SC State Hospital To Undergo JCAHO Review After Patient Demise

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South Carolina State Hospital Historical Marker

The South Carolina state psychiatric hospital, historically called “Bull Street” for decades in the past, Brian (state) Hospital in Columbia SC, recently had a sad and tragic occurrence, a suffocation death of a patient apparently undergoing a hands on restraint for out of control behavior by multiple staff.

In a recent article written by Avery G. Wilkes of The State newspaper of Columbia SC, entitled: “Suffocation Death of SC Mental Health patient under review by group that accredits hospitals,” published July 17, 2019, the sad story of this tragedy is detailed. In this article, there is described the possibility that some of the staff involved in this patient’s restraint event, were not adequately trained in these highly complicated and at times, hazardous to all involved, events. I will try to comment on my own experience with these events below. In any case,

The results of such investigations are made public. This is not a closed process with no transparency. Sometimes the public can be overly suspicious that transparency is not being followed by officials at the state or hospital levels when the media note that officials could not and would not discuss details of these reviews at first until the results are determined and made public. An article published September 8 ,2017 by the Wall Street Journal authored by Stephanie Armour entitled: Hospital Watchdog Gives Seal of Approval, Even After Problems Emerge: The Joint Commission, which the government relies on to accredit most hospitals, rarely withdraws its approval in the face of serious safety violations,” gave a cursory overview of this issue which was taken up by the U. S. House of Representatives in 2018 with a request for documentation (House committee probes CMS, Joint Commission over accreditation process,” published in Modern HealthCare magazine). Unfortunately I have not been able through my searches to find left over record by that Commerce Committee of the House as to what eventually came of the initial inquiry.

But it is my opinion and experience, that one of the reasons the Wall Street Journal found that only 1% of hospitals nationwide are ever de-accredited is that wealthy private hospitals are de-accredited less than the state psychiatric hospitals. Medical hospitals are now usually huge conglomerates and rarely are penalized at such a level. Small poorer community hospitals seem to be more vulnerable to such review based censures. And they are closing across the nation now anyway for reasons of declining revenues but that is another story for another day. Suffice it to say that state psychiatric hospitals, as maligned as they still are, operate in a far more regulated and highly scrutinized environment than private psychiatric hospitals or units/services within large wealthy, private, or university medical center based entities.

States’ governmental laws regulating their health care facilities, as well as private hospitals, require investigations and review by various bodies locally and nationally, deaths of patients by unnatural causes. Local review bodies include legislative oversight committees, the states’ own departments that oversee state psychiatric and private medical/psychiatric hospitals, national bodies such as the Joint Commission for the Accreditation of Hospital Care Organizations (the famous “JCAHO”), CMS (the federal agency for Medicare and Medicaid)C etc. Investigations such as these are very important since failure and loss of accreditation by these bodies can result in loss of ability to receive reimbursements from various insurers, especially the federal ones, Medicare and Medicaid. And for state psychiatric hospitals, this is extremely important. State psychiatric hospitals serve mostly poorer patients on Medicaid and Medicare or the uninsured, and loss of these operating funds means that the state legislatures’ budgets then have to make all the lost funds until the hospital which has lost such accreditation and funding can regain such. This always involves submitting to the mandates the hospital must put into place. This process is always lengthy, detailed and usually requires “corrections,” “actions plans” etc. It is not a trivial event then when a state psychiatric hospital has such a tragedy, and when a “deficiency” is found. The investigative review process is arduous. It requires no questions asked cooperation by the hospital staff and leaders. Staff are subject to detailed interviews and scrutiny. Hospital policies are reviewed and the review personnel check to make sure that the policies are indeed followed and fully implemented. If there are deficiencies found, then the corrective actions are imposed and possible penalties such as loss of accreditation are imposed.

Now there are wealthy(ier) private psychiatric inpatient systems that have been de-accredited in the past few years and I would be remiss in my own ethical standards if I did not mention a couple of them. One was the Timberlawn Hospital of Dallas TX that in its heyday was truly a very good inpatient treatment facility. I had a former mentor from my long ago training days who migrated to work there and did exemplary work with adolescents. But the leadership and ‘mission’ of the facility changed a decade or so ago and it went rapidly downhill, quality of care suffered and tales/rumors of its bumblings, then deaths and such, began to emerge. It underwent investigation, lost accreditation which was a genuine shock to many who knew it in its heyday, and closed only a very few years ago. Another chain of psychiatric inpatient centers in the Boston area garnered such scrutiny, was loudly hectored in the media for a variety of missteps, some of them quite major and involved a lot of financial misdoings and lost its accredited standing also. So this does happen with some monied, strongly capitalized psychiatric inpatient entities, but I feel it does not happen enough and helps the explain the findings in 2017 of the WSJ article/expose.’

At this point I would like to comment on my own experience with at least the aftermath of a state hospital-based investigation regarding the patient death undergoing a take down manual restraint.

After serving as stint for approximately 4 1/2 years is the first psychiatrist at a newly established Native American tribal mental health clinic and substance abuse services, and in the approaching twilight of my psychiatric practice career, I was looking for a more balanced and salaried position for essentially the rest of my career. As I had started out my post residency and fellowship practice career in a the North Carolina state hospital helping to start a new 44 bed acute relatively short-term adolescents psychiatry unit, I made the decision to apply for a position that my current state hospital site of employment. I initially applied through a locum tenons psychiatry job placement firm. I had a few long-term friends, fellow psychiatrists I had known through professional contacts over the years who worked there as well. I had some knowledge that this state hospital provided excellent high quality care and I was eager to apply and see if things would work out for all parties.

I’m was not prepared by the two-way exchange that I was given during the several week application and review process. I was prepared for essentially one way process in which I would furnish information and references about myself and to be judged regarding meeting the qualifications for employment at this facility and providing evidence, references and the best representation of my qualifications that I could. Instead, toward the end of the application and interview process which lasted more than one interview session and multiple visits to the hospital, I found myself being informed by the CEO psychiatrist of the hospital, of the relatively recent traumatic experience that the hospital itself had gone through. He did so for the purpose of complete transparency and honesty so that I would know fully what the hospital had gone through and be exposed to any possible negative information about the hospital organization, its own level of confidence etc. As he began to relate the history of the death of the patient within the previous two year period, I was floored by his openness. Gradually I came to understand that this incident had been traumatic for everyone involved and was witness to the extraordinary links to which the clinical leadership and staff involved at all levels, went to in order to be cooperative with the ensuing mandatory investigations, the patient’s family and the media to the extent that they were permitted by the confidentiality laws. There was no hiding of the incident, no minimizing, no bureaucratic obstruction etc. It did turn out that part of the basis for mandating corrections and deficiencies based on the circumstances of the death by virtue of the physical nature of the episode of manual restraint of a truly aggressive and supremely uncooperative patient were erroneous. I was permitted to find out and review the incident myself and learned with confirmation from the CEO that for instance, the initial pathology exam was erroneous and efficient and that a repeat exam later on in the process essentially demonstrated that the cause of death was a previously unknown cardiac condition of the patient and not the air of the hospital staff in affecting the physical restraint and control measures. But this was not accepted or validated by the investigators and sanctions were imposed including the loss of accreditation for the hospital that lasted approximately a year and a half.

I was simply ethically amazed that the hospital clinical leadership worked actively with the investigators and without any protest whatsoever submitted to the corrective actions in a dutiful accepting way seeing them as an opportunity for positive change. By the time I arrived on the hospital’s staff, the changes had been actively implemented and I was exposed to the most detailed and helpful training course in physical restraints procedures that I had ever witnessed at any hospital at which I had practiced in the past. The hospital had contracted with an outside training and consulting agency in another state and at great expense to itself, instituted a mandatory training policy for every single staff member who has any sort of clinical contact with the patient population, from behavioral nursing assistants on up through psychologists and psychiatrists without exception. This training is mandatory and is repeated annually for all clinical staff and stands witness to the openness, cooperation and commitment to high quality of patient care.

So when I read of other hospital organizations undergoing such thorough reviews and investigations by outside bodies have more appreciation for the difficulty of the task that is endured by both the reviewer in investigators and by the hospitals themselves mutually. I also am somewhat dismayed when I read accounts of hospital organizations who seem to resist these investigations and outside reviews in an almost reflexive defensive manner. I can understand usual human reactions in which we all get defensive about having our professional actions critiqued and criticized and if need be, having to submit to a professional disciplinary action especially if it involves public censure and procedures that create a negative image in the eyes of the public who cannot ever fully appreciate how difficult these processes are.

I hope that this small effort at sharing and observer’s long-term perspective and experience can help any reader more fully understand these very difficult and periodically inevitable said events and their aftermath.

My Ingenious Grifter

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This Thanksgiving there was not enough room at the “inn,” our oldest daughter’s house for my wife and I to stay on site as it were. We ended up in a massive guest hotel on a busy new byway in the Durham area that did not exist at all only a few years ago. In fact, the entire area we stayed in was all new to us and reflected the explosive growth in the corridors between Chapel Hill and Durham. and Durham and Raleigh, the area called the RTP or Research Triangle Park. However, nowadays, the abbreviation acronym “RTP” is now disconnected from the Park itself and means the huge area that is now growing together among the three cities.

The hotel we were installed in by our host daughter is massive, several stories tall, has every amenity imaginable from high tech to healthy exercise facilities, pools for the young grandkids, coffee shop for the caffeinating set, and of all things a super high end corporate steak house national chain, Ruth’s Chris Steakhouse where the price of a meal starts in the three-digit range. But all this courtesy of lots of discount plan points courtesy of daughter and we are paying thankfully a fraction of the daily inn price which would be obscene and a budget breaker for us.

Every morning when I travel, I arise very early leaving my wife to sleep in which is in keeping with her gender tied sleeping pattern. I can shower if need be, quietly, dress and go down to the breakfast area for a healthy morning meal, read all the area newspapers, catch up on my email, and talk with whomever I can engage who looks interesting. AT this hotel I found that the “chef” who cooks the omelets and waffles and such, knew off some past figures in the black independent community health center I had consulted at as the psychiatrist for this wonderful facility and group of providers. So he and I hit it off and we talked for nearly half an hour in between customers ordering omelets and such. It was great.

I sat at a row of s mall tables third from the window but out of the direct blinding morning sun’s rays, next to a very distinguished white-bearded, neatly dressed elderly man who had given me some of his personal history the morning before, that he was 84 and a past lifelong resident of the famous but nearly gone black district of Durham known as “Hayti,” pronounced ‘Hay-tie,’ not as the country. He had talked of its history the morning before and I knew he was indeed a former resident there from my own knowledge of the famous community wiped out partially two decades before by urban renewal and the cutting through of an important feeder highway that led to the RTP.

I had also noticed that my new elderly acquaintance would side in the row of tables always next to a black couple and talk in pointed asides to them. He would act as though he knew them and would call the middle ages and younger man “son” in an off-hand manner. Also when the wait staff or manager of the morning breakfast facility would come to be he would suddenly change his style of speaking and act confused and demented always looking toward the black couple in a dependent manner.

It took me a few cycles of this unusual behavior for me to catch on that something was playing out in front of me, that the elderly man was in no way related at all to the black couple he had latched onto in this subtle manner. I then thought that I caught him craftily wangling out of the couple their room number verbally but acting as though this was already known to him. As the couple made preparations to leave he quietly signaled to the waitperson that he needed a bill and signed the couple’s room to it. I was flabbergasted at what I had witnessed. It was so subtle and slick I had to run quickly the sequence of almost sleight of hand progressive steps the elderly man had effected. The black couple had no idea that they had been taken advantage of and were paying for his bill.

He saw me peering owlishly and knowingly at him at the end of all this and there was a moment of realization on his face toward me of “uh oh he knows,” but I nodded with a subtle acknowledgment signaling I was not going to rat him out. He put on his nice corduroy sport coat, grasped his cane and out he went behind the black couple to the outside. I watched carefully as he did not enter their car but took the city bus that came in a few minutes.

So this morning the old man and sat next to each other and he very obliquely acknowledged to me his entire act saying basically a poor old man has got to do what he can do. In a very sideways manner as I told him that 90% of all the explosive growth in common area among the 3 RTP cities of Raleigh Durham, and Chapel Hill was new to me since I had left the Duke teaching and private practice orbit over 20 years before, he listed dozens of hotels that he “visited” in cycles to grift his breakfasts. I was constantly thinking of safe ways to ask him more details about himself and gradually learned by elimination that he did not live in a nursing home, did have a daughter and her family who helped him but that he lived in some very modest solo circumstance he would not elaborate fully.

Also, this second day of conversing with him and observing his now apparent act, I realized that he would act mildly demented and deferential and dependent upon the black couple that was his foils for a family whenever the hotel staff would be doing their waitperson duties nearby. It was also very subtle, but effective and had the desired effect upon the hotel staff of inducing them to take care of him, never suspecting that they were being “had” in an ingenious manner. This second day, the old man knew I was fully on to him. By this time I had revealed to him that I was a psychiatrist. I had told him that I always tried to make friends and talk with anyone I met and that I had been reared in a family that taught me to be open to strangers, and that “everyone has a story worth learning.” That further reassured him so he continued his act, suspending it to converse with me when the hotel staff was not around. All the while he would include the black couple in the converse with remarks that sound innocent such as “isn’t ‘that right son?”

I bid him adieu this morning, still not knowing his name knowing I had been in the presence in the master of a craft designed for survival in this new world and realizing I had stumbled upon a man who was making his way in a way I felt I likely would not have been able to come up with were in his shoes.

My Doctor in Singapore!

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My other blog ‘mentalhealthreformblog.com informed me that a site called “Doctor World” had started following me. I try to always look at such sites or blogs that follow my amateurish offerings, so I followed the notification’s link and found to my surprise that the Doctor World entity is located in Singapore.

Furthermore, it is an Internet-based medical doctor telemedicine site for service to patients. This surprised me greatly. Reading through the site showed that even I here in the USA could download an iOS or Android phone app and then start to receive services for non-serious medical maladies.

And the rates started at $15 per 15 minutes of consultation. Right inexpensive compared to American rates known for our high cost of medical services. There were other services listed such as come to your home doctor visit which was a little confusing as I inferred that this was likely restricted to just in Singapore and not to my home in North Carolina.

In any case on a humorous note, I can just see me from now on, stating on medical intake information forms that my physician is “Dr. So-and-So in Singapore. I can just imagine the stir that would cause in front office window medical secretaries’ world. “How do we get records from all the way across the Pacific Ocean? etc. “Can we call them on YOUR cell phone?” [to save their phone bills, for which I would not blame them. I am known at my various physicians’ offices for my wacky sense of humor, but I think this would be going too far and perhaps cost me future cheery hellos in my physicians’ offices and maybe lots of other informal courtesies. I can imagine being subtly shoved off the weight scale, the blood pressure being inflated incredibly tightly, the phlebotomist drawing my blood twice because “they all clotted in the first tubes.” Yeah, it could be BAD. Or my digital rectal exam having to be done twice, because “I couldn’t feel your prostate the first time and I know it is still in there.”

On a final note, I cannot for the life of me why this Singapore site is following my mental health reform blog. But I welcome all who do!

Advice to Young Psychiatrists, But Not From Me…

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In a recent opinion piece published October 4, 2019, in the freebie psychiatric periodical that most psychiatrists in the USA receive monthly, Psychiatric Times and its column “Couch in Crisis,” Dr. Allen Francis MD, penned a piece, “Advice to Young Psychiatrists From a Very Old One.”

I have chosen to include the entire column that he wrote because of its great advice in the form of 50 tips/recommendations to young psychiatrists. However, I think that its value goes beyond psychiatrists and is of similar value to all mental health professionals who see patients if one leaves out the tips that focus on entirely psychiatrist specific forms of practice and expertise such as prescribing medicines. These tips are very well thought out and of supreme value to promote good practice and ethics. So here goes including the blurb introduction of Dr. Frances. Enjoy and ponder.

Dr Frances is Professor Emeritus and former Chair, Department of Psychiatry, Duke University; Chair, DSM-IV Task Force. He is the author of Saving Normal and Essentials of Psychiatric Diagnosis. Twitter: @AllenFrancesMD.

I recently came across this compelling tweet: “An open question on mental health as a junior psychiatrist. What do you think I should learn and focus on to be a better doctor and advocate for my patients?”

Could there possibly be a better question for all people starting out in any field to ask themselves, and others, as they embark on their careers?

The 140-character limit imposed by Twitter forced me to offer only a brief reply containing five scant snippets of advice. This troubled me—his serious request deserves a more serious response.

Here it is—the 50 most important things I have learned in my 50 years studying psychiatry:

1. Your patients will be your best teachers.

2. No meeting with any patient is ever routine for them; so it should never be routine for you.

3. Focus on establishing a strong therapeutic alliance and healing relationship—the most important goal of any first session is the patient’s returning for a second.

4. Helping serious mental illness is very much harder, but also much more gratifying, than treating mild illness or the worried well.

5. Validate that your patients are currently trying to do their best, but also set a tone of future expectations they will find ways to change themselves, and their world, for the better.

6. Always inspire realistic hope and always reverse unrealistic demoralization.

7. Follow your patient, not your preconceived notions, a supervisor, or a manual.

8. There are no bad or boring patients, but there are some bad and boring doctors.

9. Be as empathic, as caring, as involved, and as alert for the tenth patient each day as for the first.

10.Never lose sight of the practical struggles the patient faces in the real world and try to help them find practical solutions.

11. Don’t be shy about giving advice when advice is needed.

12. Don’t give advice when the patient can find their own way.

13. Include family, friends, other informants, and potential co-therapists whenever possible.

14. Be open ended enough in your questions to let patients tell their life stories; structured enough in your questions to get the specific information you need.

15. Try to create rare magic moments—things you say to patients that they will remember always and use in changing their lives.

16. Take your time and be careful—small mistakes can have major consequences.

17. Know the patient, not just the diagnosis.

18. Diagnosis should almost always be written in pencil—especially in the young and the old. Always err on the side of underdiagnosis—it is easy to later up-diagnose; almost impossible to erase a diagnostic error that can haunt the patient for life.

19. Use DSM, but don’t worship it. I equally distrust clinicians who do not know DSM and those who only know DSM.

20. Educate patients about their symptoms, diagnosis, course, the risks and benefits of plausible treatments.

21. Negotiate, don’t dictate, the treatment plan: allow the patient to pick whichever plausible treatment most suits them—with awareness that no one size fits all.

22. Do not join the bandwagon of diagnostic fads. Whenever everyone seems to suddenly have a diagnosis, it is surely being way overdone (eg ADHD, autism, bipolar disorder).

23. Watchful waiting is the best treatment whenever there is doubt or the symptoms are mild.

24. Placebo is best medicine ever invented and responsible for most of what appears to be “drug effect” when milder symptoms improve.

25. Severe illness is usually easy to diagnose reliably and always requires urgent intervention.

26. Always rule out the real possibility that symptoms are caused by medications, alcohol, street drugs, or medical illness.

27. Don’t be a careless “pill-pusher,” but do understand the great value of medications used wisely for proper indications.

28.  Know the risks, not just the benefits, of medications

29. Educate your patients on adverse effects, complications, and withdrawal symptoms.

30. Be alert to, and try to avoid, drug-drug interactions and include in your consideration all the many non-psychiatric medications the patient is likely to be taking.

31. Start low and go slow especially with young and old patients.

32. De-prescribing requires much more skill than prescribing—learn it well and apply it often to reduce the harms caused by over-medication.

33. Avoid the current tendency toward irrational poly-polypharmacy

34. Learn and use three treatments that are very effective, but relatively harder to use and thus very underutilized: lithium, clozapine, and ECT.

35. Never meet with drug sales people; ignore all drug company marketing; do not believe any study that was funded by a drug company; and educate patients to be skeptical of direct-to-consumer drug ads that misleadingly promote disease mongering.

36. Read the scientific literature with great skepticism and awareness that most studies do not replicate, positive results are always exaggerated, and negative results are usually buried. Do not be wowed by genetic findings—so far, they have flopped in finding causes and have no place in planning treatments.

37. Uncertainty sure beats false certainty. Accept its inevitability;’ dont jump to conclusions; and help your patients deal with the anxiety it provokes.

38. Learn statistics, especially as it applies to medical decision making, and think probabalistically, not in rigid yes/no categories.

39. Have a rich, varied, and satisfying personal life.

40. Embark on a personal psychotherapy to help understand yourself better, solve any problems you may have, correct biases based on your personality and experiences, and discover what it is like to be a patient.

41. Learn from your supervisors, but don’t follow them slavishly.

42. Read widely, especially the great classic novels, and see psychologically astute movies and plays.

43. Read history and try to deduce its recurring patterns.

44. Travel the world to understand the wide diversity of human experience.

45. Do not impose your cultural biases, your religious beliefs (or non-beliefs., or your personal values on your patients).

46. For every complex question, there is a simple, reductionistic answer—and it’s wrong. Don’t expect or believe simple answers to complex questions, such as “What causes mental illness and how best to treat it?”

47. Instead, do have a well-rounded, four-dimensional bio/psycho/social/spiritual approach to understanding mental disorders and selecting treatments for them.

48. Be a vocal advocate for our patients. We must do all in our power to reverse the shameless neglect of the severely ill that has relegated 600,000 of them to jail or homelessness.

49. Be yourself—and grow into an even better version of yourself as you enjoy the special privilege of helping others also better themselves.

50. FIRST, DO NO HARM!

Is Fortnite Addicting?

~ Frank ~ Leave a comment

WGN in Chicago had a news piece over the weekend that I heartily and snickeringly commend to the reader, “‘‘Addictive as cocaine’: Parents sue Fortnite creators.” Now we have the old saw and trope of a video game being addictive. Some parents in the Montreal Canada area, are now suing Epic Games with that assignation of guild in mind. (And I thought all Canadians were really polite!

I remember as the oldster in me likes to say, when very early games were judged addicting by the moralilsts, including Pong of all things. But back then in the early 1970’s that was basically all that was to be had and played with.

Pong one of the earliest video games

I supppose if you define gaming addiction by the amount of time its sucks out of the player, and how many real life tasks and roles it causes failure in, they can be addicting.

One of the comical things coming out of this story is that the law firm driving the suit, noted in a press release that the game released dopamine like cocaine does in the brains of players. As my son and all his friends, would say in mocking sarcasm, “Well YEAH!”So does watching pro football on tv, would say my spokesperson son of 19 years age and wisdom based on years of gaming. He noted that he does not gamble, do compulsive things, ignore his role in life, fall behind in his studies, waste away, etc.

He did have the final say on this latest tempest in a teacup. He and his friends over the weekend, decided the only way the game could be truly addictive like cocaine, was “if they sprinkled cocaine on the controller.”

Nuff’ said.

F

Fears of The Joker Movie

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The movie “The Joker” starring actor Joaquin Phoenix opened actually last night at the time of this writing (Friday, Oct. 4, 2019). It opened nationally for regular time movie-goers today. And before it opened there was a national flap arising among the nervous types and realistic worriers about the potential effects of this movie.

I want to just reproduce, I hope with appropriate credits for a presentative piece that is and has been appearing in the media nationally warning about this movie. It is of course as referenced in the below article that I have included a URL link for, prompted by the fears that this could set off copycat to the Aurora CO movie shooting by James Holmes at the showing of the Batman movie with a Joker character, “Batman: A Dark Night Arising.” So please read, use the URL link if you wish to go the original article then continue below:

The Joker’ raises concerns about mass shootings; Hosted by Madeleine Brand Oct. 03, 2019 HOLLYWOOD of the KCRW website:

A scene from “The Joker.”

A scene from “The Joker.”Photo credit: Warner Bros

“The Joker,” starring Joaquin Phoenix, opens on Friday. It’s been hailed as one of the best movies of the year, and there’s Oscar buzz around it. 

But in an era of frequent mass shootings, critics (including families who’ve lost loved ones to gun violence) say the sympathetic Joker fits the profile of many mass shooters. He’s lonely, he feels rejected by society, and he picks up a gun to make a public point. 

The film isn’t showing in a theater in Aurora, Colorado, where in 2012 a gunman killed 12 people during a screening of another Batman-related movie, “The Dark Knight Rises.” The Joker isn’t in that movie. 

Law enforcement and the FBI say they were tipped off to a threat of a copycat shooter at an unspecified theater. Some theaters, including in LA, are also beefing security and telling fans they can’t wear any costumes.

At the start of my psychiatric career way back after I finished general psychiatry training and two fellowships, video games started to come out and well as Dungeons and Dragons board game. After full-blown computer graphics hit at the introduction of Windows 95, the new iMac computers in the mid-1990’s, as the video games became more colorful and had decent graphics far beyond the incredibly crude games like Pong and text-based games, the more violent games came out to satisfy the aggressive impulses of teenage boys.

And “lament was heard across the land” to paraphrase some Old Testament warning. The media went nuts over the supposed harmful effects of the early and later (i.e., ever since) shoot’em up games, gory monster and zombie games and all the other genres and game franchises that had non stop violence, dismemberment, blood, gore, splatter bones and dissected spinal cords to name a few. And I cannot get into this subject without mentioning the greatly reviled game franchise, “Grand Theft Auto.” Without which my teenage son now 19, would go ballistic if it were taken off the market…

Back to many years ago. As the video game craze took over and played into a massive market, teenage boys, it became clear this was NOT going to disappear like the overly liberal hair on fire types, AND the right-leaning conservative and especially fundamentalist moralist types wished so fervently. I remember back then when the liberal enclaves thought that such video games would spawn waves of mass murderers as the early Arkansas school shootings had happened by them. Teen boys would be getting guns, pistols and long rifles from devious sources and shooting anybody in sight they were mad at, teachers, parents, their bullies at school, and the guy who had stolen their girlfriend. The fundamentalist right-wingers thought surely the souls of American teenage boys were at risk especially if any of the games had The Devil, Mr. Satan himself in them enchanting players to go out and kill and claim souls for him or whatever.

Like any therapist in mental health, I saw lots of boy gamers. Nobody I emphasize, none of them ever transferred their gaming entertainment reality from the gaming machine and controller at home to shooting somebody in the real world. And that is the nubbin of the issue. The hair on fire types of any political or moral-religious persuasion tends to forget that almost all gamers in my view, are able to keep a solid perceptual and experiential boundary between what is real and what is not real. Games are not real, they are fictional entertainment. Even my patients ranging from neurotics to very troubled kids did not fail to be able to exercise this essential function of the ego, a concept and capability we in psychiatry and mental health call, “reality testing.” That is the ability to distinguish between what is real and what is not real.

This function tends to be diminished or lost in the state of psychosis. When one is hallucinating, one often cannot tell for instance if a voice coming out of the tv, or on the street somewhere, is real or not. Some teens who are psychotic also lose this ability. There are a few cases, but a very minuscule number, of teens who have gotten “lost,” in graphic violent video games in the past 30 or so years that they have been with us. They have taken the stories, legends, narratives, and themes too much to heart, make them a reigning guidance system (if I can coin a term/concept) and committed crimes. They are very very few in truth. Perhaps at most, a few dozen since the phenomenon of mass crimes and shootings have started to be a feature of our national life since Charles Whitman in 1966? at the University of Texas at Austin Bell Tower. I always use that as the start of all this since it was the first one on national tv and for me the first event of its kind in my memory.

I have only seen forensically one teen/young adult who committed a crime that was even peripherally to his involvement with his loner immersion into video games. Forensic psychiatrists with fellowships in that subspecialty which I do not have, and who see such mass crime patients as part of their practices very likely have seen somewhat more, but they are still very rare birds.

So years ago, for the local paper where I had trained and practiced for 20 years. I went out on a limb, or so it seemed in those days with the mass media hysteria starting for the first time about the dangers of violent video games. I had only daughters back then. The main complaint they had back then was that their boyfriends were starting to spend too much time playing video games with their male friends and not dating the daughters enough! But none of their boyfriends committed any crimes. And in chatting with them before or after the dates as I always did, the boys did not show any proclivities toward such and viewed video games with great enthusiasm as they described their games, their point scores, their “winning,” and newfound prowess. And they all talked of a growing telltale marketing and economic phenomenon. They were all saving up their part-time job earnings to buy MORE video games. I realized then that this new entertainment form was going to be a massive moneymaker, even more than it was back then.

My article on video games back then tried to reassure the worriers of all stripes. I talked of teen boys seeing it all as just entertainment. I expressed faith in their abilities to keep the unreality of gaming separate from the reality of everyday life. I talked of my own sampling experiences back then of gaming, trying out a daughter’s boyfriend’s game machine he brought over for me to try out. My daughters and wife were aghast…I later bought one of the earliest machines and proceeded up through the Playstation 3, PSP3 machine. I learned that as an adult, the games quickly became “old,” to me and I habituated to them fairly soon, tired of them and did not show the teen boy continuing interest and some would say, “addiction.” (I grant that some can become overinvolved in gaming but that is another discussion for another post.)

I remember that I received in the local newspaper a number of irate letters castigating my opinion paper. I was a bad or naive psychiatrist. My training program had erred in letting me out to practice. My soul was in danger. One writer wondered if I had been “saved.” A couple of my daughters’ boyfriends followed all this out of curiosity as I had quoted them with permission and notice in the article and they were greatly tickled over the letters to the editor. They also had many teen sarcastic jokes and takes on the whole affair. It was great.

On another note, my 19-year-old son, long a gamer, has not shown any bad proclivities from his gaming except one. He has learned it can make him procrastinate and be late in approaching school homework in past years. He almost had a few academic disasters in high school. That was useful as he learned to master all that mess and now has the science of “time management” in hand, a benefit in my mind resulting from “gaming.” And yes he spends a bit too much money on new games, but it is better than spending it on drugs. And he and his many friends who congregate in our basement gaming and huge computer networking lab, are not secretive or hiding Dark Net exploits. They are forever dragging down there to game with them, and listen to sophomoric humor shows on YouTube that leaves me gasping for breath after my laughter subsides.

The final sentiment-observation in all this. My son and his gang went last night to see the early screening of The Joker movie at some ungodly hour, perhaps midnight. It was a special occasion on two accounts. First, they are all diehard Batman and Joker aficionados. So they went decked out in the best Batman and Joker clothing, Tee-shirts, some had masks (which they had to take off before the theater would let them in; they understood why but were stilled insulted, affronted and miffed since all their masks were very “cool.” Second, the oldest in this gang of friends who have known each other going on 9 years was celebrating his 21st birthday on that very night! They all thought this was the very best way to celebrate, not going out for his first beer, etc. The movie was IT. They had a great time and came right home after it was over, to wake me up to regale me with the details of the movie from start to finish. That took an hour. I was blotto but now I don’t have to see the movie, since I know it for the most part, from start to finish. Eight guys worth of spoilers after 2 a. m. But I will see it with my son for his safe and wishes for Batman-Joker father-son bonding time.

Then they all adjourned to the kitchen so they could raid the refrigerator, eat all our leftovers and massive snacks my wife had cooked for them and relive the movie once again in between or with full mouths of food.