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Book Review by Carol W. Berman, M.D.

of Lloyd I. Sederer, M.D.’s IMPROVING MENTAL HEALTH: Four Secrets in Plain Sight

Dr. Lloyd Sederer’s new book, IMPROVING MENTAL HEALTH: Four Secrets in Plain Sight, is an easy read for any of us. Published by the APA, the inside book jacket states that this book is designed for psychiatrists, other mental health professionals, medical doctors, and patients and their families. We all can be reminded of the “four secrets in plain sight”, but I believe patients and their families will benefit the most from this book. Dr. Sederer is the chief medical officer of the New York State Office of Mental Health, a professor of epidemiology at Columbia University, and the medical editor for mental health at the Huffington Post. This is his tenth book, seven for a professional audience and three for the lay public.

Dr. Sederer writes clearly and well about four fundamental truths that he calls “secrets.” These insights from his long career are 1) behavior serves a purpose, 2) the power of attachment, 3) less is more, and 4) chronic stress is the enemy.

There is no doubt that we must keep in mind that 1) behavior serves a purpose. He quotes Dr. Groves, a psychiatrist at Massachusetts General Hospital when Dr. Sederer directed the inpatient psychiatric unit there, who describes four types of “hateful patients”: dependent clingers, entitled demanders, manipulative help-rejecters, and self-destructive deniers. Nowadays we would classify these patients into personality disorders, but Dr. Groves’ purpose in labeling these difficult patients was to help doctors keep working with them when the impulse was to reject them. The dependent clinger is always there, impossible to get rid of, begging for care to the point that exhausts doctors. The entitled demanders are negative and hostile to their caregivers, who may not realize that these patients are terrified of abandonment. Manipulative help-rejecters try and try to get help which they promptly reject once they obtain it. Finally, self-destructive deniers continue to abuse drugs or alcohol and then deny any problem, because they are so afraid of getting better. All of the behaviors of these four types serve a purpose. We, clinicians, are urged to suspend everyday logic and pre-conceived notions so that we can try to solve the problems of each patient, who may turn us off at first.

For 2) the power of attachment, Dr. Sederer reminds us of the wild child of Aveyron, France, who in the late 1700’s was found abandoned in a forest. Villagers took him home and tried to teach him language and manners, but he couldn’t learn because he had missed attachment to other humans in his early years. Then he discusses the sad cases of Harlow’s monkeys who were separated from their mothers in infancy and then experimented upon by observing if they preferred wire mother substitutes to cloth substitutes. The macaque monkeys liked the cloth surrogates much better and if they had one of these, they were soothed and less anxious. Primacy of attachment is the point here and thus, the importance of our therapeutic alliances with patients, who may have had insecure attachments in infancy.

The chapter that deals with 3) less is more - - starts off with the Hippocratic oath: “First do no harm.” In our enthusiasm to help patients, we doctors might be tempted to do too much, when less is often called for. He gives examples of intensive psychotherapy with schizophrenic patients, which may have negative effects. Then he focuses on the CATIE trials (Clinical Antipsychotic Trials of Intervention Effectiveness) which surprisingly found first-generation antipsychotics no more effective than our newer, second-generation antipsychotics, except for Clozaril.

His last points about 4) chronic stress is the enemy - - addresses adverse childhood experiences (ACE)of abuse, neglect, and seriously troubled households. He wisely associates multiple ACEs as risk factors for addictions, depression, heart, lung, and liver disease, STD’s, intimate partner violence, smoking, suicide attempts, and unintended pregnancies. Dr. Sederer tells us about telomeres, the caps on the ends of DNA, which shorten with stress and inflammation. Long telomeres are correlated with long life.

In conclusion, Dr. Sederer wants us psychiatrists to invest more in prevention and early intervention with our patients. He says only 10% of our health is determined by health care, while 90% of the determinates of our health derive from lifetime physical and social environments. In other words, we should eat well, sleep the right number of hours (7-8), and try our best to keep our stress levels down. He believes that “the greatest gains in the next 10 years for people with mental and addictive disorders, and their families, will come from better executing what we now know.” I completely agree with him.

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