It's About Time

This article in today's New York Times chronicles psychiatry's miserable failure to confront the ravages of smoking in psychiatric and substance abuse patients and the feeble attempts to set things right. I have some stories of my own. 

During my residency training in New York City in the late 1970s I recall during a meeting with other residents asking then psychiatry department chairman and Kennedy friend Joe English, MD, who would later become president of the American Psychiatric Association, to put out his cigar. He glared at me and said, "Suffer." But he did put the cigar out. I hope Jeffrey Lieberman, MD, president-elect of APA, and my chief resident around the same time, has been able to quit smoking cigarettes, and I hope my influence played some role in that.

I recall attending a lecture by Joseph Califano, Secretary of Health, Education, and Welfare during the Carter administration, at Gracie Square psychiatric hospital in Manhattan around 1980. He was said to have giving up smoking himself when he took the job. Upstairs from the lecture room, psychiatric patients could still buy their cigarettes from a machine in the day room and puff away to their heart's content.

Judith Gilbert Kautto, my supervisor for family systems psychotherapy at Center for Family Learning, and coauthor of "The Evaluation and Treatment of Marital Conflict: A Four-Stage Approach," smoked during supervision sessions. She was less accommodating than Dr. English.

I recall videos of pioneers in various methods of psychotherapy smoking with their patients, oblivious to the associated health risks. I never heard an adequate explanation from any psychotherapist, whether psychoanalyst or cognitive behaviorist. Imagine the meaningful connections a psychoanalyst could draw from the practice of an analyst joining in such self-destructive behavior with the analysand. Any such explanation would belie the real explanation: both patient and analyst feared they could not get through even a fifty minute hour without nicotine fixes to soothe withdrawal symptoms.

Somehow homeless schizophrenics and bag ladies on the city streets, no matter how poor, always seemed able to afford cigarettes. Maybe the appetite suppression ("Reach for a Lucky instead of a sweet.") helped them tolerate a lack of food.

Nicotine as well as caffeine fuel many meetings of Alcoholics Anonymous and other 12 step programs. One might argue that giving up all addictions except nicotine threatens recovery from the more immediately destructive addictions. Somehow this rationale tends to trump the equally logical notion that learning to give up all addictions might improve the chances of recovery. Now at least many support group meetings ban smoking.

In the hospital setting staff used cigarettes for behavior control, and they feared violent uprisings by psychotics denied their nicotine fixes. Many staff being smokers themselves, they could empathize with the suffering inherent in abstenence from the drug. The "self medication" hypothesis provided another rationale (excuse), and indeed research has explored nicotines potential as a treatment.

Substance abuse rehab programs contemplating prohibition know that they would lose market share to other programs that continued to allow smoking.

Ultimately this dismal failure to promote health boils down to convenience and -- who would have guessed? -- denial. Let's hope for the sake of our patients we can all bite this bullet and, like the words of the Hippocratic Oath, first do no harm. It's about time. To paraphrase Dr. Freud, sometimes a cigar is just a way to get cancer.

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