Borders, Belonging, and Betrayals: A Poetic Conversation Among a Palestinian Israeli Psychologist, an Italian Canadian Psychiatrist, and a Canadian United Church Pastor in a Time of War

Winter 2024 • Volume 5, Issue 1
THE E-MAGAZINE OF THE WASHINGTON PSYCHIATRIC SOCIETY

Photo on cover by Joseph R. Silvio, M.D.
Dr. Silvio desribes the photo:
The brown headed nuthatch is endemic to
the Eastern Shore, and especially on the
Chincoteague Wildlife Refuge. When the
pine seeds are ready to fall out of pine cones,
the brown headed nuthatches flock to feed,
often hanging upside down on the pine
cones to pull the seeds free.
Photo on back inside cover by Arsinée
Donoyan. Arsinée describes the photo:
Fleming Windmill
A landmark in the Borough of LaSalle facing
Lake Saint-Louis, it was built in 1827 by Miller
Fleming (Québec, Canada).
Management
Next Wave Group, LLC
Newsletter Design
Betsy Earley / Director of Publications
Email: Betsy@baymed.com
• Letter from the Editor P6
Gerald P. Perman, M.D.
• Winter Scenes of Quebec, Canada P7
Photos by Arsinée Donoyan
ARTICLES
• Pathway Between Conflict and Reconciliation P11
Carlos Sluzki, M.D.
• Being Available to Patients P15
Edmund G. Howe, M.D.
• Overdose of Intranasal Ketamine by a Patient with a History of Stage IV
Melanoma and Depression P19
Emma Wellington, Benedicto Borja, M.D., Miglia Cornejo, D.O.
ESSAYS
• Summer Capriccios and Winter Elegies: The Cultural Paradox of
Seasonality P24
Cynthia Peng, M.D.
• Capturing the Human Figure: More Than Meets the Eye
David V. Forrest, M.D. P27
SHORT STORY
• Talent — A Short Story P31
Phil Lavine, M.D.
POETRY
• Borders, Belonging, and Betrayals — A Poetic Conversation Among
a Palestinian Israeli Psychologist, an Italian Canadian Psychiatrist,
and a Canadian United Church Pastor in a Time of War P39
Vincenzo Di Nicola, MPhil, M.D., PhD, Mustafa Qossoqsi, PhD, and
Jan Jorgensen, MAR, MDiv
• Juris — Misaligned P45
Austin Lam, M.D.
• The Point of Departure P46
Michael Diamond, M.D.
• A Voice Lesson (First of Three Parts) P47
Ahron Friedberg, M.D.

4 CAPITAL PSYCHIATRY, THE E-MAGAZINE OF THE WASHINGTON PSYCHIATRIC SOCIETY
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5
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By Gerald P. Perman, M.D., DLFAPA
L E T T E R F R O M T H E E D I T O R
Dear Colleagues,
Welcome to the winter 2024 issue of Capital Psychiatry:
the e-magazine of the Washington Psychiatric Society and
recipient of the 2023 American Psychiatric Association
Best Practices Award. We live in troubled times so, in
addition to the more usual contributions in this issue
that address the enigma of the human psyche and our
relationship to our patients, we include an article on
the nature of conflict by Carlos Sluzki, and a poetic
conversation by Vincenzo Di Nicola, Mustafa Qossoqsi,
and Jan Jorgensen that reflect on the Israeli Gaza War.
Please enjoy the photographic artistry of Arsinée
Donoyan with a collection of beautiful winter scenes in
her homeland of Quebec. These are art gallery quality
pictures and I encourage you to take a few moments to
enjoy each of them. I am also grateful to Joseph Silvio for
his beautiful ornithological photos that grace the cover of
each issue of Capital Psychiatry.
Carlos Sluzki opens the winter issue by describing
the set of stages that take place in conflict resolution
whether between disenchanted lovers or countries at
war. Edmund Howe makes the case that being available
to patients in cases of emergency between therapy hours,
in general, benefits them more than it interferes with
them developing a greater sense of autonomy. Finally, in
this section of Capital Psychiatry, G.W. medical student
Emma Wellington and physicians Benedicto Borja
and Miglia Cornejo provide a case report that illustrates
the potential lethal outcome of prescribing at-home
intranasal ketamine.
Cynthia Peng opines about how the season of winter
has been inappropriately and unnecessarily disparaged
in literature and in psychiatry and she attempts to begin
to correct this misperception. Her beautifully written
essay put a smile on my face as I expect it will on yours
as well. Artist and psychoanalyst David V. Forrest
offers a scholarly treatise on insights that can be gained
through sketching and observing drawings of the human
figure. Dr. Forrest never disappoints us with his eloquent
contributions to Capital Psychiatry.
Phil Lavine, in “Talent – a Short Story,” weaves a deeply
engaging fictional encounter between Herr Sigmund
Freud and a Mexican woman artist whom each of you
will immediately recognize. Get settled in a comfortable
armchair, sit next to the fireplace, pour yourself a glass of
your favorite libation, and enjoy this whimsical tale.
The poetry contributions in this issue are extraordinary. I
have already mentioned the dialogue between Vincenzo
Di Nicola, Mustafa Qossoqsi, and Jan Jorgensen with
respect to the Israeli Gaza war, reminiscent of the “Why
War?” conversation between Freud and Einstein. Austin
Lam reflects on the nature of borderline personality
disorder and the notion of injury and justice. Michael
Diamond has put into verse a brief poignant interaction
he had with a hallmate in his office building. Finally,
Ahron Friedberg, friend and colleague in the American
Academy of Psychodynamic Psychiatry, emailed me an
entire book of his unpublished poems. It is a treasure
trove of extremely varied verse, and I am publishing the
first third of his book in this issue, to be followed by parts
two and three in the subsequent issues.
At the suggestion of one of our readers, I’ve taken
the liberty of publishing email addresses of all of our
contributors at the end of their contributions so that
you can engage with them directly in dialogue. Capital
Psychiatry also welcomes Letters-to-the-Editor emailed
to gpperman@gmail.com.
Thank you to Betsy Earley for the selection of graphics
and putting Capital Psychiatry together, to Patricia Troy
for her continued wise counsel, and to John Clark, John
Fatollahi, William Lawson, and H. Steven Moffic, our
outstanding Editorial Staff.
Capital Psychiatry depends on you, our readers, for
your articles, essays, and poetry so please: Write, write,
write!!! Thank you!
Cordially yours,
Gerald P. Perman, M.D.
Editor, Capital Psychiatry

7
Winter Scenes of Quebec, Canada
Photo Spread by Arsinée Donoyan
Lachine Lighthouse
A landmark in the Borough of Lachine on Lake Saint-Louis, it was built in 1900 to help
transition from the Lachine Canal to Lake Saint-Louis which is a widening of the St. Lawrence
River (Québec,Canada).
The name La Salle dates to 1912, when a group of townspeople moved to the modern site of Lachine, taking that
name with them and allowing the old town of Lachine to become incorporated that year as a city under the name of
its founder, La Salle. Following World War II, La Salle was engulfed by the spread of Montreal (in 1959 it joined the
Montreal Metropolitan Corporation) and was primarily a residential suburb before becoming a borough of the city.
Among the products manufactured there are alcoholic beverages, building materials, plastics, chemicals, fabricated
steel, pharmaceuticals, boxes, and heating and cooling equipment. Fleming Mill, a four-story conical windmill built in
1816, is a local landmark.
La Salle borough is linked to the Kahnawake Mohawk Reserve, on the south bank of the St. Lawrence, by the Honoré-
Mercier Bridge. The bridge played an important role during the so-called Oka Crisis in 1990 when it was blockaded
by Mohawks from the reserve in support of the Mohawks of the nearby Kanesatake Reserve, who were seeking to
prevent the expansion of a golf course and construction of condominiums at Oka on a Mohawk burial ground.

Honoré-Mercier Bridge
Built in 1934, Honoré-Mercier Bridge crosses the St. Lawrence River and connects Montréal
to the suburbs in the South and the Mohawk reserve of Kahnawake (Québec, Canada).

9
St. Lawrence River
Waters rushing towards the Rapids along the shores of Des Rapides Park in the Borough of
LaSalle (Québec, Canada).

Bird Sanctuary
Located in the Borough of LaSalle, adjacent to the Lachine Rapids, the bird sanctuary
covers 74 acres and is home to 225 species of birds (Québec, Canada).

11
By Carlos E. Sluzki2
As, quoting von Clausewitz (1832), war is the
continuation of politics by other means, the road to a
constructive peace is also a political process, albeit a
frustratingly slow one, filled with obstacles, and extremely
unstable. In fact, whether focusing on couples entangled
in conflict or countries involved in a conflagration, the
winding pathway between conflict and integration,
between confrontational zero-sum and collaborative non-
zero-sum games, is built by a normative set of stages or
stations that takes place one at a time and in a predictable
sequence.
Detailing that sequence, as we do in these notes, provides
a framework for specifying the current stage of a conflict
and pinpoints subsequent sequential stages, facilitating
the design of interventions, and providing a frame to
understand success and failures in a reconciliation process.
A R T I C L E S
From blood to bliss: a sequence of stages
Each stage of the sequence described below (see Table)
has distinctive traits that keeps the relational and political
system operating within specific thresholds and requires
time to settle before moving to the next one: to bypass
some of these stages in the planning and implementing of
interventions may reduce the probability of their success.
Further, due to the complex nature of interpersonal and
political systems, some specific areas, sectors, or rules
of relationships are more resistant to evolution than
others3
, creating a field in which two stages, with their
own distinct goals and attached emotions, may coexist.
What follows specifies the stages of that normative
sequence.
Pathway Between Conflict and Reconciliation1
1
This article is an updated summary of Sluzki, 2008
2
Clinical Professor of Psychiatry, George Washington University Medical School.
3
For instance, a couple evolving toward reconciliation may be ready to reinitiate joint social engagement but not (yet) sexual relations.

I. Conflict
This stage entails active hostilities intending to damage
the other party’s life, livelihood, or well-being. Each party
attributes ill intent to any act of the other and defines
its own enactments as a reasonable response. The basic
tenets of dialogue are broken, and communication
is achieved, if at all, only through the good offices of
“neutral” third parties. The narrative anchoring this stage
could be summarized as “Hostility is the only option.”
The dominant emotions are contempt for the opponent,
hostility, and elation in the empowerment derived from
their enactments. The rules of engagement in this stage
are unambiguously those of a zero-sum game: “Your loss
is my gain.”
II. Coexistence
During this stage, parties coexist omitting most open
acts of violence, begrudgingly living side by side . This
stage remains dominated by assumptions of ill intent
behind any act by the other. The enactment of hostility is
curtailed by the establishment of real or virtual “neutral
zones” (Ury, 1999.)5
The dominant narratives in this
stage are variations of the motto “We are ready for hostile
acts when needed.” The emotions that sustain (and are
sustained by) this stage are resentment and mistrust fed
by rumination of past victimizations or anger tied to new
grudges. The rules of engagement between the parties
still follow the principles of zero-sum games.
III. Collaboration
While assumptions of ill intent still loom as a background,
the scenario changes when parties initiate some activities
in common, joint projects such as sharing social routines6
.
The external regulatory presence (or threat of presence)
of a third party becomes less dominant while still acting
as a cybernetic governor to minimize the deviations from
the parameters of a given agreement. The narratives
that dominate this stage read, “Hostilities are a fallback
option,” and a calmer ambivalence reduces the clouds of
mistrust as a dominant emotion. Some rules of non-zero-
sum games begin to be noticed in processes between the
parties — as this is a stage in which the first inklings of
civil society appear (or reappear).
IV. Cooperation
Some joint planning of specific activities7
is accompanied
by a shift toward an attribution of neutral intent (“We
may not be friends, but we are not foes. We are pursuing
common goals.”). External buffers may be no longer
necessary, as they become unpleasant reminders of past
hostilities. The narrative motto at this stage evolves
toward “Hostilities would be a major disadvantage
for both of us. Peace is desirable.” The relational field
displays the enactment of non-zero-sum partnership
rules, and the dominant emotions shift away from
ambivalence toward cautious empathy.
V. Interdependence
In this stage, the materialization of the common goals
overshadows the remnants of active assumptions of ill
intent as the parties engage in joint planning and actions
toward the collective good. The dominant narratives
display a consensus that “We need each other. Hostility
would be foolish,” and the relationship’s constructive
nature is carefully signaled repeatedly in an active display
of non-zero-sum reminders. The dominant emotions may
include forgiveness for prior misdeeds and a cautious
trust and open attachment.
VI. Integration
At this end of the spectrum, all relational moves are based
on an implicit assumption of good intent attributed to any
act of the other, as well as active involvement in planning
and actions toward the common good (non-zero-sum.)
Furthermore, conflict management strategies dominate
the system’s relational infrastructure. Hence, as problems
arise, as they unavoidably do, they are reformulated with
assumptions of reciprocal positive intent. Moreover, each
party supports the other’s growth. Narratives display the
banner: “We are one. Hostilities are not even considered.”
The dominant emotions are solidarity, friendly trust,
and perhaps even love. Achieving this step, which occurs
occasionally in interpersonal relations and much more
rarely in larger systems, entails a second order (i.e.,
qualitative) change in the relationship.
The specific traits that define each of these stages in
each case are, of course, contingent on the nature of the
relationship being considered — are we talking about a
marital couple in conflict, a management-labor dispute,
an inter-ethnic escalation, or two countries at war? —,
and contingent on the nature of the conflict -is it about
reciprocal responsibilities, about control of a territory,
about saving face, about resources?
As mentioned above, this sequence of stages is normative,
i.e., the reconciliation process of most conflictive relations
moves through these six configurations. The process
can stagnate at any stage and deteriorate toward more
4
Such as a couple reluctantly alternating the responsibilities of raising an offspring, two families ignoring any occasional encounter while sharing a
street block, or countries sharing a boundary in dispute.
5
U.N. peacekeeping forces patrolling a disputed territory, the presence of family members in a violent marital conflict, etc.
6
A couple in serious conflict jointly attending a wedding or a funeral—, a conjoint harvesting of cultivated boundary lands, the reconstruction of a bridge
or re-building a railroad across boundary lines.
7
Such as organizing a joint weekend outing with their children or designing a dam to facilitate irrigation for both territories.

13
conflictive stages if not enticed in the opposite direction
by circumstances, best interests, or leadership. As
mentioned above, these stages tend to follow one another,
and each contains experiences that, when consolidated,
constitute the seed of the next one. However, the
evolution from one evolutionary stage to the next is
complex: slippage is frequent and may lead to a tumbling
back to a previous stage.
In addition, the reward for active efforts toward reaching
the next stage toward coexistence appears distant and
challenging.
Confrontation and integration as attractors
Each end of the sequence (open conflict and integration)
and each of the intermediate steps operate as a “powerful
attractors,” (Gleick, 1987), in the sense that conflicts
near their sphere of influence tend to be pulled in their
direction. In addition, the climb toward interdependence
and integration is time-consuming, and parties may
experience it as extremely slow, unlike the moves toward
conflict, which are potentially quicker and tempting in
their potential for immediate gratification.
At one end of the spectrum, the fumes of conflict are
intoxicating (“I love the smell of napalm in the morning. It
smells…of victory!”8
). In its beginning, conflict reaffirms
the individual and collective self (“They see us. Therefore,
we exist”), expands the self (generates a sense of power
and righteousness), creates affiliation (fosters the sense
of togetherness of totalitarianism), provides meaning
(creates a story of optimism and protagonism); creates
hope (opens an alternative future); and fosters business
(generates micro-economies, black markets, bartering,
reconstruction expenditures.)
However, in the long run, if persistent, they have a
toxic effect (“The horror! The horror!”9
) , as it exhausts
resources and fosters hopelessness, an experience that
unravels the prior process.10
STAGE NARRATIVE EMOTION
Conflict “Hostility is the only option” Contempt, hostility, elation
Coexistence “We are ready for hostile acts when needed” Resentment, anger
Collaboration “Hostilities are a fallback option” Ambivalence
Cooperation “Hostilities would be a major disadvantage” Cautious empathy
Interdependence “We need each other” Acceptance of the past; cautious trust
Integration “We are one.” Solidarity, friendly trust
In turn, the pole of integration attracts because it
enhances interpersonal and social predictability and
prospection (planning can be done with some degree
of certainty), civility (collectively enacted behaviors
guarantee the rules of interpersonal and institutional
relations and collectively agreed-on enforcement
8
As joyfully exclaimed a military commander in the middle of a violent carnage, in Francis Ford Coppola’s 1979 film “Apocalypse Now”, with screenplay
by John Milius and Francis Coppola
9
Utterance murmured in despair by the burned out, doomed, suicidal colonel Kurtz, also in Francis Ford Coppola’s “Apocalypse Now,” inspired by Joseph Conrad’s
1899 novella “Heart of Darkness” in which a homonymous character mumbles those exact words (Conrad, 1988 edition, p.72.)
10
As Mitchell (1999, p.xii) observed in his analysis of the Irish public opinion after years of protracted conflict: “The people long for peace. They are sick of war,
weary of anxiety and fear. They still have differences but want to settle them through democratic dialogue.”
If the integration persists,
however, the sense of
commitment to the
collective, foregrounded
during the crisis, may
risk moving into the
background, debilitating the
processes that guarantee
that stage’s maintenance
and placing it at risk, at
least until an external crisis
reactivates them[ii].

References
Axelrod, R. The Evolution of Cooperation. New York: Basic Books, 1984.
von Clausewitz, C.: On War, 1832. (1989 Edition: New Jersey: Princeton
University Press)
Conrad, J. Heart of Darkness (Robert Kimbrook, Ed., 3d. Edition), New
York-London: Norton, 1988. (Original published in 1899)
Gladwell, M. The Tipping Point: How Little Things Can Make a Big
Difference. New York: Little Brown Co, 2000.
Gleick, J.: Chaos: Making of a New Science. New York, Penguin, 1987
Mitchell, G. J. Making Peace. Berkeley: University of California Press, 1999.
(New Edition, 2000)
Sluzki, C.: The process toward reconciliation. Chapter 2 in A Chayes and M.
Minow, Eds., Imagine Coexistence: Restoring Humanity after Violent Ethnic
Conflict. San Francisco: Jossey-Bass, 2003
For email correspondence you may contact Dr. Sluzki at csluzki@gmu.edu
agencies); and personal and relational well-being (in
contrast with the exhausting stress stemming from
violence.)
If the integration persists, however, the sense of
commitment to the collective, foregrounded during the
crisis, may risk moving into the background, debilitating
the processes that guarantee that stage’s maintenance
and placing it at risk, at least until an external crisis
reactivates them[ii].
A comment on narratives
As mentioned above, each stage is characterized by a
set of narratives, by stories that people tell about the
situation (defining ethic and behavioral guidelines about
good and evil, protagonists and their foils, parties with
noble and ignoble intentions, the ultimate motivations,
and hidden intents of self and the other).
Moreover, each set of stories will reconstitute (that is,
solidify and anchor) their respective stage. Thus, the
whole process toward reconciliation entails a progressive
shift of dominant narratives, from stories of victimization
to stories of evolution and empowerment. This process
of shifting dominant narratives (and therefore facilitating
changes toward more developed stages) get anchored in
(and anchoring) the individual and collective identity.
That is why the passage between stages toward constructive
collaboration becomes more viable when changes are
simultaneously enacted and anchored by activities at multiple
levels, such as the economics, education, sports, and artistic
domains that contribute (unequally) to building a civil
society and the small daily acts of reciprocal reaffirmation
that constitute a gratifying live as members if a couple and an
extended family.

15
Being Available to Patients
By Edmund G. Howe, M.D.
Disclaimer- The opinions and assertions expressed herein are those of the author and do not reflect the
official policy or position of the Uniformed Services University of the Health Sciences or the Department
of Defense. Neither I nor my family members have a financial interest in any commercial product,
service, or organization providing financial support for this research. References to non-Federal entities
or products do not constitute or imply a Department of Defense or Uniformed Services University of the
Health Sciences endorsement. This work was prepared by a civilian employee of the U.S. Government
as part of the individual’s official duties and therefore is in the public domain and does not possess
copyright protection (public domain information may be freely distributed and copied; however, as a
courtesy it is requested that the Uniformed Services University and the author be given an appropriate
acknowledgment).

Psychiatrists have a variety of approaches to being
available to their patients.1
In addition to their having a
colleague available 24/7, for example, they may have a
phone announcement that says that they will call back
within some set time, e.g.. 12 hours, unless, of course,
they are away. I have been fortunate in this sense
because, as a full-time faculty member at a medical
school, I only see patients part- time. Thus, I treat fewer
patients than a psychiatrist in full-time practice.
Because of my situation, I have been able to make myself
more-or-less immediately available to my patients
by phone in an emergency. This does not cause undo
emotional stress for me, and I believe it greatly benefits
my patients. My patients are also aware that they can
contact an on-call psychiatrist in the event that I am
unavailable to take their call..
Giving patients this close-to-full-time access may not be
feasible for psychiatrists in full-time practice. My 24/7
availability may at times undermine my patients’ ability
to rely on their own internal resources. It may also,
however, enable some patients to fare better on their
own, knowing that if they felt worse, they could call me,
as they did in the vignettes that follow.
John Gunderson, a psychiatrist renowned for his skill
and expertise in treating patients with Borderline
Personality Disorder once said at an American
Psychiatric Association Annual Meeting that he too
makes himself similarly available to his patients.2, 3
He
added - with a grin - that when patients called him in the
middle of the night because they felt suicidal, he was not
necessarily his most charming self. Instead, he would be
redundant, encouraging them repeatedly to seek help
in an emergency room, to avoid responding to a sudden
increase in their suicidal impulses and taking their life.
[Editor’s note: At a meeting I attended many years ago,
I believe of the International Society for the Study of
Trauma and Dissociation, psychoanalyst Richard P.
Kluft, M.D. said that he told his patients with dissociative
disorders who called at all hours of the day and night:
“I may be on call, but I am not on tap” (referring to the
serving of draft beer in a bar).” GPP]
In this piece, I will not discuss in detail the pros and
cons of being “always available.” Instead, I will describe
several needs that patients have had over the years that
moved them to call me during “off-hours” for help with
what they saw as an emergency. I have altered aspects
of these dilemmas so that these patients cannot be
identified, but I have retained sufficient information to
convey what occurred. The examples I report here all had
a good outcome, but this result should not be taken as a
guarantee of a similar outcome with your own patients.
Vignette #1
This first vignette involved a phone call I received
that may have prevented a patient from becoming
increasingly psychotic and that may have avoided a
hospitalization.
The patient was a middle-aged man who was becoming
increasingly paranoid. He called and told me that he was
“in a panic” and “I fear that I am decompensating.”
I asked him if he was taking each of the medications I was
prescribing for him. “Oh my God!” he shrieked. “I forgot to
take one of them. I see now that it is in my drawer.” This
was an antipsychotic medication that, once restarted,
allowed him to do well.4
Vignette #2
The plight of another patient was more disturbing. This
patient called and asked hesitantly if we could talk. I
replied “yes” and we proceeded to discuss the despair he
felt after his long-time partner had decided to leave the
relationship. After speaking with him for several minutes,
he told me that he was “okay” and we ended the call.
On follow-up, he did well. Weeks later, he told me that,
just before he had called me, he had placed a gun in his
mouth.5
He thought of me at the time, and that it might be
worthwhile to call me first. He shared with another staff
member later that, if he had not called me, he believes
that he would have taken his life.
Vignette #3
A third patient was taking what she said would be a final
vacation with her husband because of his advancing
dementia. She wanted to take this last vacation with him
while she thought he still could appreciate and enjoy
the trip. They were driving across the country, staying at
motels along the way.
I received a phone call from my patient at 3 AM, having
locked herself in a motel bathroom. Her husband thought
that she had stolen from him and was making what she
considered to be violent threats toward her.6
I discussed
the possibility of her calling the police, but instead
spoke with her and her husband, who was outside the
bathroom door. He gradually calmed down and, feeling
safe, she unlocked the door, and their road trip proceeded
uneventfully.
Vignette #5
A different sort of emergency involved another patient
who feared for his life. He had visited a friend and his
friend’s partner in another city whereby his friend’s
partner became jealous. This man claimed to be a
member of a gang and said that he would have his fellow
gang members kill my patient.7

17
My patient had planned to take a plane flight home the
next day, but called me in the middle of the night, afraid to
leave the hotel. He imagined that a gang member would
be waiting to kill him outside the hotel while leaving for
the airport. We arrived at an acceptable solution in which
another person he knew in this city would come up to his
hotel room and take him to the airport. My patient made
his flight without incident, and, since then, has flourished.
Vignette #6
The last call that I will describe was not from a patient,
but instead from my patient’s wife. My patient was an
impulsive person, and he threatened his wife that he
was going to leave her for good. I did not know him well
and had first met him when he was with his wife in my
consultation waiting room.
His wife called me late at night and told me that he was
packing. She asked me if I could call him and try to talk
him out of leaving. She also asked that I not tell him that
she had called me. I told her that, even if I fulfilled her
first request, I could not fulfill her second request and lie
to my patient.
I called my patient and asked what had so uniquely
enraged him. Based on what he told me, I validated his
reaction, and I asked him if he would be willing to listen
to some of my thoughts about his current situation. He
replied: “Okay.”
I then reviewed the history of his relationship with his
wife as he had previously described it to me. This led
him to acknowledge his wife’s many strengths and to
remind himself that she often told him how much she
cared about him. The crisis was defused that night, and
my patient has remained in his marriage. The three of us
continued to work together in treatment, and, over time,
their marriage has not only survived, but it has thrived.8
Discussion
There are several aspects of my decision to remain
immediately available to my patients outside of
appointments that merit special mention. I will first
acknowledge two downsides of this practice.
First, this policy can be disruptive to the psychiatrist’s
partner and family.9
A call in the middle of the night
can wake an entire family and the tension created may
spread. In my case, it was the infrequency of these calls
that made this policy bearable for my family members.
Second, it can also be discombobulating, for lack of
a better word, for the provider who engages in this
practice. It may be difficult after such phone calls to relax
and get back to sleep, and the effects of this tension and
insomnia may last for days.10
All of us in the mental health field know that, when
treating our patients, we must first attend to ourselves.
If we experience these kinds of disruptions too often,
it behooves us to find a better way to manage these
situations or to change our therapeutic approach in
this regard. Fortunately, for me, these events have been
sufficiently infrequent, although there are others that I
haven’t mentioned.
These phone calls may also evoke negative
countertransference feelings toward our patients that
we must be able to manage so that we can remain
therapeutically effective. This involves the psychiatrist
recognizing these negative feelings, while at the same
time appreciating that the patient is feeling extremely
alone, bereft, and possibly suicidal.
If the patient continues to call often, and at all hours,
this may be an indication that the frame of the therapy
needs to be reevaluated. For example, the frequency
of the treatment may need to be increased, and/or
consultation with a colleague may need to be arranged.
The psychiatrist will also need to address this situation
with the patient. In the event that a patient is suicidal, the
psychiatrist must spell out explicitly what steps must be
taken, whether or not they can immediately reach you or
another psychiatrist on call.11,12
The psychiatrist should only engage in this 24/7
availability if it continues to meet the psychiatrist’s
needs as well as patients. Thus, even if the psychiatrist
has decided to try this out, the psychiatrist should not
hesitate to return to an on-call system if the practitioner
feels overwhelmed and this should be done without
feelings of guilt or shame for not being “on tap” to their
patients all the time.13
I have been able to do this only, I believe, because I have a
small number of patients and those I see have fortunately
not abused this situation. Patients, of course, greatly
differ. What some patients experience as trivial, others
may find life-shattering. Thus, a phone call in the middle
of the night might, on the surface, appear to be trivial, but
to our patients, they may be anything but.
I feel lucky that, in each of the above vignettes, the
outcome was uniformly positive, and perhaps they would
have been so even if my patients had not called or had
I had not answered. We may both — myself and my
patients — consider ourselves lucky.
[Editor’s note: I, like Dr. Howe, make myself available
to take my patients’ phone calls 24/7. I believe that my
patients greatly appreciate this availability, almost all
of them respect my private time, and I don’t believe
that this has damaged their ability to lead autonomous,
independent lives. I am grateful to Dr. Howe for bringing
this important issue to our readers’ attention. GPP]

References
1
Moss J et al. Variation in admission rates between psychiatrists on
call in a university teaching hospital. Ann Gen Psychiatry 2018 Jul
10;17:30. doi: 10.1186/s12991-018-0199-x. (Accessed 9 Dec 2023).
2
Gunderson JG et al. Borderline personality disorder. Nat Rev
Dis Primers 2018 May 24;4:18029. doi: 10.1038/nrdp.2018.29.
(Accessed 9 Dec 2023).
3
Ross J et al. Promoting good psychiatric management for patients
with borderline personality disorder. J Clin Psychol. Aug 2015:
71(8):753-763.
4
Seabury RD et al. Memory impairments and psychosis prediction:
A scoping review and theoretical overview. Neuropsychol Rev.
Dec 2020:30(4):521-545.
5
Berens S et al. A case of homicidal intraoral gunshot and review of
the literature. Forensic Sci Med Pathol. 2011 Jun;7(2):209-212.
6
Pearce D et al. Paranoid and misidentification subtypes of
psychosis in dementia. Neurosci Biobehav Rev. Mar 2022:
134:104529. doi: 10.1016/j.neubiorev.2022.104529. (Accessed
9 Dec 2023).
7
Warren LJ et al. A clinical study of those who utter threats to kill.
Behav Sci Law Mar-Apr 2011: 29(2):141-154.
8
Snyder DK et al. Evidence-based approaches to assessing couple
distress. Psychol Assess. Sep 2005:17(3):288-307.
9
Parida S et al. On-call reform: blessing or bane? Psychiatry
residents’ perspectives. Acad Psychiatry Sep 2013:37(5):364-365.
10
Romigi A et al. Editorial: Consequences of sleep
deprivation. Front Neurosci. 2023 Aug 1;17:1254248. doi:
10.3389/fnins.2023.1254248. (Accessed 9 Dec 2023).
11
Labouliere CD et al. Safety planning on crisis lines: Feasibility,
acceptability, and perceived helpfulness of a brief Intervention
to mitigate future suicide risk. Suicide Life Threat Behav Feb
2020:50(1):29-41.
12
Stanley, B et al. K. (2012). Safety planning intervention: A brief
intervention to mitigate suicide risk. Cognitive and Behavioral
Practice 2012:19(2): 256- 264.
13
Mache S et al. Evaluation of self-care skills training solution
-focused counselling for health professionals in psychiatric
medicine: a pilot study. Int J Psychiatry Clin Pract. Nov 2016:
20(4):239-244.
*Professor of Psychiatry
USUHS, 4301 Jones Bridge Rd
Bethesda, Md, 20814
Edmund.howe@usuhs.edu
301-295-3097 (office)
240 463-7587 (cell)
MAGAZINE OF THE WASHINGTON PSYCHIATRIC SOCIETY
Dear WPS Members:
The editorial team for Capital Psychiatry: the
e-magazine of the Washington Psychiatric
Society is currently seeking articles for
publication in the upcoming Spring 2024 issue.
Articles should be 1500-2000 words in length
that are of psychiatric topical and scientific
interest to our readership. We also welcome
relevant literary essays in the style of The New
Yorker to allow you to give free rein to your
creative muse. We encourage members to
submit brief abstracts of articles for the Spring
2024 issue and beyond. Please email your
abstracts to gpperman@gmail.com.
Thank you and let us know if you have any
questions. Feel free to contact me for a copy of
the Capital Psychiatry Editorial Policy.
Cordially yours,
Gerald P. Perman, MD / Editor
Capital Psychiatry
Fall 2023 • Volume 4, Issue 4
Summer 2023 • Volume 4, Issue 3

19
Affiliations: Department of Psychiatry and Behavioral
Health - George Washington University Hospital
Abstract: Mrs. X is a 42-year-old patient with a history of
stage IV melanoma, in remission, and major depressive
disorder presenting to the emergency department
after an intentional overdose on Ketamine (5 pumps
intranasally), Xanax, and Diazepam. Her dose of ketamine
was approximately 10g, with the minimum lethal dose
reported by DC poison control approximating 1g. She
was admitted to the medical floor for observation.
Despite the amount of medications taken and the
administration of several CNS depressants, there were no
significant medical complications. Mrs. X was transferred
to inpatient psychiatry after the medical observation
period. On evaluation by the psychiatry team, Mrs. X
endorsed suicidal ideation (SI) and depressed mood, with
intermittent periods of hypomania throughout her adult
life. She had a long history of diagnosed major depressive
disorder (MDD) which was minimally responsive to
standard pharmacological treatment.
The patient had been receiving monthly ketamine
infusions at an outpatient clinic for eleven months
secondary to a recent increase in depressive symptom
severity. The patient reported having access to intranasal
ketamine within her home. This case demonstrates
the potentially fatal nature of at-home ketamine
prescriptions in patients who are at risk for misuse,
regardless of active suicidal intent.
Introduction
Ketamine, a drug newly indicated for treatment-resistant
depression (TRD), is a noncompetitive N-methyl-
D-aspartate (NMDA) receptor antagonist that has
historically been used as a dissociative anesthetic in
inpatient facilities.1
It has evolved in use, spanning other
fields of medicine, such as treatment for refractory
migraines and chronic pain.2
However, data is still
preliminary, and the benefits of ketamine use in these
settings requires further analysis.2
Ketamine’s use in depression management was initially
investigated by Berman and colleagues in 2000, and
it has since expanded into clinical use for TRD and
suicidality.3
Studies have been promising, highlighting
ketamine’s efficacy in treating TRD. Ketamine use has
also been explored in emergent settings to target acute
suicidality.4
Given these results, intranasal ketamine
and ketamine clinics are becoming more prominent;
and these innovations are increasing hope for patients
suffering with TRD.
Despite the positive effects of ketamine, it is imperative
that we do not overlook its adverse effects. As ketamine
affects almost every organ system, its side effect profile
warrants a closer look in determining if ketamine
treatment is an appropriate choice for patients with TRD.
More specifically, the neurological, cardiovascular, and
respiratory systems are all impacted by ketamine use5
and notable side effects include urinary tract symptoms,6
liver toxicity,7
neurocognitive deficits,7,8
and ulcerative
colitis.7
Though the 2-4-hour observation period post ketamine
administration at ketamine clinics provides a layer of
safety to ensure medical stability, this safety net is non-
existent for patients prescribed intranasal ketamine
(esketamine). Esketamine is manufactured in 28mg
devices and is available in dose packs of 2 or 3. Patients
Overdose of Intranasal Ketamine by a Patient
with a History of Stage IV Melanoma and Depression
By Emma Wellington, Benedicto Borja, MD, Miglia Cornejo, DO

can self-administer 54 mg or 84 mg in one dose. Though
self-administration typically requires observation by
a healthcare professional in the pharmacy setting, our
patient was able to administer up to 10g independently
within her home.
Here we present a unique case in which a patient took
a lethal amount of ketamine in an attempt to numb
her emotional state, without fear of possible suicide
completion. It was not clear how much additional
medication the patient consumed, though there was
concern for concomitant benzodiazepine consumption.
Despite a lethal amount of ketamine coupled with
other medications, the patient’s medical course was
uncomplicated, and she was quickly medically cleared
with subsequent transfer to inpatient psychiatry for
further diagnostic clarification and treatment.
Ketamine is a burgeoning drug in the field of psychiatry,
but many deaths by overdose occur through accidental
means.9
This case report will explore the lethal dose of
ketamine, causes of varied lethal limits in patients, and
contraindications to prescription of intranasal ketamine
in high-risk patients.
Case: Initial Presentation
The patient is a 42-year-old female with a past medical
history of stage four melanoma, diagnosed and treated
in her 30’s with subsequent remission, and a past
psychiatric history of major depressive disorder. She
presented with loss of consciousness to the emergency
department secondary to increased intake of intranasal
Ketamine, Xanax, and Diazepam. She presented to the
emergency department with a Glasgow Coma Score of
13/15 and was disorientated until the following morning.
At the time of presentation, the patient had short term
memory loss of the event and had waxing and waning
cognitive status in the setting of profound lethargy.
The patient endorsed recent insomnia, anhedonia,
imposter syndrome, decreased energy, difficulty with
concentration, and SI. She described having symptoms
consistent with a panic attack the evening prior, during
which she took many of her at-home psychiatric
medications with the intent to stop feeling her emotions.
She did reveal to the psychiatry team that she was trying
to end her life “on some level deep down.”
History and Physical Exam
The patient was taken to the emergency department
after being discovered by her husband at home, the
evening prior to her initial psychiatric evaluation. The
patient states that she was feeling extreme panic and
emotional disinhibition in the setting of a recent increase
in depressive mood symptoms. She could not pinpoint
one single trigger for her episode but endorsed that she
felt that while she recognized the sadness her death would
bring her family, it was incomparable to the emotional
anguish she felt prior to her attempt.
The patient’s husband was out with his friends at the time
when she took unknown amounts of Xanax, Ketamine, and
Diazepam. Her ketamine prescription was not recorded
in the external Rx system, most likely because ketamine
is typically not prescribed for patients to take home. This
situation suggests that patients may be given access to
ketamine packs through physician samples, which is a
dangerous practice in patients with SI.
It is estimated that the patient may have taken up to five
sprays of intranasal ketamine. According to DC poison
control, who were contacted when the patient presented
to our team, this dose may equate to 10g — far exceeding
the reported lethal limit. DC poison control reported
to the George Washington (GW) medical faculty that
there have been reported cases of fatality with only 1g
administration. Moreover, as the patient mixed ketamine
with multiple other substances, she was well beyond the
lethal limits. In combination with her benzodiazepine
ingestion, that patient was expected to suffer from
respiratory and overall central nervous system (CNS)
depression. However, the patient demonstrated stable
vital signs throughout admission.
On the initial exam, the patient had a Glasgow Coma
Scale (GCS) of 13. She was lethargic, suffered short-term
memory loss for the overdose event and was only able to
recount the events after her initial evaluation from the
psychiatry team. Two days later, the patient was entirely
alert and oriented and was able to discuss her current
condition. She sustained no long-term brain damage and
no residual physical deficits. Her depression screen was
positive and suicide risk assessment still indicated an
immediate need for inpatient admission.
On further investigation, the patient revealed that she
had been receiving ketamine infusions monthly since
November. This was approximately 9 months prior to
her current presentation. She noted that her infusions
had stopped working so the patient was given intranasal
ketamine to help augment the antidepressant effects in
the interim between infusion appointments. Nonetheless,
the patient’s depression continued to progress.
However, it is still not clear how the patient was able
to accumulate a ketamine supply within her home, as
patients are typically monitored at the pharmacy when
they are prescribed self-administered doses.
Hospital Course
After initial evaluation, the psychiatry department
contacted local poison control for further guidance on the
treatment course. It was recommended to obtain an EKG,

21
with follow up CBC and Basic Metabolic Panel (BMP).
The ECG revealed normal sinus rhythm without QTc
prolongation. The CBC and BMP were well within normal
limits. Her mild leukocytosis at admission had completely
resolved. Upon further discussion with DC poison control,
the patient was assessed to be stable, and was transferred
to the voluntary psychiatry unit.
The patient was monitored for 24 hours for signs of vital
instability and behavioral changes, common indicators of
drug withdrawal. The patient was in the psychiatry unit
for a total of 5 days. She participated in group therapy
and spent much of her time in her room reading.
During her interviews, the patient revealed a family
history of bipolar disorder in a first degree relative.
Upon further questioning, the patient also had a positive
bipolar screen. She had periods of feelings of grandeur,
impulsive spending (close to $1,000 at one time),
increased agitation, and heightened energy levels in the
context of reduced need for sleep. These periods typically
lasted one week, and they were not accompanied by
fulminant psychotic symptoms, such as delusions or
hallucinations. The patient had previously never been
diagnosed with bipolar disorder, but her prevailing
hypomanic symptoms before the initiation of ketamine
therapy are suggestive of a misdiagnosis prior to
presentation.
The patient was mentally stabilized and made plans to
stay at her cabin in Virginia post-discharge. She decided
to resume her work part-time while seeing an outpatient
therapist and psychiatrist.
Diagnosis
This patient had a complex mental health history in the
context of major life stressors that made her diagnosis
difficult to ascertain. The patient had stage four
melanoma (in remission at her time of admission). The
effects of her cancer diagnosis impacted multiple facets of
her life, including her career and her sense of identity.
The patient endorsed having to switch her line of
work due to the demands of her treatment schedule
for melanoma. Much of her identity was tied to her
career, which she stated negatively impacted her mood
symptoms. When she joined the workforce again, she was
left with a job that was less hands-on and suffered from
imposter syndrome. She had feelings of grief focused on
her diagnosis, and she felt confused and uncomfortable
by her success. The patient revealed that she felt
significant guilt because while she felt her life appeared
successful to others, she wasn’t enjoying it.
While the patient was originally diagnosed with
depression, there was consideration that she suffered
from bipolar disorder due to her family history
and reports of hypomanic episodes. Her possible
misdiagnosis brings up the point that we should be
carefully screening out patients for bipolar depression
versus MDD before prescribing Ketamine therapy. Many
cases of TRD are due to misdiagnosis, and ketamine is not
yet indicated as a medical therapy for bipolar depression.
Discussion
Ketamine Administration
There are multiple modes of ketamine administration
in patients who struggle with depression. There is new
evidence suggesting that ketamine infusions could
offer novel therapeutic benefits, such as short onset to
depression remission and decreased symptom burden in
as little as four hours.10
Meta-analysis has shown that peak effects are seen
in the first 24 hours after admission, and there could
be evidence suggesting that the efficacy is enhanced
with increased number of infusions.10 These data beg
further investigation of why this patient diagnosed
with TRD failed ketamine infusion therapy and how she
demonstrated decreased ketamine efficacy over time.
It is possible that the fundamental mechanisms that
cause bipolar disorder to more frequently show
treatment resistance could be the same pathogenesis
causing decreased efficacy in our patient who was
initially diagnosed to have depression but who was later
re-classified into the Bipolar II diagnostic category.11
Another question that this study addresses is the
role of prescribing intranasal ketamine or ketamine
packets for patients who fail monthly ketamine infusion
therapy. Research shows that intranasal ketamine
administration is only 45% bioavailable, while the IM and
IV bioavailability ranges from 93% and above.12 While
it is becoming more common for intranasal ketamine to
be used in adjunct with the IV infusions, there are serious
concerns regarding this regimen.
As the IV ketamine effects are short-lived, there may not
be enough evidence suggesting that concomitant use of
intranasal and IV ketamine provide long-lasting effects.
Further, if a patient is known to have decreased response
rate to IV ketamine infusions, then prescribing intranasal
ketamine may also not show treatment benefit. As a
short-term solution, physicians may be introducing risks
of overdose when they prescribe two forms of the same
medication, with evidence suggesting undetermined
benefit using intranasal ketamine as an interim form of
treatment between ketamine infusions.
Overdose
Patients that come to the emergency department
after a ketamine overdose need to be monitored for

many different symptoms. Ketamine affects a wide
array of organ systems and body circuits, such as
the cardiovascular, gastrointestinal, genitourinary,
respiratory and neurological pathways.5,13
DC Poison Control officers stated that they had witnessed
accounts of lethal overdose with merely 1 gram
administration of ketamine. Further reports state that the
lethal dose of ketamine is about 4.2 grams for a 155 lbs.
man or women.14
Our patient far exceeded the lethal limit
for her body mass index.
Patients who overdose on intranasal ketamine can have
serious cardiovascular, respiratory, and neurological
depression.13
What is interesting about this patient case
is that our patient only presented with disorientation and
amnesia regarding the events of her overdose.
Within 36 hours, the patient was completely alert,
oriented, and able to remember the events of that night.
She also presented with enough insight to have several
discussions regarding her emotional state leading up to
her ketamine overdose.
It is possible that the patient suffered symptoms related
more specifically to her benzodiazepine overdose rather
than her ketamine intake, especially as the source of her
ketamine supply is unclear. However, as benzodiazepines
are also known for their depressive CNS effects, it is still
unclear why this patient presented with only a GCS of 13
and mild symptom burden — regardless of how much
ketamine she truly ingested.
A further consideration is that the benzodiazepine
ingested had a protective effect for our patient.15-17
Research shows that as ketamine and benzodiazepines
work on the same receptor; benzodiazepines increase
the amount of synaptic GABA and ketamine decreases
it.15
One case report demonstrated a similar phenomenon
with a 57-year-old patient originally prescribed ketamine
with the later addition of lorazepam, which resulted in an
increased depression symptom burden.16
The effect of the
ketamine appeared reduced.16
This example highlights the
impact that the benzodiazepine ingested by our patient
may have had in a protective, life-saving manner.
Implications
It is uncertain why our patient was able to survive almost
double the lethal dose of ketamine in combination with
benzodiazepine administration. Ketamine is a relatively
new drug in the treatment of depression and other
psychological conditions, and its mechanism of action is
still unclear. While we know it works on the N-methyl-D-
aspartate (NMDA) receptors as an antagonist, it is also
speculated to have effects at the norepinephrine and
epinephrine receptors.18
Its nonspecific effects are what make ketamine such a
unique drug therapy for depression. While it depresses
the central nervous system by blocking glutamate, it
also stimulates the sympathetic drive by working on the
norepinephrine and epinephrine centers.18
These effects
are hypothesized to be the cause of the hallucinogenic/
dissociative state in the patient.18
Therefore, as ketamine is not a receptor-specific drug, it is
possible that its effects on the body could be vaster than
previously imagined. Certain receptors, and the genes that
encode for them, vary within individuals. Additionally,
as ketamine is metabolized by cyp450 and 3A4 and 2B6
isoenzymes in the liver before excretion into the urine,
there may be variability in ketamine’s metabolism.19
It is
not out of the realm of possibility that our patient survived
her overdose due to differences in her receptors affected
by ketamine as well as its metabolism.
Impacts of Home Ketamine Prescriptions
Ketamine is a drug that used to be exclusively utilized in
the inpatient setting; yet, with its emergence into the field
of psychiatry, we are witnessing an increase in ketamine
use within patient homes. According to one report, 64
percent of patients noted an improvement in their mental
health condition after utilizing ketamine therapy.20 This
high percentage gives hope to many patients with TRD.
However, we need to be cautious when prescribing this
medication at home, as 40 percent of people are wary of
using home ketamine prescriptions and a whopping 55
percent of those with home prescriptions have misused
the drug.20
Additionally, the emergence of telehealth has
been thought to be an impetus for the increase in-home
ketamine scripts without accompanied regulations for
patient supervision during administration.21
Not only is it important to look at the use and misuse rates
for at-home prescriptions, but the biochemical differences
between individuals should also be considered before
ketamine becomes a regular home medication. Research
does, in fact, support that the CYP2B6 allele could alter
how ketamine is metabolized across individuals.22
It can be
inferred that our patient was most likely a fast metabolizer
of ketamine, as she was able to survive a ketamine dose
that far exceeded the lethal limit. If our patient had
alternatively been a slow metabolizer of ketamine, the
outcome of her overdose would have been drastically
different and characteristically fatal.
This case further suggests that there may be a role for
genetic testing before providing home scripts for ketamine
in high-risk individuals for suicide. By testing our patients
for slow or fast metabolizer genes, we have a chance to
decrease the risk of fatal intentional and unintentional
overdoses.

23
Works Cited
1
Eilers H, Yost S. General Anesthetics. In: Katzung BG, Vanderah
TW. eds. Basic & Clinical Pharmacology, 15e. McGraw Hill; 2021.
Accessed August 08, 2023. https://accessmedicine-mhmedi
cal-com.proxygw.wrlc.org/content.aspx?bookid=2988&section
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2
Rocchio RJ, Ward KE. Intranasal Ketamine for Acute Pain. Clin J
Pain. 2021;37(4):295-300. doi:10.1097/AJP.0000000000000918
3
Berman RM, Cappiello A, Anand A, et al. Antidepressant effects of
ketamine in depressed patients. Biol Psychiatry. 2000;47(4):351-
354. doi:10.1016/s0006-3223(99)00230-9
4
Corriger A, Pickering G. Ketamine and depression: a narrative
review. Drug Des Devel Ther. 2019;13:3051-3067. Published 2019
Aug 27. doi:10.2147/DDDT.S221437
5
Short B, Fong J, Galvez V, Shelker W, Loo CK. Side-effects associ-
ated with ketamine use in depression: a systematic review. Lancet
Psychiatry. 2018;5(1):65-78. doi:10.1016/S2215-0366(17)30272-9
6
WHO. Ketamine (INN). Update review report. Agenda Item 6.1.
Expert Committee on Drug Dependence, Thirtyseventh Meeting
2015. http://www.who.int/medicines/access/controlledsubstanc-
es/6_1_Ketamine_Update_Review.pdf (accessed July 26, 2016).
7
Katalinic N, Lai R, Somogyi A, Mitchell PB, Glue P, Loo CK. Ketamine
as a new treatment for depression: a review of its efficacy and
adverse effects. Aust N Z J Psychiatry 2013; 47: 710–27.
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Independent Scientific Committee on Drugs
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Darke S, Duflou J, Farrell M, Peacock A, Lappin J. Characteristics
and circumstances of death related to the self-administration of
ketamine. Addiction. 2021;116(2):339-345. doi:10.1111/add.15154
10
Marcantoni WS, Akoumba BS, Wassef M, et al. A systematic review
and meta-analysis of the efficacy of intravenous ketamine infusion
for treatment resistant depression: January 2009 - January 2019.
J Affect Disord. 2020;277:831-841. doi:10.1016/j.jad.2020.09.007
Future Directions
This case raises many questions about the use of
ketamine in psychiatric treatment. First, for what
diagnosis is the prescription of home ketamine
appropriate? Which diagnoses are best treated with
ketamine? And how do we prevent patients with SI from
overdosing or mixing their medications?
Beyond these investigations, there is also uncertainty
regarding how this patient survived high lethal doses
of ketamine in combination with benzodiazepine
administration. The patient’s increasing tolerance to
ketamine infusion over time warrants further discussion
of long-term indications for ketamine administration.
Further studies are needed to assess how ketamine
may affect NMDA receptors and be metabolized across
various patients. These studies may reveal differences in
efficacy, potency, and risk that influence the guidelines
psychiatrists utilize to prescribe nasal ketamine and
manage outpatient infusions.
11
Li C-T, Bai Y-M, Huang Y-L, et al. Association between
antidepressant resistance in unipolar depression and subsequent
bipolar disorder: cohort study. The British Journal of Psychiatry.
2012;200(1):45-51. doi:10.1192/bjp.bp.110.086983
12
Jelen LA, Stone JM. Ketamine for depression. Int Rev Psychiatry.
2021;33(3):207-228. doi:10.1080/09540261.2020.1854194
13
Orhurhu VJ, Vashisht R, Claus LE, Cohen SP. Ketamine Toxicity.
In: StatPearls. Treasure Island (FL): StatPearls Publishing; January
30, 2023.
14
What is the Lethal Dose of Ketamine? AddictionResource. Net.
Copyright 2023. Accessed Aug 8, 2023. https://www.addictionre-
source.net/lethal-doses/ketamine/
15
Blier P. Exploiting N-methyl-d-aspartate channel blockade
for a rapid antidepressant response in major depressive
disorder. Biol Psychiatry. 2013;74(4):238-239. doi:10.1016/
j.biopsych.2013.05.029
16
Ford N, Ludbrook G, Galletly C. Benzodiazepines may reduce the
effectiveness of ketamine in the treatment of depression.
Australian and New Zealand journal of psychiatry.
2015;49(12):1227-1227. doi:10.1177/0004867415590631
17
Frye MA, Blier P, Tye SJ. Concomitant Benzodiazepine Use Attenu-
ates Ketamine Response. Journal of Clinical Psychopharmacology.
2015; 35 (3): 334-336. doi: 10.1097/JCP.0000000000000316.
18
(Ketamine). In: IBM Micromedex® DRUGDEX® (electronic
version). IBM Watson Health/EBSCO Information Services,
Greenwood Village, Colorado; Cambridge, Massachusetts, USA.
Available at: https://www.dynamed.com (cited: 9/8/2022).
19
Dinis-Oliveira RJ. Metabolism and metabolomics of ketamine:
a toxicological approach. Forensic Sci Res. 2017;2(1):2-10.
Published 2017 Feb 20. doi:10.1080/20961790.2017.1285219
20
2023 Future of Mental Health: Ketamine Therapy Report. PLUS
by APN. Published 2023. Accessed Aug 9, 2023. https://plusapn.
com/wp-content/uploads/2023/02/2023-Future-of-Mental-
Health-Ketamine-Therapy-Report-by-APN.pdf
21
Kuntz, Leah. Report Reveals More Than 50% of Americans Misuse
At-Home Ketamine. PsychiatricTimes. Published March 13, 2023.
Accessed Aug 9, 2023. https://www.psychiatrictimes.com/view/
report-reveals-more-than-50-of-americans-misuse-at-home-
ketamine
22
Li Y, Coller JK, Hutchinson MR, et al. The CYP2B6*6 allele
significantly alters the N-demethylation of ketamine enantiomers
in vitro. Drug Metab Dispos. 2013;41(6):1264-1272. doi:10.1124/
dmd.113.051631
For email correspondence contact Emma Wellington at
wellingtonemma@gwmail.gwu.edu

E S S A Y S
Summer Capriccios and Winter Elegies: The Cultural Paradox of Seasonality
By Cynthia S. Peng, M.D.*
The subjective value in seasons is deeply imbued
in our culture in the western world and northern
hemisphere. Throughout art, music, literature,
and history, it appears that overwhelmingly,
summer is extolled, and winter is vilified.
“Summertime … and the livin’ is easy,” croons
Clara from George Gershwin’s opera Porgy
and Bess. “We know summer is the height of
being alive,” writes American memoirist Gary
Shteyngart. Consequently, on the other end of
the spectrum, winter is painted as the lowest of
low points — many a writer and lyricist anoints
“the winter of my life” as an absolute nadir.
“Now is the winter of our discontent,” mutters
Shakespeare’s Richard III in the famous opening
line of the eponymous play, musing upon his per-
sonal unhappiness.
Why is it that our society’s mindset always
defaults to this obstinate values-based judgment
of this dichotomy?

25
We as society put forth these sentiments as a
whole, as a monolith, as if a groupthink mentality
speaks for all of our individualized experiences.
The problematic dichotomy of “winter-bad, sum-
mer-good” becomes especially germane now, as
we are in the “dead” of winter. The issue at hand
is that in both in our field of psychiatry and also
colloquially in society, we state “seasonal affec-
tive disorder” with no specifier, with the underly-
ing assumption that winter must be the culprit
and thus the accurate diagnosis. However, in that
very nonspecific statement and what remains
under-addressed is the fact that for a small subset
of SAD patients, summer is the season of concern
(Wehr et al., 1987).
To this end as clinicians, we must be specific and
unassuming in our diagnoses and documenta-
tion — we must specify “MDD with seasonal
onset — fall/winter” or “MDD with seasonal onset
— spring/summer” unequivocally in our patient
notes, our professional presentations, and other
modes of communication to leave no room for
false suppositions. In recent years in the medical
field as well as society as a whole, there is for-
tunately more awareness of the importance of
diversity, equity, and inclusion (DEI); what better
demonstration of DEI than using inclusive lan-
guage to describe a specific condition rather than
wallow in ambiguity under a blanket assumption?
To this end as members of society, it bears to be
mindful of how we speak of the merits of each
season in our everyday lives. So often we hear
phrases casually tossed around — “wow, it’s such
a beautiful day outside” — referring to a stereo-
typically sunny day, with often the conveyor of
such a sentiment trying to garner agreement.
Suffice to say, philosophers and thinkers have
posited the adage “beauty is in the eye of the
beholder” for centuries to illustrate the subjective
differences of individual preference.
The clear conditions at 80 degrees Fahrenheit
with scattered clouds at 70% humidity may be
“beautiful” to some may be pure torment for
others. Perhaps an azure nirvana of “cloudless
turquoise skies” for one person is the equivalent
of a “shouting, splendid storm” (Ruess, 1998) of a
burgeoning blizzard for another, each exquisite in
its own way.
I advocate that we be mindful of language and
describe things objectively. The unbiased procla-
mation of “it’s a sunny day” said with enthusiasm
rather than the values-imbued “it’s a beautiful
day” still conveys the ardor (and accuracy) of the
speaker without pulling for bobblehead agree-
ment about the merits of subjective beauty.
Semantics matter, and we can take a cue or two
from our meteorologist colleagues to be appro-
priately descriptive and objective, and therefore
model even-tempered inclusivity in our speech.
We can learn much from the Scandinavian cul-
tures about their embrace of winter and actions
taken to make it not only palatable but also
enjoyable. The very idea of hygge — the “qual-
ity of coziness and comfortable conviviality that
engenders a feeling of contentment or well-
being” — even in the cold, dark, “dead” of winter
is a defining feature for the mindset of our fellow
humankind across the pond. The same cannot
be said for similarly northern-latitude brethren
living in the US. One seminal study (Magnússon
& Stefánsson, 1993) compared depression rates
of Icelanders and their similar latitude-residing
counterparts along the eastern seaboard of the
US; the Icelanders showed lesser rates of both
clinical depression and subsyndromal depressive
symptoms.
As with many things in medicine that are along
the nature/nurture spectrum, one can certainly
acknowledge the contribution of the gene pool
of people who live and survive in these colder cli-
mates, but much credit should be given to a way
of life and a way of thinking that embraces the
frigid and dark and turns them into cultural values
instead of seasonal nuisances.
The American conductor/composer Leonard
Bernstein is to have famously said “if summer
doesn’t sing in you, then nothing sings in you.”

References
Magnússon A, Stefánsson JG. Prevalence of Seasonal Affective Disorder
in Iceland. Arch Gen Psychiatry. 1993;50(12):941–946. doi:10.1001/
archpsyc.1993.0182024002500
Ruess, Everett, 1914-1934. Wilderness Journals of Everett Ruess. Salt
Lake City :Gibbs Smith Publisher, 1998.
Wehr TA, Sack DA, Rosenthal NE. Seasonal affective disorder with
summer depression and winter hypomania. Am J Psychiatry. 1987
Dec;144(12):1602-3. doi: 10.1176/ajp.144.12.1602. PMID: 3688288.
*Cynthia S. Peng (@cynthiaspeng) is a PGY-4 in the Brigham and Wom-
en’s Hospital Adult Psychiatry Residency program. She has lived on the
eastern seaboard for much of her adult life and her mood ranges from
tolerance to enjoyment of New England’s various seasons. Please stay
tuned for Part II of this diptych series, tentatively scheduled for early
summer 2024, on the complementary point of summertime sadness.
For email correspondence, contact Dr. Peng at cpeng7@bwh.harvard.edu
Maestro, I dare to disagree. We must move away
from speaking in absolutes and reliance upon
presumptuous beliefs. Though summer ordinar-
ily does not sing in me, I do see its meritori-
ous aspects (begrudgingly). Though winter may
not sing in some folks, we must not fall prey to
sweeping generalizations but rather find small
splendors in its quiet magnificence.
The way we use language as psychiatrists, as
physicians, and as members of society deeply
influences the attitudes and behaviors of oth-
ers. The verbiage we use represents our inherent
viewpoints – and thus patients, colleagues, loved
ones, and acquaintances alike are quick to pick
up on it and intuit our judgment. I advocate for a
more balanced, impartial use of our own words as
well as selective invocation of longstanding (if not
inaccurate) adages.
I truly believe we can do this. Even amongst the
chaos of our daily professional and personal lives,
we can still be intentful with word choices. We as
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a society can be more mindful and equitable in
how we personify and treat the different seasons,
not as a “one-mindset-fits-all,” but rather a com-
passionate recognition of the resplendent com-
plexity of how humans relate to nature.

27
Capturing the Human Figure:
More Than Meets the Eye
By David V. Forrest, M.D.*

S
ketching the human figure has long inter-
ested me, lately at the Society of Illustrators
at Lexington Avenue and 63rd Street in
Manhattan. I draw with a fine watercolor
brush which lets me fill in shading with washes, but
many others sketch with charcoal and now digital
media. A typical Wednesday evening, for which
one makes reservations, consists of timed poses
of ascending length. A full bar provides drinks for
those who want them. The model or models begin
punctually at 6:30.
First there are ten 2-minute action poses that
would be difficult for a model to hold longer. These
are often both the most inspiring and difficult to
capture in the short time allowed. After a 5-minute
rest, the model poses 4 times for 5 minutes each
and break again for 5 minutes. Two 10-minute
poses follow, a 15-minute break, and then three
15 to 20-minute poses with breaks. The models
rest every 20 minutes, a general practice in New
York. The atmosphere is friendly, and the sketch-
ers range from beginners to accomplished artists,
or those studying to be. There is no formal teach-
ing, but sketchers may show their works to one
another.
Some other ateliers offer longer poses lasting hours
with breaks during the same pose. Short poses are
challenging. In fact, they feel a bit like a workout
- even a sport, especially when the model is male.
Males have less subcutaneous fat and more muscle
definition to draw. Women have graceful con-
tinuous curves. Men prefer drawing women and
women prefer drawing women. Each is challenging
in its own way, and it is good to alternate.
Minerva Durham’s studio in Greenwich Village,
where I sketched for many years, has similar pos-
ing, but no drinks. Minerva is a superb art anato-
mist, and during her models’ five-minute breaks,
she gives mini-lectures on anatomy - the muscles,
their proximal origins, and their distal attachments
to the skeleton. the underlying layers that work in
concert and contribute to bulk, the features.
All this we learned in medical school. But art-
ists’ anatomy is another knowledge and skill, and
Minerva teaches how the muscles look in different
postures and make up the outlines and the mass
of the forms and shapes. She draws upside down
with a pad on her lap. And how is one to make art
of this, as countless generations of artists have, and
Minerva also shows? Part of a work of art is select-
ing what is left out.
Why do artists return to the human figure, some
in the reconstituting way that musicians return to
practice scales? The short answer is that it end-
lessly instructs and improves their skills. But why
do I as a psychiatrist and physician, remain so fas-
cinated? It’s not just I. Other medical colleagues
also relish sketching the figure. Marcel Schwantes
reported in Inc magazine of 9/30/23 that studies
at Drexel University found that making art - even
as minimal as doodling - lowered stress and made
people more productive and creative.
No doubt some of us psychiatrists may be return-
ing nostalgically to the study of the anatomy we
largely forsook in our choice of specialty. But I
propose there is much more to it than that. Much
as we study the emotions in the patient’s facial
expressions, we also appreciate emotions in the
graceful expressive play of their gestures and
postures, much as we do at the ballet and other
dance. These are provided by our mammalian and
hominid inheritance, with variations shaped by cul-
ture and nurture.

29
Accounting for all of this graphically is a never-
ending challenge. It is a learned skill, and many of
the sketchers are honing their skills to assist their
developing careers in fine art and illustration, car-
tooning, animation, and visual storytelling. They
can become members of the Society of Illustrators
because they earn or will earn their living by their
skills. The rest of us who mainly earn our living by
other means can become Friends of the Museum.
One satisfaction is the learning and exercise of
mastery in accounting for the human figure before
us. Producing a concrete and enduring material
work is fresh and satisfying for those of us who
labor in the less tangible realm of mental change.
But surely there is something more elemental to it.
We affirm our connection to the physical humanity
before us, to which we belong. How does light and
dark illustrate the proportions? How do the folds
gather, does the drapery of costumes fall? How to
capture the human spirit of the silent model?
An interview study of 30 female and five male
fine arts models who pose in the nude, which I
published with my images of them (Beyond Eden:
The Other Lives of Fine Arts Models, Outskirts Press,
2017), was surprising in many ways. The models
independently agreed their posing is not erotic. They
are not sex workers and, though they allied with
and often also performed in theatre arts, posing is
sui generis. Although it is demanding physically and
emotionally, it felt uplifting and beneficial. In fact,
the effects were so positive it led me to suggest that
disrobing for physical exams, handled well, was itself
an important part of our physicianly care. The study
attempted to interrogate the psychoanalytic basis for
the effects.
Religions have dealt variously with depictions of the
human body, from veneration to hatred or avoid-
ance, holy to dangerously seductive. In their extremes
they have avoided depicting or worshipped the divine
body. Buddhism prohibited its stereotypical image of
the Buddha before permitting it in the second century
CE. Hinduism sees multiple and complex symbolisms
in the body while permitting its erotic use. One is that
the body is a temple. Judaism believes circumcision
perfects the body in a covenant with God and avoids
depictions. In Christianity, Christ’s tortured sacrificial
body becomes the panis angelicus of communion.
The Greco-Roman tradition elevated the beauty of
the body as an ideal, continued in the Renaissance.
It is difficult to contain one’s awe upon entering the
Borghese Gallery in the center of Rome and viewing
the greatest marble statuary. My favorite is Bernini’s
Apollo and Daphne, portraying the moment when
she is resisting him by turning into a laurel tree with
marble leaves so fine they are translucent. I apolo-
gize today for loving a sculpture of an unasked divine
advance upon a woman, a subject which has inspired
the art of other religions. See it while you can.
Canova’s Reclining Naiad also appears preternaturally
alive. In such sculptures the marble seems more like
flesh than flesh itself. It does also in Bernini’s Sleeping
Hermaphrodite at the Met.
Leonardo’s Vitruvian man was named for the Roman
philosopher Vitruvius who proposed that if a man
lay on his back with his arms and legs extended, his
fingers and toes would touch the circumference of a
circle with his navel at the center. The height of his
body would be the same length as the outstretched
arms, forming a perfect square. Leonardo could and
did address many scientific matters but returned to

his fascination with the human body. This might be
a literal representation of his humanism, and that
of the Renaissance, and even that of us who return
over and over to capture the figure.
In more modern times perhaps Egon Schiele is the
most admired by the figurative artists I have drawn
with, for his line and his elegant distortions.
The dyad of artist and model is an ancient one. If
it can be said that the relationship of analyst and
analysand, patient and physician, is like no other,
the same can be said of artist and model.
In a small way, I find my own depicting of the
human figure makes me feel allied with the history
and antiquity of figurative art. The figure is inex-
haustibly inspiring. There is so much more to mak-
ing art from it than I have been able to say here.
*For email correspondence with Dr. Forrest,
contact davidvforrest@gmail.com

31
By Phil Lavine, M.D.
Artwork
by
Brett
Sayles
S H O R T S T O R Y

I
have attempted to present cases here-
tofore not reported due to the need
to protect my patients from being
revealed as psychoanalytically treated. In
the years since I conceived of this type of
treatment for neurotic disorders, it has
become apparent that our patients have
not escaped the ravages of negative so-
cietal attitudes which have always — for
centuries — been attached to individuals
with mental problems. I had hoped that
this poor regard for our patients would
have lessened once more scientific expla-
nations and treatment had been found.
Alas it has only been transmuted into hos-
tile regard for us as psychoanalysts and
our patients. It seems society in general
cannot tolerate those whose minds have
gone astray and must denigrate and ridi-
cule those who truly try to find effective
remedies through psychoanalysis. I must
insist — paraphrasing the great Socrates
— that an unexplored life is a superficial
one. Time will show — as it has to some
extent already — that talking analytically
about one’s problems is profoundly ben-
eficial to the human condition!
To support this latter point, I present
now, one of my prior cases, of a remark-
ably talented, yet severely traumatized
woman who was brought to see me in
1927 all the way from Mexico City. At
the time of this writing in 1939, I can
feel proud of having helped this woman
to recover enough of her resilience and
stamina to become a serious and success-
ful — I would even say world renowned
— artist. But I get ahead of myself and as
always will start at the beginning.
Miss K’s father had begun writing to me in 1926 about
his daughter. She had been involved in a serious and life-
threatening accident when she was 18 years old in the fall
of 1925. He described the injuries as horrible, yet she sur-
vived several surgeries and months of hospitalization and
invalidity. She had given up and was seriously withdrawn.
Much of her being bed ridden was due to this neurasthenic
state complicated by pain and physical problems. Would I
consider taking her into treatment?
I was intrigued and agreed to evaluate her. Indeed, if they
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were willing to seek out my help on such a long journey,
then I should provide my expertise.
According to her father, she had been ambulatory since the
fall, but alas would do little, remaining in bed, withdrawn
from the world and sullen. She was of a hostile disposition
to any who visited her. During the summer when she had
been encased in neck to pelvis plaster casts to help her se-
verely injured spine to heal, a special easel had been made
for her to allow her to paint while being forced to remain
on her back. Although she painted numerous pieces while

33
locked into the plaster, she had apparently lost interest
since. Her father sent me a photograph of a remarkable
self-portrait which she had painted for her boyfriend A.
She and her father booked passage to Europe and then
came to Vienna where they remained for many months
while her treatment proceeded. Not exactly a case of
depression — more of a hostile battle with her condi-
tion — the analysis of Miss K proved to be one of the more
arduous in my career. In tandem with the listlessness, was
a spirit that was infused with energetic rage, an acerbic
personality and tremendous creativity. Her transference to
me was immediate, mostly negative, but vibrant and very
much of — to my dismay — an uncontrolled process.
I recall my first encounter with her. It was difficult at first
to see she was a petite young woman as she was attired in
brilliant red and green skirts, a colorful blouse and jacket
embroidered in traditional Mexican styling. Her hair was
complexly arranged on her head with jeweled and ceramic
pins, one of which was a skull. She looked impatient as I
beckoned her into my consulting room. The scowl on her
face was enhanced by the significant dark eyebrows that
almost met in the midline.
She spoke fluent German — as did her father — but clearly
with a sharp Mexican accent. She immediately, but cau-
tiously, sat down on the divan and fixed her dark eyes on
me. Before I could speak she began!
“Well Herr Doctor, I am here but I want you to know that
my case is hopeless, and it is unlikely you will be able to
help me. I am here because my dear father begged me to
come. My life is ruined, but I agreed, as a trip to Europe
seemed an interesting thing to do while I wait to die. What
do you have to say about that?”
“That is quite an introduction, young lady….” I said in a
grandfatherly fashion, “Tell me more about why you don’t
want to live.”
“You didn’t listen to me HERR Doctor,” she said the “Herr”
with notable insolence, “I said my life was ruined, not that I
wanted to die….”
Already feeling attacked by this dark but attractive girl, I
said, “Go on…”
She only stared at the carpet, and I could see the telltale
signs of tears coming to the surface.
“Your father wrote that you had been in a terrible accident.
Perhaps you could tell me about that.”
“That!” She spat at me, “How could you insult me so by
summarizing my experiences in one single word.”
I remained silent again, but noticed now that her eyes
showed an air of devilishness in them as she stared at
me. It seemed she would rather fight than cry, revealing a
palpable strength which I considered a positive prognostic
sign.
“I am glad to hear that you do want to live, yet you seem
unable to do that … well. And this makes you very angry.
I would like to understand how you have come to this
impasse in your young life, but your anger at me is likely to
prevent that from happening… I am not the cause of your
problems, yet you act as if I am.”
My gentle confrontation led her to look away. Her profile
was graceful, and I began to feel positively toward her. She
had been severely traumatized, yet had traveled halfway
around the world, perhaps with some hope that psycho-
analysis would help. If only she would be willing to collab-
orate rather than fight. I had interpreted her instantaneous
negative transference and it had shifted ever so slightly,
but my experience led me to expect this would be a con-
stant irritant to the treatment if she continued.
“I wonder why there is so much anger….” I queried after a
few moments.
“I am not ready to discuss that Herr Doctor… perhaps the
next time we meet….”
So, she was planning to return!
“I accept that, in the meantime tell me about yourself….and
what you know about me and psychoanalysis.”
I gave her a choice, to either talk about herself or about
something more neutral. Indeed, most intelligent people
by 1927 had heard about me and psychoanalysis. My theo-
ries and techniques had become well known and even in
some quarters had been targeted for ridicule — a sure sign
that my theory and research were getting under peoples’
skin, revealing unconscious resistances.
She began to talk about my book “The Interpretation of
Dreams” which she had read in the National Preparatory
School in Mexico City where she had gone to study medi-
cine.
“I enjoyed reading that book but came away thinking you
were some big shot doctor who thought he could open up
people’s brains and then tell them what was wrong with
them. Were you trying to be just like a surgeon?” She raised
her formidable eyebrows and smiled sadistically.
Alas she had returned to trying to hurt me, and I must ad-
mit that her comment did trigger defensive stirrings. It was
nothing I hadn’t heard already from many critics.

The time was running out and I wanted — perhaps a bit
desirous of engaging her in the boxing ring she had created
— to once again focus on her pain.
“I assume that you have had plenty of experience with
surgeons….” I said to her in a playful retort. Perhaps the
way around her massive defensive transference was with
humor….
She scowled at me, then smiled.
“Our time is up, but perhaps when you return tomorrow
you’ll consider lying down on the couch.”
“You would like that wouldn’t you? Perhaps we will see….”
...
She did indeed return the next day but failed to recline on
the divan. She sat rigidly and stared at me with a mix of
interest and anger.
“Perhaps reclining might be too painful for you?” I started
off with the last topic from the day before.
“What is it to you Herr Doctor? Why is my lying down so
important to you?”
She was attacking again.
I remained silent briefly.
Being silent in the face of negative transference was a
skill I had worked hard to cultivate over my career, and in
which, I must admit, I never became proficient. It was not
in my nature to remain passive, especially when attacked,
but I was convinced that introducing conflict would not
help my patients and, in particular, would not be of benefit
for Miss K.
On the other hand, she might respond to a more lightheart-
ed approach.
“Well, it certainly isn’t in the service of this old man taking
advantage of you. What I know of you already is that would
be a serious mistake!”
She again smiled.
“Would it feel bad to you if you reclined? I was more neu-
tral, choosing not to discriminate between emotional and
physical pain.
She looked momentarily puzzled but quickly re-estab-
lished her haughty countenance.
“What do you know of feeling bad Herr Doctor? Nothing
could feel worse than what I have gone through in the last
few years. In fact, I feel very good about not giving into this
terrible pain.
“Is that how you have tried to manage it? By fighting?”
“Do you have any better suggestions?” Scowling, she
looked away.
Again, side stepping her challenging questions, I noted, “I
wonder how ‘fighting it’ has worked for you.”
“It works just fine Herr Doctor, I am here, I’ve traveled
halfway around the world to your consulting rooms, and I
am surviving!”
“You asked if I have any other suggestions than taking a
fighting stance — to your accident, to me, to who knows
what else — and I would suggest that perhaps talking
about what bothers you might help you feel less angry.”
“How can you know what bothers me, Herr Doctor?”
I assumed, as anyone would have, as her father had in his
letters, that the source of her difficulties was related to her
accident. As I discovered later, and as I had seen countless
times in other patients, it wasn’t the best thing to make
such assumptions. It was more important to listen to the
words of the patient.
“I suspect there is much pain….” Again, I was ambiguous
about the source of her pain.
She took a deep breath and sighed.
“Indeed, there is much pain, but explain to me how talking
about it would help it go away.”
“Perhaps the pain is not just physical,” I wondered. “Your
father told me in his letters that you just lay in bed most of
the time and have no interests to speak of, and you said at
our first meeting that your life is over. Physical pain alone
doesn’t create these feelings.”
“It is not true that I have no interests. Are you aware of my
art?”
“Tell me about that.” I urged her on.
“Always words Herr Doctor, does everything have to end up
in words?”

35
“What makes talking about your art something to resist?
Or is it just that I value words and you must fight that….”
“I do not resist art. It is the way I express my feelings; it
works much better than just talking…”
“I would like to understand that more, but what makes
me more curious is why you must fight with me. As I said
before, I didn’t cause your accident, I haven’t ruined your
life, all I’d like to do is help you find some reasons to live
and even — hopefully — enjoy life.”
She remained quiet and sullen. I kept silent. Eventually she
spoke in a less combative manner.
“I suppose it is true that you are not the cause of my pain.”
She smiled, then very matter of factly said, “It is just what
is in the cards for me.”
“Do you enjoy your painting?”
She looked at me with a sparkle in her eyes and said, now
in a more playful fashion than hostile, “you have caught
me in a trap now, of course I enjoy my painting, it’s the one
thing that I do that I enjoy.”
“Well, that is a good thing then, is it not? And if you can
enjoy painting, then the world opens up for you to enjoy
other things, no?”
“I will bring a painting next time for you to look at and then
you will see my ‘enjoyment’.”
...
We met daily for the next several weeks. She indeed
brought in various works of art with many different sub-
jects, a most unorthodox style, almost surrealistic but not
exactly. Almost always she was present — sometimes twice
— as a portrait or a figure. She even came in once and
spent almost the entire session sketching me. (She gave me
that drawing, but alas in our move from Vienna to London,
it, like so many other cherished mementos was lost…)
She still refused to lie down and free associate. Yet our
interaction took on an easier cadence; we traded jibes
with good natured humor. I kept waiting for her to talk
about the accident, hoping this would be cathartic, but I
was happy just to let our interactions occur and allow time
to facilitate the growth of trust she needed to share her
secrets.
She would at times refer to the accident, but in a passing
and unemotional way. It had become a fact of her existence,
nothing more or less, something she had to live around rather
than bemoan or blame. It was difficult to accept that this
might be the case, but she was quite convincing. I began to
wonder about what else might be making her feel hopeless
and in need of controlling as much of her world as she could.
She talked about her life before the accident, how she had
had polio as a child, but survived that, and worked excep-
tionally hard — and successfully — to overcome the slight
weakness in her lower leg. She enjoyed regaling me with
stories of her mischievousness as a student and talked of
all the friends she had at school.
“And you mentioned you had a boyfriend for whom you
made a portrait of yourself….”
There was a break in the rhythm, a slowing that was pal-
pable.
Of course, the boyfriend! Was this the thing that was caus-
ing her failure to live?
“I do not wish to talk about A. I do not believe he loves
me anymore.” She tried to remain matter-of-fact but tears
seemed to appear in her eyes.
Now I did remain silent.
...
She did not talk any more about A that session but re-
turned the following day appearing happier with less
anger.
“I do want to tell you about A. He was on the bus with
me. He had been my “novio” for 3 years, but I fear he has
abandoned me. He never came to see me after the accident,
even though I pleaded with him to come.
“Never?”
“Well, it was good as never…. He sent letters and from time
to time and would deign to visit me occasionally. But when
he did, it was strained you know. I think he stopped loving
me then but has just been trying to pretend ever since.

Borders, Belonging, and Betrayals: A Poetic Conversation Among a Palestinian Israeli Psychologist, an Italian Canadian Psychiatrist, and a Canadian United Church Pastor in a Time of War

Borders, Belonging, and Betrayals: A Poetic Conversation Among a Palestinian Israeli Psychologist, an Italian Canadian Psychiatrist, and a Canadian United Church Pastor in a Time of War

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Borders, Belonging, and Betrayals: A Poetic Conversation Among a Palestinian Israeli Psychologist, an Italian Canadian Psychiatrist, and a Canadian United Church Pastor in a Time of War