Customer Reviews

Danger to Self: On the Front Line with an ER Psychiatrist

5 star:		(14)
4 star:		(4)
3 star:		(0)
2 star:		(2)
1 star:		(0)

 

 

Dr. Paul Linde, a psychiatrist at SF General Hospital, provides a fascinating glimpse into the mental health issues, patients, and practitioners of an urban psychiatric emergency room in DANGER TO SELF. Loaded with interesting medical information, Linde's first person narrative is presented as a series of stories that are highly readable and convey the various roles asked of psych emergency doctors and nurses (e.g., jailor, jury, or clairvoyant). Written for the educated lay reader, the book not only gives a sense of the atmosphere and problems encountered in psych emergency, but also provides a context in which to understand the complex decisions and value judgments that acute care psychiatrists must make. Dr. Linde has a good grasp of the historical and legal contexts in which decisions need to be made, e.g., how does one protect an individual's civil liberties while maintaining the public's need for safety? When is it morally justifiable to revoke a person's right to freedom? Analysis of these issues and others offer much for the reader to think about further.

Dr. Linde writes in the Preface that his intention is to humanize psychiatrists, other mental health professionals, patients, and their loved ones and that it is okay at times to laugh, to swear, to self-reveal, and to cry with patients. Linde's stories convey the humanity and compassion of the doctor-patient relationship in a truly engaging and engrossing manner. In my opinion, Dr. Linde has clearly succeeded.

As a fellow traveler in the trenches of public sector emergency psychiatric services, I found Dr. Linde's book very evocative. He captured the emotional tone well with its mix of sadness, humor, horror and ambiguity. I appreciated his exploration of the training issues and deeper policy issues that underlie the complexities of psychiatric care.
The book is a good companion to Fuller Torrey's new book about the unintended consequences of laws designed to protect the rights of the mentally ill. I recommend this book highly for those who work with the severely and persistently mentally ill. For those who love the caretakers and wonder what they do all day, this book sheds light on their day to day experience.

This is not quite an entertainment, so those who look for "hot stories about crazy people" will probably be a little disappointed. The author does not display people in distress like they are in a human circus; he tells their stories in a calm and compassionate manner with respect for who they are and where they come from. Those who look for serious discussions of particular disorders or medications, or health care system will also be disappointed. This is not a textbook or a diagnostic manual.
Psych ER is a highly stressful environment with insanity pushed to its limits; patients represent a danger to self, or others, and to keep oneself not just calm and professional but respectful and sensitive to others' pain is a gift.
I like how Dr. Linde places main focus on his patients and the hospital/city environment, not himself; this allows seeing unfolding dramatic stories in a context of a bigger picture of current medical/urban reality. At the same time there is a strong author's presence in this book, and his personality gradually reveals itself through little phrases, observations, and humor.
I enjoyed every story and I highly recommend this book to those who are in the process of becoming mental health professionals or just curious what it is like to be a psych doctor in ER.

I find it hard to believe that everyone before me has rated this book as 5 stars. I have to admit that, having worked in the mental health field for a number of years, I seem to read a lot of books in this genre. Most tell the stories of the doctors and the people they help in a clear, concise, and compelling way. While reading this book, however, I felt like I was back in school, listening to a lecture. There were just not enough STORIES in it. I wish he had spent more time relating situations and patients that he had come across in his practice rather than such technical information. To be honest, I couldn't wait to finish it so that I could move on to another book - any other book.

XXXXX

"On the surface, this book demonstrates the nature of my work as a psychiatrist in a wide variety of settings , but mostly in the psychiatric emergency room at SFGH [San Francisco General Hospital]. It shows the kind of tasks given to me, what I do, how I talk to patients, how I think, and how I make decisions that can best be described as knotty, enigmatic, and almost never routine. When all is said and done, society is paying me to exercise my best professional judgement in trying to solve seemingly insoluble problems. My decisions are made in a financially deprived and pressurized environment, often with incomplete data, and the tasks are rife with ethical dilemmas. Though I am...obliged to be an able and compassionate colleague, supervisor, teacher, and practitioner, I mostly get paid to make good decisions as a proxy for society as a whole...

As you read this book, you will no doubt see the setting of psych emergency for what it can be: loud, chaotic, smelly, messy, and dangerous, among other things. And you will sense the tension [or stress!!] inherent in the work. But you will sense the redeeming essence of the work: the moment-to-moment relationship between doctor and patient...

While [this] book is part memoir, part primer, and part commentary, what I am most interested in is documenting my experiences and those of my patients...This book is intended to humanize psychiatrists, other metal health [workers], patients, and their loved ones."

The above comes from the preface of this intriguing book by Paul Linde. Linde Is Clinical Professor of Psychiatry in the School of Medicine, University of California, San Francisco. He is also an author.

The fact is what most people know about the psychiatric emergency room (ER) is that they don't what to be there. This book details that there is quite a bit more to "psych emergency."

This is a gripping and, at times, unsettling account of an ER psychiatrist. It is VERY reality-based and illustrates the complexities of the job. In each chapter, Linde plays a slightly different role. (That is, this job is definitely not routine!!)

While Linde's own experiences practising psychiatry make for an interesting read, for me, it's the descriptions of his patients that make this book truly compelling.

People from all different backgrounds pass through the psych ER. There are people such as addicts, trauma survivors, psychotics, and many high-functioning people who are simply "having one of the worst days of their lives."

Linde also gives some historical, legal, theoretical, ethical, moral pharmacological, and anatomical information, where appropriate.

Finally, one thing becomes clear as you read this book. Linde is a rare breed of doctor, that is, a compassionate doctor.

In conclusion, this is a mesmerizing account of the life of an ER psychiatrist. This book will open your eyes to the important work these people do!!!

(first published 2010; acknowledgements; preface; 10 chapters; epilogue; main narrative 235 pages; notes; references)

<<Stephen Pletko, London, Ontario, Canada>>

XXXXX

Its the blend of compassion, self possession and great storytelling that makes this such a moving and fantastic read. Paul Linde made me feel like the secrets of the universe are out there, and I'd have them if only I'd chosen to become a psych doc in the ER! I'm studying the components of great narrative non-fiction right now and this book has them all. The information and patient stories seem to take over only because the writing is so good, the narrator so unflinching and trustworthy and known to us. Great book if your interested in the subject matter or are in the field. Great book if you, like me, aren't. I love non-fiction that inspires and makes you wish you could jump in.

In this provocative first-person account, DANGER TO SELF, psychiatrist Paul Linde takes us to the troubling front lines of America's mental healthcare crisis. We see the devastation of meth, and the results of a failing safety net where insurers care far more about their profits than the lives of desperately ill patients. So much is demanded of Dr. Linde and his colleagues that it's hard to imagine how they survive, but they go back each day and save lives in the most challenging circumstances. DANGER TO SELF exposes one of the darkest sides of the nation's healthcare debacle. With one in three people experiencing some form of mental illness in their lifetimes, this is a story that needs to be told. Linde waves a red flag that can't be ignored.

Kemble Scott, bestselling author of The Sower and SoMa

Linde's book gives us a window into emergency psychiatric care. He works at a psych emergency room, and sees an incredible array of mental illness and drug abusing patients. The writer paints us a picture of this setting, where most would not dare to tread. The portrayals of the patients are excellent, and there is some humor and also genuine caring for these people, who he is seeing "on the worst day of their life." I recommend for anyone who works in the world of psych, and also anyone curious about it.

The author is more than a Clinical Professor of Psychiatry in the School of Medicine at the University of California, San Francisco (UCSF)... he is a person who prides himself on being an "everyman" despite his educational credentials. He unabashedly wears his heart on his sleeve... in an arena where many doctors, nurses, and administrators have become too hardened by the sad... bizarre... and frightening parade of the human condition that they witness day in and day out. Paul Linde is a doctor in the "PSYCH EMERGENCY ROOM" at UCSF... and with this emotion-dripping memoir takes the reader by the hand through his early days in training through his current veteran status. Dr. Linde quotes famous Doctor's... mental patients turned writers... writers turned mental patients... personal mentors... and even the Grateful Dead. But what comes shining through... regardless of the situation or time stamp in his life... is his inner soul... his caring and desire... to do the right thing... his empathy... towards fellow human beings... regardless of their stature... foul smell... or hazard to themselves or others... this is the beacon of light... that will continually shine on the reader... regardless of how dark the human tragedy is displayed on these pages.

The hub that all decisions in Doctor Linde's world revolve around... whether he wants them to or not is CALIFORNIA'S WELFARE AND INSTITUTIONS CODE SECTION *5150* WHICH "PROVIDES FOR THE INVOLUNTARY DETAINMENT OF AN INDIVIDUAL FOR UP TO SEVENTY-TWO HOURS, SO THAT THE PERSON CAN UNDERGO PSYCHIATRIC EVALUATION TO DETERMINE WHETHER HE OR SHE IS A DANGER TO SELF OR OTHERS OR IS GRAVELY DISABLED. THE LAYPERSON CAN EASILY UNDERSTAND THE CONCEPT OF BEING SUICIDAL OR HOMICIDAL. BUT GRAVELY DISABLED? TECHNICALLY IT MEANS THAT A PERSON IS UNABLE TO PROVIDE FOOD, CLOTHING, AND SHELTER FOR HIMSELF OR HERSELF BECAUSE OF A PSYCHIATRIC ILLNESS."
The ten chapters plus the Preface and Epilogue... are almost like gripping one act plays encompassing parts of life that you can only pray that you or a loved one never go through. All the while... Dr. Linde educates himself and the reader. He has to deal with life and death... lunacy... and scamming alcoholics and drug addicts all day... every day. Are they really hallucinating... or are they acting in order to get a clean bed for twenty-four to seventy-two hours? Did they really want to commit suicide... and if they did or didn't... are they really going to try again if Linde releases them? If Doctor Linde is wrong... and believe me... there are times he is wrong... and then... there are deadly repercussions. The reader will feel what the Doctor feels when his heart has voted along with his brain in potential life and death situations.

One of my favorite chapters is chapter two "THE ROOKIE: BRUNO'S MAN DOWN" which covers part of Linde's early training days when he had a very brief limited amount of time to interview prisoner's who might be suicidal. As he made his way to the pre-ordained cells... there were unabated taunting and screaming from every cell on every floor... but when one of the interviewee's attempted to take his own life... the change in the entire prison population was like the sea after a great storm. The spreading grief engulfed the inmates in such a way that even an army of prison guards couldn't have willfully beat it into them.

The reader will be left with a unique feeling towards the doctor and the life he faces on a daily basis. The only way I can describe it... is to share some educational information I received from this book:

"RECENT ADVANCES IN THE NEUROSCIENCES CONFIRM THAT THE EXPERIENCE OF DEEP EMPATHY, WITH ITS ASSOCIATED GLOW OF EUPHORIA, SHARES SOME FINAL COMMON NEUROBIOLOGICAL PLEASURE PATHWAYS WITH NARCOTICS, ALCOHOL, AND CIGARETTES. IN OTHER WORDS, EMPATHY IS ADDICTIVE AND PLEASURABLE."

Paul Linde sees patients in the San Francisco General Hospital Psychiatric Emergency Service and is also a clinical professor of psychiatry at the University of California. In his candid and moving book, "Danger to Self: On the Front Line with an ER Psychiatrist," Linde touches on his early training in "psychotherapy boot camp," during which he learned to "go where the patient leads you." He acknowledges that his job can be difficult and frustrating at times, but Linde loves the adrenaline rush of evaluating men and women--some walk in voluntarily, and others are brought in by family or the police--to determine whether they pose a danger to themselves or others or are "gravely disabled because of a psychiatric illness." Many of these individuals are "already on edge, their emotions intensified and jangled." They may be addled by drugs and/or alcohol, suicidal, or display symptoms of such illnesses as bipolar disorder or schizophrenia. Occasionally, people who are desperate for "three hots and a cot" seek a place to eat and sleep as an alternative to life on the streets. The psychiatrist must decide whether to admit the patient or send him home, with or without a prescription and a plan for further treatment.

Dr. Linde has reams of paperwork to fill out and must constantly be on top of the mental health laws that govern the treatment of psychiatric patients. Sometimes, it would help to be clairvoyant ("the crystal ball standard"). Is the young patient who promises not to make another attempt on his life telling the truth, or will he say anything in order to be released so he can try again? Linde and his staff have to be ready for anything; this is definitely not an occupation for the faint of heart. They see homeless men who have not bathed in months, meth addicts in the grip of vivid hallucinations, and women who have overdosed on pills. Dr. Linde uses humor as a buffer to help get through the rough spots, calling himself "one part bouncer, one part traffic cop, one part standup comedian, and one part maitre d'." He is painfully honest about his mistakes and uncertainties, admitting that psychiatry can be more art than science. In addition, he cites a variety of sources, including psychiatrists and authors R. D. Laing, Kay Jamison, Viktor Frankl, Peter Kramer, and Thomas Szasz, to put his profession in a historical, medical, sociological, political, and philosophical context. The author also discusses the controversial issue of deinstitutionalization, which empited many state hospitals but did not provide enough community mental health services to meet the needs of ex-patients. This policy led to an army of "ambulatory schizophrenics" living rough on the streets of American cities. Linde poses the thorny question of how much autonomy society should grant an individual who is in desperate need of psychiatric treatement and social services.

"Danger to Self" is a thoughtful work by an intelligent and compassionate man who knows that he cannot come close to solving everyone's problems. However, Linde realizes that a sense of perspective, a strong support system, and a realistic idea of what is doable can go a long way towards controlling his stress level and avoiding burnout. He is proud of his efforts to put "a human face on the system, on the institution, of mitigating the legal, financial, political, and bureaucratic constraints" that can undermine even the most idealistic doctor. How does Linde approach his patients? "My heart, and not my words, provides the first and strongest line of defense...." He is not afraid to empathize with the individuals who place their trust in him. In a country where the severely mentally ill have been maligned and marginalized for so many years, it is refreshing to read this honest, sometimes distressing, but always illuminating look at one man's effort to light a candle in the darkness.