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


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Paul Linde uses both to show readers the full range of day-to-day life in the ER. As a result, Danger to Self speaks both to health professionals and those interested in a good story; Linde delivers through chapters dedicated to individual cases and the insights they provide. His vivid, often chilling descriptions of the situations he must mediate show us why.

With each emotion, Linde tells us a story. In an era where nearly every network TV show is set in a hospital, Danger to Self provides an accurate, prescient account of real-life psychiatric care, eschewing a dramatic tell-all format in favor of warts-and-all faithfulness to the experience. January Rachel Mennies.

Disclosure: This article is not an endorsement, but a review. The author of this book provided free copies of the book to have their book reviewed by a professional reviewer. No fee was paid by the author for this review.

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Thank God you guys are there. Society as a whole would much prefer not knowing what happens behind the closed doors of psychiatric emergency. It could happen to you. There but for the grace of God go you, your partner, child, sibling, parent, uncle, aunt, grandparent, cousin.

Severe psychiatric illness can happen to anyone. On the surface, this book demonstrates the nature of my work as a psychiatrist in a wide variety of settings, but mostly in the psychiatric emergency room at SFGH. It shows the kind of tasks given to me, what I do, how I talk to patients, how I think, and how I make decisions in situations that can best be described as knotty, enigmatic, and almost never routine. When all is said and done, society is paying me to exercise my best professional judgment in trying to solve seemingly insoluble problems. My decisions are made in a financially deprived and pressurized environment, often with incomplete data, and the tasks are rife with ethical dilemmas.

Though I am, of course, obliged to be an able and compassionate colleague, supervisor, teacher, and practitioner, I mostly get paid to make good decisions as a proxy for society as a whole. I provide a skill set, experience, and a willingness that few others can give to the work. The task is a grave but wonderful challenge. As you read this book, you will no doubt see the setting of psych emergency for what it can be: loud, chaotic, smelly, messy, and dangerous, among other things.

And you will sense the tension inherent in the work.

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But you will also see the redeeming essence of the work: the moment-to-moment relationship between doctor and patient. What kind of doctor becomes an emergency psychiatrist? A psychiatrist friend of mine once said, You guys who work in PES are good at chatting people up—kind of like a bartender. My mentor in the psych ER, Dr. Bob Buckley, differentiates emergency psychiatrists from other psychiatrists in this way: I think a lot of psychiatrists are reflective, maybe a little obsessive.

The surgeon-author Richard Selzer writes, If all Medicine be considered a religion, why, then, the psychiatrist is the cloistered nun, a contemplative whose pale hands are unused save for the telling of beads. The surgeon is burly, brawling Friar Tuck, out in the world, taking up his full share of space, and always at some risk of exposing rather too much of his free-swinging beef from beneath his habit. While the book is part memoir, part primer, and part commentary, what I am most interested in is documenting my experiences and those of my patients. I search for verisimilitude; I aim to capture the essence of the work.

But in doing this I am, of course, required to strike a delicate balance between getting the real story out and protecting the confidentiality of patients, without sacrificing the essential truths that I explore. The patient stories in each chapter are closely based on actual events and circumstances.

In other words, they really happened. The names of some of the nurses were changed to protect their privacy. The dialogue as presented here was not transcribed from audio recordings. Taping patient interviews in the psych emergency setting and in most psychiatric clinical environments is considered illegal, unethical, and a breach of confidentiality. Because of this, the conversations presented here have been reconstructed from memory.

PAUL LINDE, MD / Danger to Self: On the Front Line with an ER Psychiatrist

Every attempt has been made to follow a credible line of inquiry between doctor and patient and to capture the general tone of those interactions. I wrote this book for the educated lay reader. It is a work of commercial—dare I say literary? It is in no way intended to be a comprehensive perspective on emergency psychiatry.

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Though I provide citations to identify sources of quotes and to support certain statistical facts, the book is not meant to be a scholarly work. Topics such as civil commitment law, malingering, violence, cognitive neurosciences, the nature of consciousness, and suicide are areas of concentration suitable for full-length academic books. These topics can be only superficially summarized, at best, within the confines of narrative-driven chapters like the ones I offer here.

The first chapter in this book details my introduction to psych emergency in , my first day on the job as a fully trained attending psychiatrist. The first narrative describes a hair-raising experience I had while moonlighting at the county jail. The second illustrates my reaction to a potentially homicidal patient in my office.

PAUL LINDE, MD / Danger to Self: On the Front Line with an ER Psychiatrist | The Booksmith

And the third chronicles my fledgling attempts at learning to become a psychotherapist. The remaining chapters are organized as much by theme as they are by chronology. Chapters 5 through 7 not only give you a greater sense of the atmosphere and problems experienced in a place like psych emergency, but they also provide a context in which to understand the complex decisions and value judgments that acute care psychiatrists must make. These chapters touch on fundamental existential questions: What is the nature of freedom and autonomy?

Who deserves treatment? What are the historical and legal contexts in which these decisions are made? How aggressive should a psychiatrist be in making decisions and delivering treatment? Chapters 8 and 9 document two common problems seen in psych emergency—methamphetamine abuse and the lingering effects of childhood trauma. The questions explored in these two chapters include: Why do people use drugs? What is the nature of suffering? How does one cope with demoralization in the face of overwhelming life problems?

How does one find resilience and a sense of meaning to counterbalance such things? The tenth chapter is an outlier. It occurs in a different setting—with me as a consultant to a liver transplant team in the medical-surgical part of a private hospital. Yet it more deeply explores the questions of who deserves treatment and how scarce resources get distributed. In writing this book, I discovered that psych emergency has cast a sort of spell over me. For many of the mental health professionals who work there, myself included, the attraction to the place and the work borders on the obsessive.

Even after living and working as a psychiatrist in Zimbabwe for a year in the mids—an experience that formed the basis of my first book, Of Spirits and Madness: An American Psychiatrist in Africa —I made a beeline to my next job in psych emergency. The place drew me all the way out of Africa—a subconscious clarion call. Working in such a place as psych emergency is not just compelling but actually addicting. Yet working there is one thing; writing about it is another. Mine is considered an out-of-sight, out-of-mind job for a reason.

There were many, many days when I sat down to write about my work in psych emergency and nothing came out. Or I had to literally force my fingers to move across the keys. On other days I was in the mood to vent, and what came out was splenetic, bilious, over-the-top, sanctimonious—in a word, unusable.

However, these eruptions proved cathartic—a laxative for the psyche, so to speak—and much, much cheaper than becoming a perennial Woody Allen manacled to an analytic couch.

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On the face of it, Danger to Self refers to the physical dangers for both patients and staff—self-injury, suicide attempts, assaults, illness. But for legal purposes, danger to self means a risk of suicide or other self-harm. On a deeper level, the title refers to the emotional danger—of absorbing toxic energy with no outlet—inherent in the work of a psychiatrist, particularly an emergency psychiatrist. Occupational hazards for the modern-day psychiatrist include anxiety, depression, alcoholism, addiction, and emotional withdrawal.

The writing of this book manifested an enormous psychological defense—the creation of an Other to counterbalance my shadow self. A deeper consideration of the day-to-day suffering that I witness and try to alleviate has forced me to confront my actual feelings about my chosen career, which are highlighted by ambivalence. Am I really the informal, irreverent jokester that I sometimes like to consider myself? Well, yes and no. The clown is also a persona, a defense, created to soothe and bandage raw emotions that are stirred by the serial suffering and tragedies that confront me daily in psych emergency.


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Is it me? Or is it a defense? Can it be both? This book is intended to humanize psychiatrists, other mental health professionals, patients, and their loved ones. It is okay for psychiatrists and other mental health professionals to be ourselves with patients. It is okay at times to laugh, to swear, to self-reveal, to cry with our patients—to emphasize our humanity. It does not mean transgressing boundaries.


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  7. This stance does not categorically detract from some idealized notion of what it means to be a professional. Detachment, woodenness, adherence to diagnostic checklists, therapeutic neutrality, and undue formality on the part of a psychiatrist all do much harm to a patient in the context of a clinical interaction that might otherwise offer a wonderful opportunity for healing.

    clublavoute.ca/canas-conocer-gente.php I am not my job when I am not there. I am my job when I am there.

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

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