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Tuesday, 20.11.2018

Martin Kassell: One of a kind of psychiatrist
by Barry Blackwell

 

         Martin Kassell was born on January 18th 1918 in Philadelphia, the first child of Russian Jewish immigrants. His father came from Odessa at age eightand his mother from Kiev at age 13. It was a hardscrabble time as the Great Depression began to evolve following the end of the Great War. Father was a journeyman printer and his mother, lacking much education, worked in a clothing factory.

       Six years later his only sibling, a sister Sylvia, was born into an economically deprived household. Martin recalls the day the “family hit rock bottom”; after an unpaid utility bill their gas and electricity was suddenly cut off. The larder was bare so Martin roamed the local streets and purloined a few potatoes from a nearby store while his parents lit a coal fire over which they cooked a meager meal of potatoes and canned meat.

       Economically deprived, Martin was genetically well endowed. His father lived to be 86 and his mother died at age 96, but only because she refused to wear a seat belt and was killed in a car crash. Martin’s sister Sylvia is 94 and Martin celebrated his 100th natal day this January.

       At age fiveMartin began his education at the South Philadelphia Public Schools. He did well academically always in the top decile of achievement through grade school, middle and high school, graduating at age 16. He did well in all subjects but especially enjoyed English classes here he learned to write concise, well worded essays. Latin was difficult and still a required subject for medical school; the teacher was remote and disparaging, so surprised at Martin’s skill translating a difficult text he refused to accept that the work was unaided and dealt him a failing D grade.

Poverty dictated Martin’s work for a year as a stock boy in a clothing factory to earn tuition for college before entering Villanova University in 1935 – before the outbreak of the Second World War in Europe. Both his parents were supportive but also had high expectations. At the end of his first semester at Villanova he received a report card he shared with his parents over dinner. He had finished proudly as second in class, to which his mother responded, “Why not first?” It felt like a bucket of ice water and for the rest of that year deterred him from reading his assignments. None the less at the next report he remained second in class!

At that time the student body was barely a thousand strong and the only women were eightnuns. Martin’s choice of Villanova was influenced by learning from an acquaintance that it had good access to local medical schools. This was a career choice he developed at around the age of eightwhen his paternal grandmother joined their household. She suffered from diabetes and was treated by a family doctor who visited the home to give her insulin injections daily. His bedside manner made Martin think “I want to be a doctor like that.”

        Philadelphia was blessed with four medical schools for which the graduates of all the city’s colleges competed. Martin’s grades from his professors at Villanova were all A’s and his expectation of a top placement was high. Anxiously awaiting his final oral viva in Bacteriology for which he was well prepared the exam went badly; asked to provide definitions he knew were correct the professor disagreed and marked him down. Worse still, aggravated by Martin’s refusal to defer to him, this professor falsified Martin’s entire record and, as a result, Martin was denied entry to all four medical schools.

       Fortunately, Martin’s grandmother was a patient of the Chief of Staff at Hahnemann University Hospital who securedhim a place; not Martin’s first choice but close to home and named after a German homeopathic physician. Students graduated with doctoral degrees in both allopathic and homeopathic medicine, an unusual distinction.

Although clinical work was mainly doing “histories and physicals” he was impressed with two aspects of the curriculum. His mentor in the science and art of medicine was Garth Boericke, an internist who espoused the William Osler model of bedside teaching (McCarthyand Fins 2017). Martin recalls he taught how to determine a patient’s fitness for surgery by taking the pulse while telling the patient to hold their breath. Anyone who could do so for 25 seconds was safe for anesthesia and the knife. He also noted how Boericke came from behind his desk to sit with patients, engaging them in a discourse that revealed the person beneath their problem.

       The second feature of Hahnemann’s curriculum that influenced his own future practice was the unique combination of allopathic and homeopathic procedures. This also influenced him to see patients in their entirety, beyond their symptoms alone.

       While a student Martin helped finance his education by working in a cafeteria as a chef, earning a free lunch as well as a small wage. He was also an aide for the school’s secretary for $30 a month – a job that gave him access to the files on admission. In 1939 admission was basedon quotas influenced by religion, ethnicity and gender with a hierarchy from the top down; Christian non-Catholic, Catholic, Jewish, Black, but no women.

       Martin also had a natural talent for surgery but was deterred by the scanty salary future surgeons earned while learning the trade. The psychiatry curriculum was limited to a couple of lectures without exposure to patients and failed to attract his interest.

        After graduation in 1943 a year of rotating internship followed, during which time all of his classmates were drafted into the US Army. Martin was rejected when his EKG revealed a first-degree heart block. Feeling he needed to make reparation for his colleagues he delayed going into practice to take a two-year training program in internal medicine at the Lahey Clinic in Boston. The training was excellent; he learned to do and interpret both EKG’s and X-rays of the upper and lower gastrointestinal tract. His mother’s internist at the Hahnemann Hospital encouraged Martin to return to Philadelphia to join him working on the inpatient units. This was an unusual opportunity but after accepting the offer and leaving the Lahey Clinic it was rescinded by the Chief of Medicine, known for his Anti-Semitism.

       Instead Martin decided to go into family medicine in which most general practitioners referred their complex cases and had office hours into the late evening;Martin equipped his practice with an X-ray machine and EKG as well as a lab technician andpracticed general medicine using his training at the Lahey Clinic to provide a high quality of care, hoping he could reduce the need to refer to specialists.

       Martin’s plans were almost disrupted when the Korean War broke out in the early 1950s and he was again drafted for military service. His physical exam was conducted in an armorythat had two exits – one led to a bus waiting to shuttle recruits to boot camp, the other was passage back home. His EKG was read as “normal” by a military physician who clearly did not know how to interpret it.So, Martin offered his expertise and pointed out the heart block before dashing through the door marked home. 

       Martin’s model for his own practice did not work out for two reasons. Patients themselves preferred referral to specialists. Increasing domestic demands at home eroded his time at work; he had married his wife Evelyn at age 22, two years younger than he was. Now they had two children, first a son, Neal, who was born with microphthalmia of the left eye that limited vision to shadows and carried the threat of developing cancer. This clouded the first five years of his life but Neal eventually has become one of the world’s leading neurosurgeons. A second child, Stephanie, was bornthreeyears later; during her career as recruiter for physician office workers she remained single and is now her father’s primary care taker.

In addition to child care Martin’s time at work was cut short afterhis wife developed Multiple Sclerosis at age 32. Described as a very sweet, gentle, loving wife and mother she suffered from regular relapses that eventually invaded the central nervous system before her death of ovarian cancer at age 81.

       Martin worked as a primary care physician for 22 years, which he found unrewarding both financially and intellectually. The hopes he had, based on mentoring in medical school and time at the Lahey clinic,went unfulfilled in a practice treating mild self-limiting conditions with little of interest to diagnose. In 1968 he began to consider residency in a discipline that might be more intellectually stimulating but also with limited night or weekend work that would allow more time devoted to his wife and children. Radiology, Dermatology and Ophthalmology came to mind but when the last became a possibility his wife had a relapse. His golf partner Abe Friedman was a Professor of Psychiatry at Jefferson Medical College(now the Sidney Kimmel Medical College in Philadelphia)and suggested Martin might try a new program set up by the NIMH to recruit primary care physicians to train as psychiatrists. This was at a cross roads when biological psychiatry was seeking a foothold in the mainly psychoanalytic programs throughout America and psychopharmacology was in its heyday but still sparsely represented in academic teaching programs.

       Martin was skeptical about all that “oral and anal crap” but the lifestyle sounded conducive for his family needs.  He accepted the challenge and began to read Freud as a first-year resident; instantly falling in love with the insights of psychoanalysis and the opportunity to explore his patients in depth, a satisfying luxury missing in primary care. 

        Martin began his psychiatric training in 1968 and completed it in 1971. These were pivotal years in the evolution of the discipline in America only about two decades after the first anti-psychotic medication, chlorpromazine, was introduced into asylum care. On February 5, 1963, President John F. Kennedy addressed Congress to propose a new Federal program to fund Community Mental Health Centers (CMHC’s):“Reliance on the cold comfort of custodial isolation will be supplanted by the open warmth of community concern and capability.”

       An early consequence of this well meant but flawed legislation was to speed up the discharge of persons with severe and persistent mental illness into communities poorly prepared to accommodate them, coupled with a marked reduction in inpatient beds.

       American psychiatry was also ill equipped to cope with this new burden imposed on the profession. Almost all academic departments and training programs were chaired by psychoanalysts and some of the residents were in analysis with their mentors. Making matters worse, the national accreditation committee had absolved aspiring psychiatrists from the need to undertake a year of rotating internships; in addition, there were few psychopharmacologists to serve as mentors in biological psychiatry.

       This zeitgeist created a unique opportunity for a mature skilled physician like Martin both during and after his training in psychiatry. One of his supervisors had spent two years with Freud in Vienna and played chess in Philadelphia with his neighbor, Einstein. Martin’s psychological mindedness and understanding of patient dynamics prospered to the point where he considered a personal analysis and sought the advice of his Chairman. He was invited to consider the relative merit of spending $30,000 on analysis spread over several years compared to investing the same amount in the stock market. Any ambivalence was dispelled by the news that consultation with his supervisors revealed they considered him a mature well-rounded individual with no need for analysis.

       This outcome was best for Martin and the 2,000 persons awaiting his graduation who suffered with severe and persistent mental illness, lodged in the local asylum and about to seek a tenuous foothold in a Philadelphia community unprepared to accept them.

       Martin was appointed an Assistant Professor in the Department and for the next five years spent his entire time developing an innovative spectrum of programs to serve these patients, includingoutpatient, emergency room, inpatient and outreach for vulnerable individuals.

       Instead of a 15-minute individual session with each patient, he dealt with the large volume of outpatients in a group setting; a number of oval tables arranged in a circle, amply stocked with coffee, orange juice, milk and day old “oral treats” that Martin purchased from a local bakery at modest cost. Every patient came with a family member or case manager in a climate designed to facilitate interaction and mutual interest. Meetings were held twice weekly in the morning and afternoon. A cadre of health professionals assisted:a nurse to help with prescriptions, a clerk to schedule follow-up appointments, a secretary to keep notes and social workers for home visits. An atmosphere developed akin to the Fountain House movement that began in New York where “peer pressure did the work for me.” There was virtually no recidivism or “revolving door” to the asylum in this population. Even the most “rank” individuals were capable of self-renovation – cleaning themselves up so they could earn promotion to become a “server” providing food to membersof the group in session.

       The continuum of care Martin developed included a 20-bed inpatient program as part of a newly funded Community Health Center, staffed by psychiatric nurses and a resident under Martin’s supervision. His own learning was enhanced by the tragic case of a middle aged Italian woman who requested additional Stelazine from her primary care provider. Admitted because she might be suicidal she presented herself the entire day as cheerful, dancing and smiling, interacting with others and participating in day long activities while still placed on 15-minute observations.  She went to bed and at the next check was found dead with a silk stocking wrapped around her neck, attached to the door knob of her room. Martin developed an interest in such tragic occurrences and subsequently gave talks about suicide and the extent to which it was a preventable condition.

      He also developed a psychiatric intake program for the hospital’s emergency room designed to create a supportive, non-threatening environment for patients and residents treating them; they were taught “Never to let the patient get between you and the door.” Advice that one unfortunate resident overlooked when a paranoid patient appeared to settle down and asked to close the door. When granted permission he did so,and then turned on the resident and brutally attacked him with hisfists, fracturing the resident’sorbit, mandible and maxilla.

       Finally, Martin also developed an outreach program for patients whose lack of skills impaired their community integration. He partnered with a highly creative African American woman, a mental health aide who was also a talented seamstress, skilled at making African costumes. Together they worked at a Mental Health Center in groups up to 16 people with a variety of problems, including communication and hygiene. He remembers a group of eightpeople who were virtually mute. So, he divided them into pairs and gave them fiveminutes to find out as much as they could about the other person and then report to Martin. It worked!

       The spectrum of programs and innovative ideas Martin developed to deal with deinstitutionalization may well have contributed to the longtime reputation for excellence Philadelphia later acquired in community mental health care.

       In 1976, after five years of work he loved and at which he excelled,Martin decided the family needed to move to a warmer climate – his wife’s multiple sclerosis was deteriorating rapidly, demanding more of his time.  Preparing for retirement he considered Mexico. On his way to a meeting in San Francisco he decided to stop and explore Phoenix. After a one-month trial they fell in love with the city and decided to stay.

       His own sense of loss at what he had left behind in Philadelphia was profound and shared by those he had worked with. Several wrote letters asking, “Please come back.” But within a month the innovative programs he had so successfully created were disbanded.

       Nationally what happened in Philadelphia was the harbinger of worse to come. The fate of Kennedy’s mental health initiative was told in a Wall Street Journal op-ed written on February 4, 2013,by E. Fuller Torrey, a psychiatrist at the Treatment Advocacy Center, headquartered in Washington DC. It tells of the bleak outcome of Kennedy’s legislation. While this sealed the fate of asylums and speeded up deinstitutionalization it was seriously flawed and poorly implemented. Only half of the planned Mental Health Centers were built and most chose to deal with the “worried well” rather than severe and persistent mental disorders. None were fully funded and there was no long-term funding to follow up.

       Belatedly, psychiatrists learned that while anti-psychotic drugs stifled the positive psychotic symptoms that led to institutionalization they lacked benefits for the negative cognitive and social deficits that led to failure in the community. This was a lesson Martin Kassell learned and successfully coped with in programs that disappeared overnight in Philadelphia in 1976.

        So, Martin left Philadelphia for Phoenix, leaving behind an early innovative community mental health system. His formal career in this new environment lasted for 18 years, from 1976 until1994, when he officially resigned his last post to begin an active retirement that has continued for more than two decades up untilhispresent age of 100 - and still going.

       Phoenix in 1976 was a pleasant environment to live in, raise a family and care for his wife, although it lacked the academic and urban sophistication of an ancient metropolis like Philadelphia. During this time Martin would work in several different clinical settings where his dual experience in medicine and psychiatry, coupled with an innovativeenergetic, clinical and management style,would serve patients, staff and trainees well in a variety of organizational settings.

       Martin began as a visiting staff member and Lecturer at the University of Arizona and as Chief of Consultation-Liaison Psychiatry at the Maricopa County General Hospital. This included mentoring residents in medicine and psychiatry, a job ideally suited to his dual training and skills. Altogether he was “having a ball”; occasionally wearing a long white coat but always putting patients at ease, while tutoring residents at the bedside -sometimes as many as five at one time.Some of these residentsare still in practice and stay in touch, one of whom came to his100th birthday party. The building was seven stories high and, using the stairs not the elevator, the team was kept fit and on its toes.

       Unfortunately, Martin’s nemesis was the university’s head of psychiatry; a small man with a Napoleonic temperament. Over two years the Psychiatry Department built a new annex to house inpatients and Martin was assigned to become an attending psychiatrist on one of the units. It was a “take it or leave it” offer and when he demurred Martin was fired.

       What followed was a six-month stint at the Phoenix VA hospital as staff person to a unit for alcohol and other drugs of abuse (AODA) patients abusing drugs or alcohol, relentlessly gaming the system, threatening suicide to gain admission, demanding and disrupting the milieu. Clearly,this was not a match for Martin’s talent or temperament so he resigned and accepted a position at the Arizona state mental hospitalwith 1,500 beds, on the cusp of beginning deinstitutionalization, a problem he knew how to handle.

       He had no formal teaching responsibility but the clinical task matched experience he used to re-organize a child and adolescent unit troubled by staff turnover, coupled with lack of discipline and clinical profiles. Martin went to work defining job descriptions and setting clear expectations until a therapeutic environment was restored

       A period of institutional chaos ensued, the Director of Mental Health resigned, a business man took over who announced to staff that anyone who complained about an employee could be assured that person would be fired. A lazy internist almost lost a patient and when Martin disciplined him he complained to the Director who promptly fired Martin.The Superintendent then re-hired him as Chief Psychiatrist. This time he was assigned the chore of cleaning up and re-designing a chronic backward, a task he relished. First by creating a cheerful milieu in which both staff and patients joined hands to paint the walls and hang pictures. To make a small day room seem larger Martin empowered a staff member to design a mural that depicted open windows looking out onto an attractive vista and had the patients paint it on the inside wall. Skeptics forecast it would soon be despoiled but patients were so proud of their accomplishment nobody dared lay a finger on it. Morale was excellent and the mood congenial. Then Martin soon realized the house keepingstaff was good at talking to and bonding with patients, so he included them in staff meetings and evaluations. This paid dividends:one patient, incarcerated and ward bound for 20years was able to leave the unit along with staff for the first time. While at the State Hospital he continued to supervise residents and, as always, received appreciative feedback.

       In1985 Arizona decided to set up a 76-bed Psychiatric Unit at the Durango Jail as a licensed Psychiatric Hospital, second only to the State Hospital,with two sections for men and women. With Martin as Chief Psychiatrist it obtained national, state and local accreditation and commendation.  As usual he initiated innovative programs. The Correctional Officers became members of the treatment team and attended all its meetings, also participating in both group and individual treatment, a strategy that radically reduced the amount of acting out. He made the continuous patient record simpler and informative by having each discipline write notes in different colored inks:nursing used red ink, psychology purple and psychiatry blue. He replaced the traditional “subjective, objective, assessment, and plan”(SOAP) method of charting with PAR – Problem, Assessment, Resolution. In addition to supervising the different disciplines he also taught third-year University of Arizona medical students for a full day each month and received appreciative feedback from the Chair of the Department. Privacy was at a minimum; he held court and interviewed patients at his desk on the periphery of a huge day room; staff opinions of his demeanor were graded on four levels:barely audible, heard, elevated and reaming the patient out.

       The end came abruptly and unexpectedly for political reasons in December 1994; until then Martin was on a 30-hour/week contract, allowing him sufficient time to care for his wife. An administration decided to replace all part-time staff with full-time personnel. Martin’s farewell party is a fond memory; Martin was well known for giving the male inmates a hard time in therapy sessions but here they were, smiling and lined up to shake his hand and present him with a framed picture each of them had signed; embellished with a photograph of Freud. It hangs in his study at home, among his proudest possessions.

       Martin also received a letter of commendation from the Directors of the Maricopa Health Services expressing their dismay and regret at his departure and eulogizing his accomplishments:“His quiet wit, his usually silent but not passive, participation in staff meetings, and his infrequent verbal opinions which, though gently delivered, always had the impact of a Sherman tank upon us all.He has been a good teacher to all of us, not free from a certain degree of obstinacy, yet open to criticism for he has a damned good sense of humor. We have never failed to know where Martin stands which, in these days of ‘political correctness’has been refreshing.”

      The letter ends expressing the hope that he will be able return in the future to resume his teaching and training responsibilities. It was not to be. History repeated itself, within a month of his departure the innovative program he initiated was disbanded and became a traditional forensic unit.

       Martin would not remain idle. He put the forensic skills he had acquired to good use as a consultant to the Maricopa County Superior Court, a position he filled until 2010. At age 92 he began to perform court ordered evaluations, advised the judges and gave testimony in court, enjoying word play while sparring with defense attorneys. When accused of prescribing the wrong drug to a client he was happy to point out that the plaintiff’s attorney was quoting from a Physicians Desk Reference (PDR), used by lay persons while his own wise choice of the appropriate medication was from a volume by a widely accepted psychopharmacology authority, Goodman And Gilman's The Pharmacological Basis Of Therapeutics.  Among his other triumphs was the exposureof a Vietnam war veteran,indicted for shooting and killing his wife then raping his step daughter,who wasfaking mental illness to avoid a lengthy prison term.

       During this time Martin continued to see private patients and also initiated a monthlyKoffee Klatch meeting, first at a coffee shop and later in his home, for psychiatric residents from the local academic program eager to tap into his experience and wisdom;fellow psychiatrists later joined,eager to “shoot the breeze.”  In a sad reflection of current orthodoxy, the residents eventually stopped coming and went in search of a mentor less psychologically minded to tutor them in psychopharmacology.

       In the last six years Martin has received three well deserved awards for his career-long commitment to mentoring colleagues and residents. In 2012 the Arizona Psychiatric Society named him Best Teacher of the Year and in 2013 they awarded him their Lifetime Service Award. In 2014 the American Psychiatric Association recognized him as a Best Mentor of Residents and New Psychiatrists and also awarded him their Distinguished Lifetime Fellowship (DLF) Award.

On Reflection

The author’s summaryconversation with Martin Kassell

      This biography was a delight and enlightening to pen. Martin and I spoke by phone weekly until its completion when we engaged in this final dialogue, a reflection on the whole.

       My pleasure was kindled by realizing we were kindred spirits, not in age or precise parameters but with a synchronicity in style, interests, experiencesand opinions. While my métier is the written word and I competed in the academic “publish or perish” sweepstakes, Martin’s forte was the spoken (or unspoken) word; in his consummate skill as mentor and therapist across the full biopsychosocial spectrum.

       In the material he provided me were two versions of a talk he had given on several occasions about the Psychology of Suicide:to the World Psychiatric Association Annual Meeting in Philadelphia, November 1981; to the Medical Society of America and Mexico Annual Meeting at Guadelajara, October, 2004; and, most recently, to the National Annual Meeting of the Creativity and Madness Society in Santa Fe, NM,August, 2006.

       Over his career he had cared for about an estimated 200 attempted suicides, mostly during his work in Consultation Liaison at Maricopa County Hospital and the Forensic Unit at Durango Jail in Phoenix between 1976 and 1994. The essence of Martin’s hypothesis is encapsulated in the following abstract from the larger of his two papers(Kassell2006):

       “Relatively few who are depressed or suffer commit suicide. This poses the question of what makes suiciders different… So, I began to ask the patient to go back to the time just before they began to think of the actual act of suicide.  I would ask them what was happening in their life and what their thoughts and feelings were. I then decreased the time interval to when the act was just beginning, during the act, and even their last thoughts and feelings.

       “Using this approach, I was able to develop some patterns. The personality of most of the individuals was often either immature, narcissistic, passive or a combination. The IMPULSIVITY led me to believe that suicide is mostly NOT PREVENTABLE. Another was the presence of ANGER, the suicide act being the discharge of that emotion. It was often accompanied by the IDEATION such as I’LL SHOW YOU, OR I’LL GET EVEN WITH YOU, or YOU’LL BE SORRY (for what you made me do). These are manifestations of PASSIVE HOSTILITY … SPITEFULNESS. Another theme was ESCAPE. The background of these individuals suggested avoidance of conflict. Often the ideation was of going to sleep. An interesting addition to this occurred in some cases where there was an additional thought of REAWAKENING. This may have had its origin in childhood where being chastised, sent to the bedroom, going to sleep and, when awakening, all magically will be well.”

       This is a brief synopsis of a lengthy paper that provides several elegant and convincing case histories with additional speculation about the psychodynamic nuances in assessment and therapy. Martin related an illustrative vignette of a gay couple who had a contentious relationship prone to conflicts and fights, after which his patient repeatedly made a retaliatory suicide attempt with serious consequences. Finally,he jumped off a highway bridge fracturing both legs. In a therapy session on the day of discharge Martin said to him, “It seems peculiar to me that when I get upset with somebody I want to punch them out – but you seem to want to hurt yourself.”  At his next therapy session, he arrived with a large black eye:“I got into a fight, I hit him, I feel good.”

       What impressed and intrigued me was that while the initial suicide was impulsive and likely unpreventable Martin’s elaboration of the psychopathology led to therapy that might well discourage future attempts. This aspect intrigued me because after completing my rotating internships at Guy’s Hospital in London I spent six months as resident on a neurology service while waiting to start psychiatric training at the Maudsley Hospital in the fall of 1962.  A significant part of my case load was to admit and treat attempted suicides from barbiturate overdose via the emergency room. In the pre-benzodiazepine era I became expert in the use of brain stem stimulants, sitting by the patient’s bedside until they recovered. For this work I received the hospital’s Annual Research Award and the results were published (Blackwell 1966). Lacking any psychiatric training I never attempted therapy; the patient was discharged to the outpatient psychiatric clinic until I sometimes welcomed then back.

       Impressed by Martin’s work I consulted Google, typing in “Dynamics of Attempted Suicide.”  This produced a seminal paper titled, Characteristics of impulsive suicide attempts and attempters(Simon et al.2001). Nearly two decades after Martin first proposed his theory the Abstract to this article reads as follows:

       “Suicide attempts are often impulsive, yet little is known about the characteristics of attempted suicide. We examined impulsive suicide attempts within a population-based case-control study of nearly lethal suicide attempts among people13-34 years of age. Attempts were considered impulsive if the respondent reported spending less than 5 minutes between the decision to attempt suicide and the actual attempt. Among the 153 case-subjects, 24% attempted impulsively. Impulsive attempts were more likely among those who had been in a physical fight and less likely among those who were depressed. Relative to control subjects, male sex, fighting, and hopelessness distinguished impulsive cases bur depression did not. Our findings suggest that inadequate control of aggressive impulses might be a greater indicator of risk for impulsive suicide attempts than depression.”

       This study has impeccable design, credible findings and has been cited in the medical literature more than150 times since it was published. The first author is a psychologist and now Acting Branch Chief of the Surveillance Branch in the Division of Violence Prevention at the Atlanta Centers for Disease Control (CDC).

       The fact that Martin described this syndrome almost 20years before it was scientificallyratified reminds us that astute clinicians also identified the significant benefits of the first psychotropic drugs well before controlled studies confirmed their efficacy. We have no means of knowing the impact Martin’s hypothesis may have had on the careers of those he mentored and lectured or their patients but the fact he was almost certainly first to describe the psychopathology of impulsive suicide attempts and suggest a strategy to prevent recurrence makes me wonder if this now widely recognized formulation might be fairly named “Kassell’s Syndrome,” a fitting eponym with which to reward a centennial psychiatrist.

       I also posed a series of probing questions for Martin to consider during our final discussion. Older than I and an experienced family physician Martin began his psychiatric career in 1971, three years after I arrived in America but at a time when we were both new faculty members in strongly psychoanalytic departments. This was also the “golden era” in psychopharmacology when biological psychiatry was beginning to gain a firm foothold in academia. I had also spent a brief time as a family doctor so we were both exposed to the novel concepts of psychoanalysis. Without blindly accepting the dogma Martin describes how becoming psychologically minded provided insights and intellectual satisfaction in patient care he had never experienced before, a benefit I also experienced. It was, “the best of times,” with no regrets about his change of specialty and in similar circumstances he would do the same again, “helping people help themselves.” Interactive dialog with patients and students was exceptionally gratifying.

       Martin recalled and related several cases of successful therapy, sometimes assisted by hypnosis in which he also received training.  A PTSD victim whose working life was disrupted by sensitivity to loud noises was desensitized and returned to full time employment. A young woman who made repeated suicide attempts was treated with regressive hypnosis and recovered completely after he helped her recall the time her sadistic mother beat her with a bicycle chain when she was aged three.

       Martin and I shared a primary care physician’s experience with brief fifteen-minute interviews structured to enhance our relationship with the patient at the same time as systematically assessing treatment progress. Today’s insurance mandate,the much maligned “15 minute med check,” is a source of contemporary angst expressed both by patients and psychiatrists, many of whom have had no training in the art and science of brief sessions or their benign potential for cumulative benefit long term.

         When asked if he would recommend psychiatry today to an interested medical student Martin was adamant. Psychiatry has become a business and not a profession; training has become almost exclusively biologically skewed and treatment has little to do with human nature and the whole person. This is abetted by the DSM,a “ridiculous system” that no longer diagnosed the human person but substituted symptom clusters called “disorders.” A sentiment shared by many psychiatrists today.

       Martin contrasted his life as a psychiatrist with his former unsatisfactory role as a family doctor whose popularity was linked to being a “nice guy” rather than a competent practitioner. 

        I asked Martin to what he attributed his longevity in addition to genetics.He replied that he had been overweight, ate unwisely and seldom exercised other than golf he plays thrice weekly, but no longer counts strokes. His other hobbies are playing poker with friends, ham radio, acrylic painting,concerts and ballet.

       He does believe that longevity is helped by always maintaining a positive attitude, “dwelling on the bright side.”This was enhanced when, late in his career he learned to listen. As an early psychiatrist in training he realized that as an internist heused to do all the talking, asked all the questions. Adapting to his new role he taught himself to listen by biting down on his lower lip until it bled. Once he learned to “listen with a third ear,” he noticed what the patient was not talking about. Talking more to him about his demeanor with patients and those he taught sounded like the equanimity that Osler saw as the essential ingredient of the “good physician,” putting himself, the patient or the other person at ease.

       This style of practice, knowing his patients and pupils in depth, made distractions from work difficult but he learned to plan time to care for his wife and kids,without guilt.

       Finally, I asked Martin if he had a philosophy or model from which he created the innovative treatment programs he instigated in the Arizona State Hospital and Jail. His answer was always to improve the situation as an innovator by utilizing the tools provided to create something more efficient and interesting. This included empowering and training housekeeping and correctional staff in how to deal with difficult patients. What made him proudest was the respect and gratitude he earned from those he helped, patients,employees and trainees of all kinds.

       I also feel proud to have listened and learned from Martin Kassell, truly a “one if a kind” psychiatrist.

 

References:

Blackwell B. The simplified management of barbiturate overdose. Int Med Digest 1996; 1: 940-3.

Kassell M. Paper presented on Psychology of Suicide and Risk Case Presentations. Annual Meeting of the Creativity and Madness Society, Santa Fe August, 2006.

McCarthyand Fins. Teaching Clinical Ethics at the Bedside: William Osler and the Essential Role of the Hospitalist. AMA Journal of Ethics. June 2017, Volume 19, Number 6: 528-532.

Simon TR, Swann AC, Powell KE, Potter LB, Kresnow M, O’Carroll PW. Characteristics of impulsive suicide attempts and attempters.Suicide Life Threat Behav. 2001;32(1 Suppl):49-59.

 

October 25, 2018