something that may seem odd. Please be patient with me. It is not the event that is the fear but the inability to know the likelihood of it happening. Anxiety is not merely the fear of something unknown. Anxiety is caused by the inability ascertain the likelihood of the event happening.

Let me give you an example. We all know that we will die. We are anxious obout death only when we are not certain that it is not imminent. Generally but always the sufferer can point to the cause of his anxiety. When he cannot as he has so many the same principles applies. The anxiety is the inability to say what the likeliness is.

We not only flow with our river of experiences. We navigate our river too. In our river here are rocks. We know that. They are only important when we do not know at what depth they are. If they are near the surface then the navigator is alert. He is anxious. If the rocks are defined then he suffers from ‘specific anxiety’. If he feels that there are undefined rocks but he cannot ascertain if they are not immediately imminent then the navigator suffers from ‘General Anxiety’. The shallower the river, the more it is blocked ‘upstream’ the closer the rocks are to the surface.

So what is depression? Depression is a sense of loss accompanied by grief and often anger. After, any event for better or worse, the river of your experience continues to flow. If you have left something behind that you wanted with you, there is a sense of loss. Your river of life has lost its richness and quality. This is true depression.

So you see life’s quality is about the depth and quality of our own river of experiences. How we flow with them. How we deal with events is called coping. Coping is a mixture of ability, expectation and complexity of the problem.

At critical moments when a bomb falls we can do but a few important things.

1. Expectation: By carefully explaining what is happening to the traumatized person one can efficiently and effectively change expectations. In the early stages[ hours to days] it is generally more than enough to simply explain to the person what is happening to him as it happens. In other words to minimize his criticism of himself. Avoid the ‘name of the rose’ mistakes. Avoid labeling.

2. Strengthen and enrich his ‘river of experiences’. Help him identify with the events, to feel actively involved in a struggle that he identifies himself with. To use examples in his past where pain passed.

If you can get into his river, help him enable the flow to restart then you have helped. To survive remember to get out of his river and back into your own.

‘She is a very beautiful lady. I have never really seen her. Just glimpsing the occasional glimpse. I have sent her letters and I  have received answers. Maybe one day I will see her.’

That incredible description was written by a Pharmacologist about receptors.
There was another beautiful lady,  by the name of Barbara. Her boy fried dedicated his Ph. D. thesis with these words  ‘To the beautiful Barbara’.
This how Barbiturates — the first ‘non natural’  sleeping pill came into being.
Judith is a beautiful lady too. She cares about her beauty. So she is worried about being overweight. This article is for her.
Judith knows that I am deaf. But strangely the conversation that invariably I did not hear was when my body spoke to me.
But this ’self deafness’ is the root cause of being overweight.
Normally your body says to us very clearly that you are hungry and when you ‘have had quite enough thank you’.
But you stopped listening a long time ago. So your body resorts to new strategy. It goes onto an emergency footing. It is as if your body no longer trusts you to look after it in a normal and regular way. In fact your body stopped talking to you. It adopted a new ‘independent strategy’.
And the new strategy is:
* Eat as often as you can. Grab snacks.
* Get on board as much high calorie food as possible.
* Eat as much as you can till you feel full.
Not hard to see why you are putting on weight is it?
How do you start listening and trusting what your body is telling you?.
Well you have a problem with that. Your body has lost faith in you. It is not telling you when it is hungry, really hungry that is.
Your body does not really trust you enough to again abandon it and it’s needs. Your body depended on you for a regular supply of calories. And you let it down.
You have to prove to your body that you are reliable.
You have to prove to your body that you are really listening.
But to do that you have to convince your body to speak to you again.
And that is quite a long process.

You can do it in stages.
* Start eating three regular meals at set times. The adage about breakfast being the most important meal of the day is true.
* Between meals religiously eat a fruit or raw vegetable.
After a while something interesting will happen. You will start feeling hungry. Just before eating you will feel hungry.
Congratulations. Your body is speaking to you. Don’t be too overjoyed. You have not entirely regained its trust. But your body will start telling you something else. It will start telling you when you are satiated. It is a different feeling from that of ‘being full’. At this point your body is prepared to rely on you to give it the calories that it needs at the time it needs them.
But if you want you can encourage your  body to speak. Chew slowly. Sometimes it is not too clear to you if yur body wants to calories or water. At each meal drink water as you eat.
We are almost there.
Now that you are talking to each other you can begin a dialog. But you both must be honest and open.
Don’t fool your body into thinking that it just got sugar by using an artificial sweetener. Be fair. Either use natural sweeteners or don’t use them at all. Sweeteners do not satiate your need for sugar. If you pull a trick on your body, your body will trick you in return. Just by avoiding all sweeteners, included in soft drinks,.
You can now set yourself a realistic diet that you can maintain.
My tip would be this. Never eat potatoes, rice or bread on a weekday. Eat vegetables instead. I won’t go into Glycine Index. Or even how beneficial exercise is.
There you have it, Judith. My letter to a beautiful lady. I hope it gives you all that you want.

I was sat watching Rambo.
Now what the hell has Rambo got to do with you?
Because Rambo really happened.  I want to tell as many people as I can about the ‘accidental’ Rambo I met.
I met Adi in October 1974. A tall almost emaciated Yeminite soldier. He was admitted into our Shell Shock Unit. He had been in a general Psychiatric hospital –where he had thrown the director into a decorative pool. To the directors credit he got out and threw Adi in the pool. Then he sent this misfit to our unit of complete misfits.
The shell Shock Unit.|
Adi was almost mute. All he would say was incomprehensible.
We could follow nothing.
So I gave him Pentothal. Until Adi we could always trace the cause of the trauma and recycle in a way that somehow made it ‘psyche-digestible’. But  Adi  just went berserk. In those awful long nights I was obsessed not by the mayhem that we were seeing. why was it not working? An injection then complete mayhem. Till then it had been the opposite.
I had to get Adi back…. and I could not.. Then one night I reasoned like this:-
Adi under Pentothal is virtually Psychotic. So why not give him an injection of antiPsychotic intra venously?
At midnight I phoned up my boss and asked permission. Tomorrow I would inject both Pentothal and an anti-Psychotic.
At eight in the morning we started. In went the Pentothal and we lost Adi again to his demons. In went the anti-Psychotc and Adi stated repeatedly : ‘Carol, how big he is. So small he is.’.That was it.
Nothing more. But something.
Like  all successful Pentothals Adi woke up. But this time I was at a loss as to what had happened. I asked him what  ” How big he was –How small he is.” meant? Who is Carol?
Adi simply looked amazed. “How do you know?” “Did I say that?” .
As in a very few other Pentothals we had gone to the wrong place in time. The ‘wrong trauma’.
With Ephraim we had blundered into Auschwitz.
With Mike, a hysterical blind victim we had found ourselves in a tank battle in 1971.
With Shalom we were in a Moroccan prison.
Adi had gone back to 1967— the six day war. …….
Adi had a son called Shai. Shai, his only son had died before the 6 day war started. In the 6 day war Adi was a non combatant. He was a driver of the Burial Corps. He was present when the Clergy tried to piece enough body parts to bury. Some times there was not enough. What there was they put in ammunition caskets and nailed that in the coffin and filled the rest was earth to make up the weight. Carol was Adi neighbour. There was barely enough of Carol, a very tall guy to put in the ammunition box. Adi sat by his neighbour, Carol’s, coffin all night. He asked Carol to look out for his dead son Shai when they met. He muttered to himself — well you know what….After all Carol was very tall and now there was not enough to fill the ammunition box.
Adi and all his unit had sworn to keep the secret of what happened when preparing the dead that week. The Chief Military Rabbi then asked them made them swear an oath never to tell. Honour the dead and their memory. But Adi had told. Under Pentothal. Six years had passed. Inadvertently he had told us. This in his eyes was unforgivable.
I want to jump forward a month.
We worked a lot in Adi and made real progress. The Chief Military Rabbi in the Yom Kippur War visited us. It was a warm spring afternoon. We sat on thee grass and the Rabbi answered questions.
Adi asked if what he had done was excusable? Adi was well known and respected. So there was a very heavy silence. The Rabbi turned to his two assistance.
“I now declare this a Rabbinical Court and we are now in session. Adi Chatuka cover your head.” The rabbi then placed his hand on on Adi’s head. ” This court absolves you from all your oaths that you took in 1967. This court absolves you from all guilt”
Adi said. ” Rabbi, these guys have fought hard for me , to help me, but no injection helped like this”.
We were all in tears.
But I have still to explain why Rambo?
What happened in 1973?
First a bit of history and a brief explanation.
The Egyptian were helped by the Sudanese commando brigade as they crossed the Canal. In accordance with Soviet doctrine they were doped to their eyeballs with Ritalin. The Sudanese were the bane of our soldiers existence . They were big, fearless with bulging ferocious eyes. They were unstoppable. Well almost unstoppable. Adi stopped one. But at what a price
Here’s how. ….
Adi was a tank driver. They were trying to stop the Egyptian advance. They were surrounded by Sudanese. The Sudanese were unstoppable. They were like a swarm of locusts. They were everywhere.
Adi’s tank commander was a greenhorn. This irritated Adi who felt he had a liability and responsibility. Adi wanted to get everyone home safely. He drove over Sudanese. He mowed them down. Adi was doing well. He was getting out of the mess. Then it went awfully wrong.
The tank commander was sat half out of the tank. A Sudani killed him. Adi went after the Sudani. Adi got out of the tank and fired a machine gun at the Sudani. The Sudani kept coming . Adi was screaming at him “Die — you are already dead.”  More rounds and still the Sudani is running. So with one long burst Adi cut the Sudani into two. But still the legs of the Sudani kept running. Adi past out and was mute.
Months went by.The treatment was working.
Adi then did something that  no other soldier of mine did. He went back into reserve duty. My mistake maybe but also fate played a hand.
Adi was posted to almost the exact spot where he had fought his Sudani. Then it was the demarcation line between the Israelis and Egyptians.
Adi dissociated. He saw the Sudani and Adi attacked. Adi was  running , weaving and firing as he advance on the now docile Egyptians. There was only one way to stop him. We ran Adi over with a command car. In the turmoil Adi was shot in the leg.
There was an enquiry. There always is. This one was fair. The investigators told me that Adi was a few yards from starting the war all  over again. There was grudging admiration for Adi’s soldiers craftmanship. My mistake was generously overlooked. The authorities let it pass.
I went to see Adi in hospital. The Orthopedic Surgeon asked me if this was another faked malingerers suicide. I told him that it was not.
No this was a real genuine fucking hero.
Adi almost started another war. But his own never ended. The Sudani never left him. He drifted. Adi was in and out of trouble. Often they wanted to put Adi in a closed ward. I stopped them. But it was getting harder. Adi’s wife and neighbours were all suffering outbursts and wild behaviour. Then one day the Police phoned. It was three in the morning. They were laughing at this lunatic that admitted to a murder.
“Did he murder someone?” I asked, a bit nervously. The reply was negative ” Only some Sudani” .Accompanied by more laughter. I said OK — tomorrow we’ll put him into the closed ward and I put the phone down.
Then it hit me. So I phoned back to the Police. ” Are you sure that he said  a Sudani?”—” Yes very sure” was the answer.
At three thirty in the morning I got Adi out of the holding cells. ” You realise that the Sudani is dead — no more night mares”. I took him home. Nothing sensational. We were both very tired –of everything.
Things got reasonably manageable but never any where like normal. Adi made a living as a Taxi driver. Very rarely I saw him.
One day a journalist came to my clinic. She asked if what she had heard was true?  —- A taxi driver had told her his story without identifying himself. He had picked her up as a fare by the clinic. How did she find me? Adi had said that whenever he felt bad he would drive by the clinic. He knew if things got really bad he always go in. That was enough for him.
Adi’ s wife died of cancer. So did Adi. They are all together with Shai, Carol and the two Rabbis.
Wars are fought and payed for by heroes. But heroes who did not ask to be heroes. Adi was an accidental hero and a great guy.
I don’t know what this did to you. If you think on Adi for a minute —  that is good.
I sent this to people I know well, people I don’t know well, people that will understand and people that will not. If anyone is offended — well I am sorry.
I simply wanted to share and honour Adi. I hope that you do too.

No surgical technique has been more successful than having Surgeons wash their hands. The most dramatic medicine of the last century was the virtual eradication of Smallpox and Poliomyelitis.  The cessation of smoking, healthy eating and exercise have all helped to prolong life. Quality of life has also improved. Social intervention and rapid intervention have helped enormously in our fight against AIDS.

We have delayed and prevented onset of Diabetes and Hypertension. When they occur they are dealt with rapidly and effectively.

We are screening for cancer of the breast, bowel and pancreas with great success.

Modern medicine  knows what causes an illness. Modern medicine can take steps to prevent it.

I t seems that if we act 10 years ‘in front’ we can eliminate or minimise the diseases that the most expensive of  medications do not cure effectively.

Can Psychiatry orientate itself similarly? It would seem that Mental-Health has not even changed its approach. We know that over twenty percent of the population will suffer from Anxiety, Panic and Depression. The illness can last a month or more. It will return, on average three times or more times.   We know that approximately two percent will have serious debilitating Psychotic disorders. The majority are Schizophrenics. The majority of the Schizophrenics will never return to what they were. They will need support and care for large part of their remaining lives. This is even more distressing as the illness tends to start relatively early in life.

Mental illnesses start earlier than other illnesses. Yet we treat them as we treated Depression and Diabetes twenty years ago. We are waiting for the disease to develop, waiting for the damage to occur and then apply rehabilitation and damage control.

Are there steps that we can take that prevent, delay onset and intervene at an early stage?

It is universally accepted by professionals that the use of addictive drugs including the ‘safe drugs’ can and does precipitate psychosis. There is alarm at that use of Ritalin. All in the profession agree that Ritalin is prescribed far too easily. People are not given Ritalin in accordance with ‘accepted practice’. It would seem that people who have received Ritalin are more liable to later be treated with medication used in psychosis than people who did not receive Ritalin. Strangely the same group, who received Ritalin, receives fewer medications for Depression than those who did not receive Ritalin. We know that children brought up in social stress and with a poor family support system are more prone to mental illness. We know that Schizophrenia has genetic loading. We know hat certain behavior traits in childhood are prone to develop Psychoses. We could make a list of loading factors. We have a pretty good idea who is prone to develop Schizophrenia.  We know what the prodromal signs occur before the first Psychotic breakdown. Psychotic breakdowns do not occur overnight. They are festering for weeks before the break. More distressingly we can prevent a Psychotic breakdown if we intervene at the right time. Yet we do nothing.

We know that not everyone will develop Depression or Anxiety. The family Doctor is never surprised when one of his patients does develop theses illnesses. We know how is going to develop the illnesses. He or she is typically of two types. They are either the rigid worrier or the very dependent personality. They have in common a defect. Their Coping Style is inadequate. We can readily and easily correct this defect. Cognitive Behavioural Therapy, CBT, can improve coping. CBT is made available Online. Over forty percent of people feel that they want to improve the way that they cope. By doing so they would prevent Depression and Anxiety and improve significantly their quality of life.

It would seem that Mental Health will start to re-align itself with the rest of Medicine. We can reasonably hope that prevention and early intervention will become as important as they are in the other fields of Medicine.

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Coping styles are a mixture of experience and personality. By personality I mean the way that we think, feel and behave in given situations.

Are you getting a little edgy? How do I change my personality? Don’t worry you will not.

There is a dyad that we all accept as true. Feelings and thoughts, they interact and effect each other. Feelings and thoughts are the reaction to an event. Very often we have thoughts or basic assumptions which are completely wrong. The assumptions are unchallenged. They generate feelings. These feelings generate thoughts. Vicious circles are in the offing. A reaction to an event becomes prolonged. The reaction outlasts the event. The thought feeling dyad has led you into a mood. The mood makes it harder for you to cope.

Some people are very bad with their basic assumptions. They exaggerate. But by their very nature basic assumptions are unchallenged.

Cognitive Behavioural Therapy [CBT] is the way to challenge and change theses assumptions. Online Self-Help CBT is a very effective, easy tool to use. Almost immediately you feel a sense of mastery. You start to cope better. You will rapidly observe traits. Similar, wrong assumptions crop up regularly. You change them individually. Then you will soon see and change traits.

Maybe you wish to exchange experiences. A burden shared is a burden lessened. Online Self-Help CBT allows you to participate on a e-Group designed to do just that.

Dr. Michael Benjamin.

Psychiatrist

myRay: http://www.myRay.com Free Online Self-Help CBT

But we are always aware of our surroundings. We have a sort of scan or radar scanning what is going on. It may be something in our vicinity. But it may be a relevant subject. Say we are nearing an exam.

This scanning process defines the importance of the subject that it is scanning. It has three levels of grading. The first is to tell us that the subject is of no significance. It is virtually telling the headlight attention ‘there is no need to refocus.’

 The next level is ‘Well I am not too sure ‘. ‘You can stay focused but I am putting you on standby’. This is object or event is labeled. But how is this done? By marking it with an emotion. So we have one subject in our ‘headlight’ but a feeling can occur. We are unaware of why we are feeling it. Obviously the event in the ‘headlight’ too can evoke an emotion. The event in the ‘headlight’ can evoke subjects associated with it to appear in the ‘scan’.

We are subject to a range of emotions. Many of which we are completely unaware of the source.

Now some people do this labeling process badly. They tend to over emphasize the possibility of something happening. Events are given emotions where they need not be.

We know this person. He is the worrier, the over conscientious, ever ready guy we all know. He is permanently tense. Happiness for him is not being unhappy. Relaxation is the absence of tension. Eventually he may well develop depression or anxiety.

Now  we know the problem can we find a solution?
CBT – Cognitive Behavioural Therapy – is that solution. CBT allows us to examine easily the thoughts that were previously ‘hidden’. On doing so they are automatically corrected. More so we can see that very often the same thought and emotion occur. People can rapidly discover traits. They can readily correct theses traits.�
Online Self-Help was designed to specifically help correct erroneous traits. 

Dr Michael Benjamin

Psychiatrist

I learn from my patients. As we push the myRay, the online CBT site to its maiden voyage I have gained two valuable insights from them.
As good as any explanation can be it must be plausible. It has to be very firmly supported by the trusted Family Doctor. I will deal with the second point in a later blog.
I have described the relationship between Appraisal of an event, (Automatic Thinking), Feelings & Mood. I explained the interaction between Mood, Personality & Automatic Thinking. On using this information we can easily, rapidly and efficiently choose the correct therapeutic intervention.
The concept Automatic Thinking needs clarifying. We notice every event that occurs. The “noticed event “ is categorized according to its importance and significance. We react emotionally to the results of this categorization.
Very often we are completely unaware of this process. This process allows us to both react appropriately and yet not be easily distracted.
 We often are only aware that we have a feeling but not why.
This categorization process is profoundly influenced by Mood & Personality.
What does this mean?  It means that what emotions are not irrational. They are formed and driven by a “submerged “ thought process.
But what if the categorization process is incorrect? We can feel erroneous feelings and react to them without really knowing why. Even worse these feelings will eventually and persistently fuel our mood. In turn mood modifies the categorization process. We can get into a vicious erroneous cycle without knowing why or how to correct it. To compound the problem we are not aware of the error. We act as if the information we are being fed is always correct.
The pure simplicity and beauty of CBT is its ability to examine and find a fast remedy for this process. CBT enables us to raise the process above the water line. It makes it observable. We can review it systematically. Correction then becomes easy.
The free online CBT site myRay offers an added value. By using web technology we can rapidly observe and correct trends. Why is this extremely important? Personality and mood influence the process. One definition of personality is the collection of trends in the way a person acts feels and thinks. Need I say more?

There is an ABC of Psychology and Psychiatry. The A is affect or the way that we feel. B is behaviour. C is cognition, the way that we think.

The way that they think and feel determines the way we will behave. The way that we think, feel and behave is called our coping style. Our coping style is an admixture of our personality and life experience.

Let’s discuss thoughts and feelings. Thoughts and feelings are the reaction to an event. The dyad should be limited in time. If the dyad continues after the event has ceased to exist it is now called a mood.

It is common knowledge that thoughts and feeling interact. Nice feelings good thoughts. Bad feelings bad thoughts. We can see the possibility of a vicious circle. In fact this will help us define depression. The circle may become so tight that we do not respond as before to any situation. Our mood has worsened. We are now depressed, anxious or in stress.

Let us make one final distinction. Are we talking about poor quality life? Is there a limitation in functioning? This is important. If we are merely discussing you should be offered Cognitive Behavioural Therapy (CBT). In my effort to make CBT readily available I built the free Online Sef-Help CBT site myRay [http://www/myRay.com] to do just that this.

Is there a limitation of functioning? Are you no longer behaving as before? If so then you should be offered medications.

In my next article I will explain how feelings and thoughts interact. This explanation explains why and how CBT works.

There are two aspects about treating depression. How do we cure it? How do we prevent it?

They are not the same. No matter how we may cure depression this will not prevent depression.

Why is it so important to prevent depression?

Depression reoccurs. People who have the tendency to be depressed suffer from a permanent poor quality of life.

I no longer believe that Medications to be a panacea. They may cure depression. They do not increase quality of life.

But this begs a very serious question. When is someone depressed and not merely very sad? When do we cure? When do we prevent?

As a rule of thumb we can use functioning. If sadness is such that there is an objective limitation of functioning then we should address the problem as ’curing depression’.

If a person is sad but is not suffering a limitation in functioning then we should address the problem as ‘preventing depression’.

VNS, ECT, and Medications cure depression. They do not really prevent it.

Cognitive Behavioural Therapy, CBT, prevents it.

It really is as simple as that.

If you want a fuller insight into how CBT works, or how CBT can be offered online please refer to my free Online site http://www.myRay.com

If you wish to understand more about: Thoughts, feelings, emotions, moods, depression, what it means, what re your choices and how to choose please refer to my free online site http://www.MyDoctorExplains.com

Both sites, http://myRay.com and http://MyDoctorExplains.com are non commercial and free.

Use them as often and as long as you so wish.

Dr. Michael Benjamin,

Psychiatrist

myRay is the pioneer in presenting a program specifically designed for use on the Internet. We have used state-of-the-art techniques for presenting and storing information. We have melded the modern psychotherapeutic techniques with the latest IT technologies.

We have made innovations in the way we use tool tips to define key words and in the way the results are presented with an ability to “drill down” to different levels. The e-Group is also completely new in its conception.

Multi-faceted, interlinking, personalized program

The program consists of the following sections, which have all been rigorously tested and examined by professionals in the field:

• Daily Habits and Timekeeping
• We deal with ways of indirectly reducing stress by highlighting healthy habits with reference to eating and exercise. We place great emphasis on the efficient management of time. A few very simple techniques will relieve a lot of the feeling. It occurs at the time of stress.There is a tendency to experience physical discomfort such as muscle pain, headache or stomache ache.It is often harder to cope when tension is felt and it increases the likelihood of developing psychosomatic illness..
• Relaxation techniques
• We introduce you to three techniques which will enable you to gain all the benefits of tension and other unpleasant feelings.The methods used here are:-
  • breathing exercise
  • muscle relaxation
  • enhanced relaxation
• Cognitive Behavioral Therapy
• The way that you perceive what you are doing and how you think about it is of great importance. In this section we will instruct you how to identify and rectify the cause of disturbances in your thinking processes. You will rapidly gain the ability to change the way you perceive a situation.
• Personality traits
• Often the ways we behave and think are governed by certain personality traits. In some cases these traits can increase the likelihood of our becoming angry, pessimistic or easily disappointed. We will help you discover and rectify these personality.We will pay attention to depressive traits.
  Personality traits influence the way we cope under stress.
  If not, tension is increased and it is possible to enter into a vicious circle.see also:
  • Coping style
  • Coping strategies
• Experiential aspects
• The quality of experience can often determine the amount of stress felt. We will focus on two key aspects. These are: the amount of control that you feel you have over an event compared to that which you actually have and the level of desire that you think you have to be in a situation compared to your real desire to be in that situation. They are often misleading and cause cope is being tested.There is a likelihood that an unpleasant feeling may be felt, particularly tension.It can trigger entry into a vicious circle.
• e-Group
• We have designed a format and protocol for this form of group therapy. It has been tested on the Internet and found to be of great benefit. You can share either personal or technical problems. We strongly recommend that all our subscribers join an e-Group.

Individualized and customized

The program is customized. You can decide if you wish to read about the subjects in depth. Every section is accompanied by an easy-to-understand explanation of the concepts behind the technique. A video tutorial is also available to guide you in mastering the techniques that the program requires. You will be presented with an individualized course of treatment based entirely on the results of the assessment that you undergo every week.

Ongoing assessment

Assessment is given once a week, although you can initiate a re-assessment if you so wish. However, we recommend only one assessment every seven days. It is perfectly natural for there to be fluctuations in your results and performing an assessment once weekly tends to iron out these anomalies and allows you to get a clearer picture of the real progress you are making.

The assessment allows us to provide you with the course of therapies most likely to help you. Ongoing assessment allows you to chart and monitor your improvement which we store for you. You can readily see where and how you are improving.

Your profile

This comprehensive summary of your sessions with a breakdown of all the previous results in each section is one of the program’s most powerful features. You can see very quickly what is really going on and what still needs to be worked on.

Joining myRay

Enrolment is easy, simply take our 28 question assessment test. If your results indicate that you could benefit then you will be offered the chance to subscribe.

Traditionally, CBT has been given on a “one to one” basis between the therapist and the patient but, with the advent of the widespread use of computers, it has been possible for the patient to use a computer program to learn and practice the required techniques.

myRay uniquely takes this one step further and uses an Internet-based suite of modules that teach relaxation techniques, time management and stress reduction.

It invests heavily in teaching the patient the principles and techniques of CBT in an interactive environment. myRay has extended CBT; the program not only deals with the ways in which we appreciate an event, but also the ways in which we tend to behave and experience it too. Its main advantage is that the program monitors your responses and gives you feedback on your progress and responses.As long as you have Internet access you can use the program in any location at any time, to suit your needs and schedule.

The program contains: a glossary of terms, explanation of concepts, video tutorials, feedback scores and charts, breathing and relaxation exercises, instruction in time management and the opportunity to join a confidential e-Group where you can share your experiences and advice with other users. The e-Group, in particular, is a very exciting concept in up to date, Internet-based group therapy.

The key concept of the program is based on your working with real personal experiences to understand how you have traditionally reacted to them, how to modify your reactions, using the techniques learned in the program, so that you will become less troubled, anxious, stressed and depressed about challenging experiences in the future.

myRay has been devised by a Consultant Psychiatrist with over thirty years experience in clinical practice and a team of information technology experts. It has been thoroughly tested. The basic concept has been evaluated and published in internationally renowned professional journals where it has been shown to be very effective.

Enrolment is easy; simply take our 28 question assessment test. If your results indicate that you could benefit, then you will be offered the chance to subscribe

Abstract

Emotional distress is unlike any other complaint because the sufferer diagnoses it.

There are two modes of treatment: medication and psychotherapy. A large proportion of sufferers need psychotherapy. The demand for treatment is vast. Because of a shortage of suitably qualified therapists, most sufferers receive medication.

Where medication is used, it is associated with side effects and compliance is low. This causes poor client satisfaction and a renewed search for a better solution. New medications are constantly being introduced at ever increasing costs. Psychotherapy has developed popular therapies that are educational in nature.

The widely used Cognitive Behavioral Therapy (CBT) has been computerized and found to be as effective as any other therapy in present use. It is now possible to mesh the psychotherapies that are educational in nature with the advances made in e-Learning. (Presentation, Immediacy, Openness, Interactivity, Data Storage, Tracking and Security) This white paper lays down the blueprint for e-Psychotherapy. The specifications cover:

• Professional acceptability
• User friendliness
• Personalization
• Client safety
• Data security
• Data management

e-Psychotherapy has the following advantages:

• Efficiency
• Reliability
• Convenience
• Intimacy
• Medication free
• Analysis of results

e-Psychotherapy, by being non labor intensive, can greatly reduce the cost of delivery. e-Psychotherapy will probably change the use of medication, leading to savings in the costs of therapy.

Read the full article.

The file is in PDF format and you will need Adobe’s free Acrobat Reader application to view it. You can download this from Adobe.

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