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Advice from Dr. Steingard

sandy_steingard_headshot-200Dr. Steingard was asked to give the commencement address for Goddard College's masters program in psychology and counseling. This is what she said.

How many psychiatrists does it take to screw in a light bulb? The classic answer is that the bulb needs to want to change. This is old but still true. Coming to grips with our limitations is a topic I will return to once I dispense with the humor.

And finally, we come to the classic part of the commencement speech – advice to the newbies:

1) Hold Your Theories Lightly

I know you have just worked very hard to accumulate expertise. The problem, however, is that our fields – and I include myself in this – are audacious in their attempt to offer help while we still are so much in the dark about so many things. It is an easy trap to deal with the uncertainty of clinical work by enclosing ourselves in theories. We then see the world from the perspective of our particular theory and we allow our observations to only confirm what we already know. We get blinded to observations that challenge our world view of "how things are."

This has happened to me. No one should really come to me for advice because in truth I have been wrong so many times in my career. And while I am open to the possibility that this is perhaps reflective of a personal problem, I suspect I am not alone. We all benefit from the work of our intellectual forefathers – or foremothers – but we also belong to professions that have made many, many mistakes. For me, the only honest position is one of humility.

Holding that humility in balance with expertise and training is no easy task. For sure, you have learned something. It was not all for naught. But do not rely on your diploma to address your own needs for respect and validation at the expense of those we try to serve. For although psychiatry might own the lion’s share of potential to harm, we can all do harm and the advice – First Do No Harm – can aptly apply to all of us.
2) Do Not Lose Intellectual Rigor

Goddard has a fine tradition in the so-called alternative world. I suspect you have been encouraged to challenge convention. I support you in this. At the same time, I continue to value reason and critical thought. When I label myself and the work I am doing, I call myself a critical psychiatrist. My writing is geared to a critical evaluation of psychiatric diagnosis and treatment. Those of us who choose to question convention are nevertheless as obligated to maintain rigor as anyone else.

Read Daniel Kahnemann's book, Thinking, Fast and Slow. He is a Nobel-prize-winning cognitive psychologist and his book is about the remarkable power of intuitive thinking but also about how it can lead us astray. Many of us who are drawn to this field have good intuitions that we need to use every day. The evidence base only gets us so far. But we have an obligation to actively question and look for our own blind spots.
3) Give Your Heart, But Protect It

I am a student of Finnish Open Dialogue. Jaakko Seikkula and David Trimble wrote a paper with the title "Dialogue as the Embodiment of Love." Honestly, for me this notion is both moving but also a bit uncomfortable. We understandably and appropriately need to be careful about our boundaries. But I also understand what they mean by this.

A couple of weeks ago, I went to meet a patient in the waiting room. I have known him for 20 years. He used to refuse to come to the office and even to talk to me. I would go to his home to see him. I have committed him to hospitals. Suffice it to say, he is doing much better. Despite his struggles, he has managed to be married for 20 years and to raise 2 kids. On this day his now teen-age son was with him in the waiting room. He turn to his son and said, "This is my friend, uh, my doctor."

It is the relationships, the connections, we have to offer that may be most helpful. In the psychotherapy outcomes literature, only 15% of the variance of the outcome is accounted for by the particular technique one uses. Most of the variance is attributed to the therapeutic alliance and the qualities the person brings to the treatment. So we make connections. And this is fundamentally a paradox. For we are walking in the hinter land between professional and friend. This is not easy and it is often confusing. I have no easy answer to this other than to recommend that we at least acknowledge it.

But when you give your heart, it can be wounded. This can be very draining work. You need to take care of your self. A way to stay out of trouble is to be honest about your limitations. We can help the light bulb to change. We may even have ways to increase the light bulb's desire to change. But in our world, in the end, the light bulb indeed does the changing.

We all need validation and when the bulb doesn't change, we have a tendency to blame. Another aspect of Open Dialogue that appeals to me is that all conversations about the person are done in the person's presence. I was at a conference with the Finns and someone asked if they always adhered to this and a senior psychiatrist said that they mostly do and she commented that she notices that when they begin to talk without the person present that the talk tended to veer into a negative and blaming tone. You may not operate in that model but you can think that way: talk about a person as if that person was present with you.

When I was a resident I worked in a VA hospital. We some times saw some very scary and angry guys. A senior resident once told me: if you are afraid to be in the room with someone, open the door, if you are afraid to be inside the room, talk in the hall, if you are afraid to talk in the hall alone, have someone stand with you. I am kind of a wuss. Those word stayed with me. I bring this up not so much to talk about dangerousness but to talk about acknowledging one's limitations. By not thinking that I had to be someone who I was not, I could say to someone without rancor or blame, I am not able to be with you right now.

I once read that one secret of happiness is to be of service and to express gratitude. Although we are not laborers, this work takes a different kind of toll. But we are also privileged in being able to be of service. We are privileged to be part of people's lives in the darkest times. This is a choice we made, not something that was imposed on us. Try to remember that on the tougher days.

Six Core Strategies to Reduce the Use of Seclusion and Restraint

Six-Core-Strategya-2The first in a series of articles on this project

The Vermont Cooperative for Practice Improvement and Innovation (VCPI) is partnering with the Vermont Department of Mental Health to lead a major practice improvement initiative aimed at reducing Emergency Intervention Procedures (EIP) – such as seclusion and restraint - in Vermont hospitals, specifically the three hospitals licensed as Level I facilities to replace the state hospital. This important initiative has been supported by advocates statewide and utilizes “The Six Core Strategies”, an evidence-based clinical model designed for use by institutions providing mental health treatment to adults admitted to inpatient or residential settings. Kevin Huckshorn, RN, MSN, CADC, ICRC - Director for the Delaware Division of Substance Abuse and Mental Health (DSAMH) and an international thought leader on recovery oriented mental health and substance use treatment- has been the leader in Six Core Strategy implementation at SAMSHA and she and her team have been invited to Vermont to conduct the project. The Six Core Strategies have been guiding state and private hospitals and agencies in the US and abroad since 2003. . The Six Core Strategies outline a best-practices approach by highlighting the need for organizational change, data-informed practices, workforce development, and consideration of consumers’ roles in their own care.

VCPI will be working in partnership with DMH, Kevin and her team, participating hospitals and other stakeholders - including the EIP Steering Committee - to provide overall facilitation of the project as well as specific technical assistance and implementation support VCPI will have a critical role in structuring the implementation of the practice as a system-wide partnership to engage in a performance improvement project that will build capacity within the Vermont system to support sustainability of the Six Core Strategies. VCPI will commence initial engagement work with hospital implementation teams at the three Level I hospitals - Brattleboro Retreat, Rutland Medical Center and The Vermont Psychiatric Hospital - in July. Other community hospitals that provide psychiatric acute care services are also welcome to participate in this project. For more information, please contact Sarah Squirrell, Executive Director of VCPI, at

Practice Guidelines for Video Conferencing – Telemental Health

The American Telemedicine Association (ATA), with members from from thoughout the US and Internationally, is the principal organization bringing together telemedicine pracitioners, healthcare institutions, vendor and others involved in providing remote healthcare using telecommunications. ATA has embarked on a effort establish practice guidelines and technical standards for telemedicine to help advance the science and to assure the uniform quality of service to patients.

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Telemental Health Comparison

This independent telemental health technology comparison site was created to help mental health providers quickly identify the best technology for their online therapy practice or network. From HIPAA compliant video platforms to encrypted email, or therapy Apps, you'll quickly identify the latest mental health technologies available in an unbiased comparison.

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Intentional Peer Support

Boston University Psych Research Center

The Boston University's Psych Research Center - run by the world renowned Kim T. Mueser. The Center is a research, training, and service organization dedicated to improving the lives of persons who have psychiatric disabilities. Dr. Mueser previously of Dartmouth was a valuable consultant for the Vermont Clinical Practice Advisory Panel.

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International Society for Psychological and Social Approaches to Psychosis

ISPS is and international organization promoting psychotherapy psychological treatments for persons with psychosis. They are committed to advancing education, training and knowledge of mental health professionals in the treatment and prevention of psychotic mental disorders.

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UCLA Psych Rehab, Robert Paul Liberman, MD

The mission of the Psychiatric Rehabilitation Consultants (PRC) is to distribute clinical tools and services that enable practitioners to help consumers recover from serious and persistent mental illness. We recommend utilizing their "publications" page for references and articles related to recovery.

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WRAP – Mary Ellen Copeland

The Wellness Recovery Action Plan, or WRAP, is an evidence-based practice that is used worldwide by people who are dealing with mental health challenges as well as medical conditions. Diabetes, weight gain, pain management, addictions, smoking, and trauma are just some of the many life challenges that can benefit from WRAP. WRAP can also be used as a framework to guide relationships in peer support, recovery groups, agencies and organizations.

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Center for Excellence

Do You Know Someone Who Has Experienced Trauma

Brief one page overview of trauma and its affects and impact on those we may know. A simple informational reference related to trauma, it effects and healthy and unhealthy coping strategies.

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Changing the Course of Schizophrenia Through Early Detection and Intervention

An excellent article related to the emerging understanding of schizophrenia and an innovative care model developed for individuals with first-episode psychosis that aims to foster recovery and prevent disability. This model maintains that effective treatment targeting the early stages of illness has the greatest potential to limit the progression of the illness and maximize achievement of age-appropriate advances in social development, education, and functioning in the workplace.

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The Protective Factors Framework

Five Protective Factors are the foundation of the Strengthening Families Approach; parental resilience, social connections, concrete support in times of need, knowledge of parenting and child development, and social and emotional competence of children. A brief overview and description of these protective factors.

Sequential Intercept Model

Developed by Mark R. Munetz, MD, and Patricia A. Griffin, PhD, the Sequential Intercept Model provides a conceptual framework for communities to organize targeted strategies for justice-involved individuals with serious mental illness.

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