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Book Review: In Her Wake: A Child Psychiatrist Explores the Mystery of Her Mother’s Suicide (Hardcover)

An absorbing book

In Her Wake: A Child Psychiatrist Explores the Mystery of Her Mother’s Suicide (Hardcover)

By Nancy Rappaport, MD, Basic Books, 2009, 320 pages, $25.95

Reviewed by Lois T. Flaherty

This book is an account of the unaccountable – when the author was 4 years old her mother committed suicide. The author was the youngest of 6 children in a prominent Boston family. She and her 5 siblings were raised by her father and a series of mother figures after their mother’s death. The story of her childhood has Dickensian elements but she survived to achieve success in love and in work. This book is an account of her life-long struggle to understand her mother and come to terms with her own traumatization as a result of the cascade of events the suicide set in motion.

Of particular interest to ASAP members will be her descriptions of her adolescent experiences –– she experienced, by any definition, a turmoil-filled adolescence. Psychotherapy played an important role in her overcoming many difficulties, and her descriptions of her therapy from an adolescent’s point of view are worthwhile for any adolescent psychiatrist to read.

Rappaport left no stone unturned in fact-finding – as her mother had been prominent in Boston social circles and politics there was a lot of material available. The book has elements of biography, autobiography and investigative journalism. In a way, the city of Boston is really one of the characters in the story. The parts about Boston politics and history were fascinating.

As another Amazon reviewer, D. Kulick reported, In Her Wake is a beautiful, powerful memoir about the process of belonging to a family, coming to know oneself, making meaning from the lives of those closest to you, and, ultimately becoming established and grounded in your own identity and life’s mission. We get to know Dr. Rappaport from the inside out, from a frightened child, bewildered and sad about the tragic loss of her mother and confused by her family’s reactions, but also a child who is resilient and is able to develop strong connections with others and see a future for herself. Others who have endured tragic events in their childhood will easily identify with Dr. Rappaport’s journey. It’s more than a memoir though, it’s a tale of hope, connection, forgiveness and learning to forge ahead and make a life of meaning even though there is an emptiness at times. Dr. Rappaport shares how she became a dedicated mother and a child psychiatrist who has dedicated her life to working with children and families affected by adversity. Her book shares how she comes to honor her mother and how her search to know her mother has made her more alive and connected in every part of her life.”

I loved it and found it very absorbing and moving. It reads like a fast-paced novel. But, in addition to the compelling story, the insights are amazing. Using the perspectives of so many different people really adds a lot. I loved the way that Rappaport interweaves her own thoughts and feelings with the narratives of interactions with her family, patients and other people.

There is a beautiful sparseness in her writing and the way in which she shifts from one topic to another is suggestive of actual thought processes, the narrative of an inner life, rather than a historical account.

The book is a good illustration of resilience, a concept that is receiving increased attention, and shows the value of narrative in coming to terms with traumatic experience. This book has already received considerable critical acclaim and I definitely recommend it. An added reason to read it — the author will be speaking at our Annual Meeting in Los Angeles in March!

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From The President, Adam Raff

2011-01-29_17-05-42From the President

Dear Society Members,

The executive committee and governing board of ASAP recently held its annual business meeting in Dallas and I want to share with you several of its important outcomes. First, after years of struggling to clarify some complicated financial issues that linked ASAP and its Board (ABAP, American Board of Adolescent Psychiatry), a merger has been successfully negotiated. The details include ABAP merging into ASAP as a semi-autonomous component of the latter, which will continue to carry out the duties and responsibilities and goals of ABAP. Since it will no longer exist as an independent organization, ABAP will be known as ASAP’s Council on Certification in Adolescent Psychiatry and will continue its primary function of promoting and maintaining ASAP board certification. ASAP’s obligation to this council will continue until the fiscal 2013 or the last re-certification of an ABAP diplomate, whichever occurs first. All ABAP funds will be set aside exclusively for expenses incurred by the Council on Certification in Adolescent Psychiatry to be expended upon the approval of the ASAP President and The Council on Certification in Adolescent Psychiatry. In addition to reconciling important outstanding debts to ASAP, we hope that this merger, long in the making, will also serve to create a more integrated administration and maintenance of certification as well as act as a spring board for coordinating new examinations for future certification.  Also, in the best spirit of this merger, we hope to encourage those ABAP diplomates, who have let their ASAP membership lapse, to rejoin the society at a reduced rate of $195.00.

Second, our society’s finances, while not robust by any measure, appear to have withstood significant debts, helping us to maintain some modest profits made at our last meeting. In fact, despite our perennial struggle with increasing new membership, our standing membership has stabilized. I believe this was due, in part, to our group’s decision to coordinate a more affordable annual conference while still providing high quality presentations. The fact that we can no longer enjoy the benefits of holding longer meetings in more luxurious venues has not escaped me and some of you who attended in New York City.   I can only attempt to reassure those who expressed their disappointment that such program decisions, based on our finances, were not easily made but have been essential for us to survive to see better days.

Third, ASAP has a proud history of participating in and taking positions on a range of major legal issues and health care policies that have impacted our adolescent population. Our group has been notably present in national issues such as the death penalty for adolescents.  To that end, we are hoping to stimulate society members to participate in submitting ideas and that our community can promote in the form of ASAP position papers or briefs.

Finally, please reserve the dates, March 6-7, 2010 for the ASAP annual conference at Cedars-Sinai Hospital, West Hollywood/Beverly Hills, CA. The two-day program, to be coordinated by our own Dr. Joseph Kenan, will focus on themes of trauma in the practice of adolescent psychiatry. It should be a wonderful meeting and I look forward to seeing you all there.

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Report of the APA Assembly

Richard Ratner, M.D.

Folks:

So the APA Assembly met again in November at the JW Marriott in Washington, DC.  It’s unclear whether it will ever meet again in its current form because of APA’s seriously declining revenues from the loss of big Pharma advertising and participation at annual meetings.  During the past year, the Board of Trustees laid off at least 12 people, cut 20 positions, combined or disbanded some committees, and has left others to die on the side of the road.  One of these was the Committee on Psychiatric Dimensions of Disasters (CPDD), whose members have been passionately trying to reconstitute, possibly as an Assembly committee.  The trustees mandated a $200K reduction in the Assembly budget, and then as the meeting began, directed that an additional $200K be cut.

Finances

The Assembly went about cutting expenses via a variety of proposals, which included changing to one meeting per year, cutting out the deputy representatives from the Assembly, or keeping everyone on board but requiring that all the delegates pay some or part of their own travel expenses to Washington each November (Nobody is paid to attend the other Assembly meeting that takes place just before the annual scientific meeting in May).

Ultimately, the Assembly voted to de-fund most of the dep-reps, reduce representation from certain parts of the country, eliminate certain meetings and travel budgets, but continue to meet twice yearly.  Further cuts are entirely possible. One bright light at the end of the financial tunnel is DSM-V.  When it comes out it will doubtless prove another windfall for APA (DSM IV was a gift that even now keeps on giving).

Ethics

With all the attention on state of finances, there was less time and energy left for other initiatives.  One, the approval or rejection of the Draft Report on Relationships between Psychiatrists and the Pharmaceutical/Medical Device Industries, was put off for reconsideration until the spring.  This document, dubbed the “Appelbaum report”, if passed will have the status only of “recommendations” rather than ethical precepts.  In other words, members would have the option to ignore them if they so choose.

There has been a lot of controversy over this document.  It basically frowns on nearly any “perk” traditionally extended from industry reps to psychiatrists, including “gifts”, even of “token value”, food of any sort paid for by drug companies, and involvement in many consulting arrangements.  The real objects of the guidelines are colleagues who have gotten too dependent upon drug company money and who are likely to shade their research or clinical presentations, not to mention involvement in other forms of potential conflict of interest

Many of the rank and file among us are upset by the guidelines, which not only imply but virtually state that the presence of pens and pads in our offices and luncheon sandwiches over which reps make their pitches adversely influences our behavior to our patients.  My view is that the colleagues who have made such Draconian recommendations necessary are the relatively few who have allegedly sold out in big ways and have reaped rewards of a different order of magnitude than pens and pads.

Nonetheless, the temper of the times, coupled with the misbehavior or a few, have brought these recommendations about.  The AMA and other groups have already enunciated similar guidelines, and for its part, Pharma seems to have cut far back on its own.  If APA were to reject them, we would likely be singled out for abuse by all the usual critics of organized psychiatry.  They are in any case, recommendations only, and after an opportunity to vent their frustrations, I expect the Assembly to approve them.

Other Issues

Among motions that were passed was one calling on the APA to “endorse and promote “patient” as the official and appropriate term for psychiatrists to use in referring to those persons they diagnose and treat. It should be clear to all readers where that resolution came from.  A position statement was also passed cautioning against the abuses implicit in what was called “high volume” psychiatric practices, where individuals are simply not given enough time for any meaningful treatment.  Another motion that passed calls on the government to do away with the “don’t ask, don’t tell” provision for dealing with homosexuality in the ranks of the military.

One other measure passed requested that APA look at the issue of so called “me-too” medications.  Many organizations would like to limit their formularies to only a couple of antidepressants or antipsychotics, complaining that the numerous other medications in those classes are simply “me-too” and as such are not needed.  All of us with actual experience have found that, whatever the reason, some of these meds will work when others, closely related, will not.  To either not keep them available or to discourage research and development is a negative outcome that this action paper hopes to prevent.

The Assembly will meet again in May 2010 in New Orleans, site of the next annual scientific meeting.   Before then, elections will be held, with Donna Norris and John Oldham running for President-elect, and David Fassler and Paul Summergrad running for Treasurer.  As usual, this issue of the ASAP newsletter contains the president-elect statements for us to read before voting.

Until then your trusty APA rep/liaison is signing off.  Hope to see you all in March in LA and in May in New Orleans.

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