Okay, welcome everybody we'll get started. There's still a few more people joining but I think we're ready to go. Welcome to the latest installment of our let's talk series for the bed for playhouse presented to you virtually. Hi, my name is Dan. I'm the director of development and programming and we're very glad to have you with us this evening to hear Dr Gerber speak on what we feel are some pretty important topics. Just wanted to remind you all that please feel free at any point to post a question. You can do so. So if you go to the bottom of your screen on your laptop or PC. There's a button that says q amp a, and you can type in any question you want, and we'll do our best to get to them. You can also, if you're on a iPad or iPhone, it's towards the top of your screen. But please use the q amp a feature to ask any questions that you might have. Also, I like to mention that bed for playoffs is a 501 c three nonprofit that is currently closed, thanks to the effects of the coven 19 virus and social distancing and we're hoping to reopen as soon as possible but as some of you may know, movie theaters have been exempted from the phase for reopening plans. We're still a little bit limbo in terms of when we will be allowed to reopen but we are working on a strategy to do so and keep everybody safe.  Please consider going to our website, which is bed for playhouse.org. And there's a link there called ways to give and please consider making a donation to help us through. The expenses were incurring in order to be compliant with CDC guidelines for reopening and any amount is appreciated and we really appreciate all the support that we get on a very grateful for it. That being said, let me introduce to you to tonight's special guest. And please forgive me while I read this because it's a rather impressive biography and I want to make sure that I get all of it in one place. Dr. Andrew Gerber is president and medical director of Silver Hill Hospital in New Canaan, Connecticut. He's distinguished career combines his work as a clinician scholar, research scientist and executive. He completed his medical and psychiatric training at Harvard Medical School Cambridge Hospital and while Cornell and Columbia Medical School Medical Schools and his psychoanalytic training at Columbia. Dr. Gerber completed his PhD in psychology at the Antifroid Center and University College London, where he did advanced work in psychoanalysis and psychoanalytic psychotherapy in young adults. Prior to joining Silver Hill, Dr. Berger was medical director and CEO of the Austin Riggs Center in Stockwood, Massachusetts. In his many affiliations, Dr. Gerber has served as associate clinical professor in the division of child and adolescent psychiatry at Columbia University Medical Center, and as associate clinical professor at the child study center Yale University. He's the former co director of the Sackler parent infant program at Columbia University, former director of the MRI research program at the New York State Psychiatric Institute, and former director of research at the Columbia University Center for psychoanalytic training and research. He has authored or co authored a number of major presentations and publications over his career. His research on the intersection of neuroscience and psychoanalysis is at the cutting edge of our understanding of the neurobiological effect of psychotherapeutic interventions. He's published and received grants in many areas. He's been involved in planning and teaching psychoanalytic research as head of the science department at the American Psychoanalytic Association. He's the chair of the committee on scientific activities, secretary of the psychoanalytic psychodynamic research society and a member of the psychotherapy research committees of the American Academy of Child and Adolescent Psychiatry. So I'm very, very happy to welcome Dr. Andrew Gerber to the Bedford Playhouse Virtual Playhouse. Great. Dr. Gerber. Thank you so much Dan, can you hear me okay. Yeah, we can hear you great. For those of you listening you may if you do adjust your volume please do it now and Dr. Gerber the floor is all yours. Fantastic. Well thanks so much Dan and thanks thanks for that nice introduction. I hope you can hear me okay and I hope you'll feel free to write in if there's any trouble hearing me or if there's any interference, or if you have questions during my presentation. As Dan pointed out there is the Q&A area which will pop up I know Dan's monitoring that. And I will I won't look at it while I'm talking because otherwise I'm likely to get distracted with your terrific questions, but I will look at it once, once we're ready and happy to answer any questions that you have. It's been a real pleasure and privilege to to be at the Bedford Playhouse even though physically I'm sitting in my own basement. I have had the nice opportunity to spend a little time in Bedford and gotten to know some of the members of your community. But I also imagine some of you are not necessarily in Bedford right now as I am not. I live in New York City, but spent several years in Stockbridge where when I ran the Austin Rig Center, and have now been in Fairfield County for the last year and a half. So I live near near a Westport little town called Weston, but spend my day is working in New Canaan not not so very far away from from Bedford. It's really great to talk on this topic. I sometimes say to people that that when you hear somebody like me say that they're presenting something new. There's good news and there's bad news. The good news is that that it's fresh and it's not just a canned talk I promise what I'm about to give you is not a canned talk. I have not given it before, but of course the bad news is it's not been tested on anybody yet. So you will be the judge of whether it's worth ever repeating and whether this particular way of putting some ideas together is useful or not. I don't plan to speak for very long I plan to speak for really no more than half an hour at the most. If I can speak fluently hope maybe it'll be more like 20 or even 25 minutes. But my hope is that I'll share some ideas with you things that I've been thinking about at various stages of my career and certainly in my new role as the president medical director at Silver Hill, that hopefully will resonate and and also stimulate a good discussion. So I really think of this talk as comprising a description of two systems, and the two systems that I want to talk about are the systems that we've had in this country over let's say the lot will get over the last 1670 years for the treatment of severe or acute mental illness. That's one system and sorry to say it's not a particularly cheerful story about what has happened over this last 70 years in terms of failed hopes and ultimately what I believe has led us to a terribly broken system, which I imagine some of you have had some contact with. But the second system I want to talk about, which is a little more optimistic, although still not where I think it should be or where I'd like it to be, is a system of what I think we've come to call emotional wellness. That is the non acute and severe side of mental health, but one that is far more widespread and common. And one might even say these two systems roughly map on to be in the medical acute medical system when you need to go in for a surgery, or for a hospitalization or sent to the emergency room of the ICU. That's system versus a second system of health and wellness that I would describe as to do with exercise and nutrition and regular visits to your primary care doctor or even regular normal visits to your obstetrician when one's pregnant with and having a baby. That is the systems that are built for when things get really bad and the systems that are really designed to help prevent things from getting really bad. And those are the two systems that I want to talk about today and make some proposals about how we think about the relationship and ultimately between those two systems and ultimately how to optimize them in our in our society. So let me start with the first system and unfortunately that that's a story that I think is somewhat sad. I want to recommend a book to you which is relatively recently released called the bedlam and threatened by Kenneth Rosenberg. I have no ties to Dr Rosenberg. So this is really just an appreciation for what I think is a highly readable and and accurate account written by a psychiatrist practices in New York City, but perhaps even more importantly, had a sister who suffered from a severe mental illness, and writes from the perspective of a family member who watched a really tragic story develop. And so so I'm not going to give nearly the level of detail that that he gives in his book but I'll touch on a few of what I consider to be the major points. The first thing and I apologize if this is something that that you're familiar with but I think it's such a powerful historical story that it warrants really mentioning in any talk like this. 70 years ago in the early 1950s, there were over 100,000 state psychiatric beds in this country. And these were long term beds that were filled by individuals with severe mental illness, often schizophrenia by polar disorder treatment of refractory just another way of saying it doesn't respond to the treatments at the time. Depression, as well as at the time, some of what we would today consider neurologic conditions but at the time we didn't understand their neurologic basis, or had no way to treat them neurologically, including for example, the complications of tertiary or neuro syphilis, which at the time, really before antibiotics had been around long enough to treat all these cases caused psychiatric illness in a very large number of individuals. And at the time, nobody thought this was a great system, of course, state hospitals were often filled over capacity. They were often underfunded. They were more custodial than they were treatment oriented that meaning that they were more about just keeping people going, rather than making their lives better. And individuals most often did not return to their families and certainly did not return to productive lives in part because the treatments weren't available, but also in part because the systems weren't designed for this. Now, fast forward through the 50s, when the first psychiatric medications started to appear and they appeared accidentally these were serendipitous discoveries of drugs that may sound old to us now, but at the time a revolutionary drugs like Thorazine, or Haloparadol, which were the first drugs to treat schizophrenia and psychosis of the original antidepressants, which now fit into the categories of tricyclic antidepressants or monoamine oxidase inhibitors, which could free individuals from depression, the use of electroconvulsive therapy, which despite its depiction in movies and seems so horrible, when done well and safely can be really a powerful treatment for individuals. And then also treatments for things like bipolar disorder, lithium being the first and foremost of its kind, that really freed people of symptoms that they in some cases had suffered for decades. You take those new medications and all the hope that went with them. And now you move into a progressive era in the 1960s, when the idea became more and more conceivable, that rather than warehouse individuals with psychiatric with severe psychiatric illness in the state hospitals, one could move them back into the community and have them either live alone or with their families or in even group settings, but be part of communities and beyond their medications and be taken care of at community mental health centers. This is what is usually referred to as the institutionalization. And it was well motivated and really a grand dream of what it would mean for individuals with severe mental illness to be part of society again to do so much better. John Kennedy was a major proponent of this. And a lot of this was executed by Lyndon Johnson through the 1960s. And the number of beds in these state psychiatric hospitals over a relatively short period of about 20 years went from over 500,000 to where it is closer where it is today, which is under 100,000. And meanwhile, of course, the population of the country continued to grow. So it's even more dramatic than might appear just by the raw numbers. So the people often ask the question, well, where did that go wrong? It sounds, you know, as I presented it sounds like it might be a positive change and a good idea. Well, the general wisdom about this is that even as the state psychiatric hospitals were being defunded and we've all driven by these massive places, often in the countryside of New York State or Connecticut or other places, these funds were not put into community health as much as were originally promised. So the institutions that were supposed to pick up the need out in the community were even more cash strapped than the large mental hospitals and therefore couldn't handle the number of individuals who are coming out. The hope that medication was going to make up for that difference because it was going to be so revolutionary that individuals weren't going to need that level of service. Never materialize the medicines were helpful, but individuals with with severe psychiatric illness, don't go from being severely ill and needing custodial care to being just like everybody else. And putting that in quotes because none of us are like everybody else were all different, but they couldn't just go suddenly get jobs have have normal families and everything be fine. They still needed support and the funding and the institutions to support that never showed up. So you moved into an era in the late 60s and into the 70s, whereas the homeless population of this country grew. And increasingly, the difference had to be made up by medical centers who grew their psychiatric services and hospitals that you all know well like Columbia for now or NYU, or, you know, Stanford hospital and Norwalk hospital and so on, all had increasing psychiatry departments that were a combination of inpatient and outpatient services that struggled to take up these these patients. But here's where we get into the next sad part of the story. Into the 1980s, they're continued to be some hope the psychiatric hospitals were growing. We're doing a decent job and they weren't warehousing people they weren't keeping them as long as the psychiatric state hospitals had. But they could keep patients for weeks and months, as they needed to stabilize individuals and get them back into the community using the medicines at the time. And in fact, the new medicines continued to be developed. And most importantly, in the in the early night to mid 1980s, the first selective serotonin reuptake inhibitor Prozac was released, and was truly revolutionized, revolution in the sense of providing a medicine for depression in particular that and to some society that did not have the same side effect profile of some of the earlier medicine. So this was a still a time of excitement. But the next thing to really go wrong was the fact that the rising cost in our healthcare system, not just psychiatry but all over the system led in the early 90s to the failure of the Clinton healthcare plan, and ultimately to the spread of managed care in order to keep costs down. And the effect on psychiatry was that the amount reimbursed to hospitals all across the country was reduced in order to cut costs within these facilities the length of stay, which in one era in the 1950s and 60s had been years, and had gone to months into in the in the 70s and 80s, now started to come down closer to where it is today. It really is days any of you who've had relatives or friends or yourselves been in psychiatric acute stay know that the push to be released in most a general psychiatric hospitals now is such that they really have aimed to have you out in a week. The average length of stay in most hospitals is somewhere between seven to 10 days. And in fact, from the perspective of, you know, cheer people up psychiatry departments or directors of hospitals. I will leave Silver Hill and Austin Riggs out of this because we have quite a different model which I'll tell you about in a little bit. The goal was bragging rights went to somebody who could keep the number of day average number of days down. Of course, what might be good financially for the hospital or good financially for the Department of Psychiatry was not good for the patients and their families, because these patients had to go home. And when they did, they were often still suffering in various ways from one disorder or another, and the burden and fell on whoever else was there to pick it up, or in the case there wasn't that real deterioration in the patients themselves. So this is where things I would argue really got bad. And this is now pushing into the 90s and early 2000s. Therefore, it is not a surprise to those of us who've been in the field during this time that you had rise in epidemics like the opioid crisis or rise in epidemics like the suicide crisis, both of which kill over 50,000 people every year. In fact, to us, those are just the stories that make the front page of the newspaper, the so-called tips of the iceberg that we read and hear about. But actually, there are many hundreds of thousands of individuals in psychiatric hospitals throughout this country who go through some kind of revolving door. And that is end up hospitalized for an acute stay, are out in a week when their insurance runs out, are then either back in a home that can't care for them out on the street in the case of individuals without homes. And then in a very predictable fashion ending back up in the hospital a short time later. You might imagine, of course, that this immediately ties into a differentiation between people with the resources to take care of individuals personally, or those who don't have that resources. And as with most things that is true, individuals who had fewer resources, had fewer options, and were likely to have worse outcomes.  Of course, if you have the capacity to pay privately, things were a little bit better, but not a lot, because most of these facilities really offered very few options. And the other thing that was missing in this system is what about an in between level of care, which we often refer to as intermediate care. That is, we understand when somebody is acutely ill needs to be in the hospital, and we have providers in the community, you could see for once a week psychotherapy or once a month psychopharmacology, which particularly if you can pay privately but even if you have to use insurance, you have some availability in certain areas of the country, but that middle range where you don't need an acute hospitalization you may not be a risk to yourself or other, but you're not well enough to be home and doing once a week psychotherapy, that intermediate level of care, that's smaller and smaller and smaller, and to the place we are today. So, so that that's really where things are. Let me update that a little bit before we move to the second system. I would argue that the only thing that has protected us as a society somewhat from this problem has been the freestanding nonprofit, a private psychiatric hospital and there are a number of us around the country Silver Hill, founded in 1931, the Menninger Clinic, which originally was out in Topeka, Kansas, and then moved to Houston, you know, found it around that same time. A Clayne Hospital, which is affiliated with Harvard, founded in the 1800s, Shepherd Pratt down in Baltimore, there are about a dozen, let's say, of these hospitals around the country that have, I believe, held a very special and important place, because they're neither part of the academic medical center system, which has been so driven by the need to be able to essentially break even or turn a profit in their medical care, and driven by the same system that dictates how you change cardiology or internal medicine or surgery. But also are small and independent enough, these these private psychiatric hospitals that new strategies can be evolved that are patient focused and ultimately care for individuals in the way that they and their families would want to be. These hospitals are by no means perfect and we've all rigged Silver Hill and the others have all suffered our ups and downs as we've navigated the complexity of the system. But by and large, we all operate through what what is sort of euphemistically referred to as a cross subsidization system, which is we offer services to some who can afford to pay. And then with the the excess revenue from those can then subsidize the care. And sometimes it's the very same families and patients at a different stage of the illness. And sometimes it's different patients, those who can't afford to pay. Most typically these days and I'll speak to the to the models of most of the hospitals including Silver Hill that are out there. We'll accept insurance for the acute inpatient side, even though what the insurance pays is less than what a high quality treatment facility would need in order to provide that care. But have a small profit margin on the residential side that intermediate level of care that can be used to subsidize sometimes outpatient is used in a similar way. But that's the system by which Silver Hill operates by which a claim by which effort Pratt, and to some extent, some of the others as well. And we try to do the work that we believe in we're nonprofits, we're nonprofit we obviously aren't doing this to store up big funds or to distribute the profits to our employees. But but rather to provide care for as many people as possible, using this cross subsidization model. So now let me switch to the other system and that's going to be a little bit of a shorter part of the story. But, but I think it's important to add it on, because if we're thinking from a societal perspective, and if you're thinking about where this fits into the Bedford Playhouse or your lives or the community. So I would argue the second part is as and perhaps even more in some circles important than the first store. And the story here is the following. When, for understandable reasons when psychiatric illness was first conceptualized, the model that was used was often one taken from medical illnesses. And that is a broadly speaking a categorical model of illness. That is, when you make a diagnosis, you're determining whether the person has the problem, or they don't. That is, it's not something in between. If you go to the emergency room with right lower quadrant pain. And, and your doctor does the exam and sends you for a CAT scan or an MRI. They want to know whether you have an appendicitis or not. If you have an appendicitis the treatment is clear, get taken to the emergency to the operating room, the appendix is removed. And that's, and that's a curative treatment. You don't have appendicitis anymore. You'll need some recovery, you'll need some antibiotics, but by and large, it's a very straightforward matter. If you don't have appendicitis, then there are many other options, but it is no great. You have appendicitis or you don't. All medical illnesses are like that. And in fact, increasingly over time, we have been gotten better and better in the medical non psychiatric field at solving the the categorical illnesses and now working much harder on those gray areas. I want to give as an example, hypertension. We talk about somebody as whether they have hypertension, high blood pressure or not. You might look in their medical chart and say, it's checked or not. But in reality, hypertension is not one of those things you have where you go. It's a continuum. It's, it's a gradation or scale. One person may have a systolic that's that first number in your blood pressure of 161 and another may have 159. And technically, by the definition that 160 is the cutoff, you could say one of them has hypertension and one doesn't. But every doctor and certain and I would argue most informed patients know that that's a bit arbitrary that 161 and 159 are pretty much the same thing. And 161 and 200, even though they're both technically hypertension are very different 200 is a dangerously high blood pressure that needs emergent interference 161, not so much. But 159 and 120, even though both not hypertension are also quite different. Now it turns out that psychiatric illness is not at all like appendicitis and virtually every case, but it is a lot like hypertension in the sense that all of the symptoms that we suffer from and that our patients suffer from or our family members suffer from whether it be depression, anxiety, even mood disorders, attentional disorders, eating disorders. And this one surprises people, but even psychosis exists on scales or spectrum. That is, people are not categorical and have it or they don't we make talk that way it's short hand doctors use that shorthand family members even patients do, but it could be very misleading, because every one of these symptoms is a normative component. And this is where things get very confusing, because we talk in common language about feeling depressed, and we need to talk about that feeling. And I would argue that probably most people have some conception of that means, but talking about depression on a normative spectrum is not the same as talking about a severe clinical depression that necessitates being in the hospital. And we need to be able to make those differentiations in a way that doesn't increase stigma, but does clarify the difference of what we need. Because if we're going to reach a point where we can talk to our children, and our adolescents in schools and our communities to our friends and even at a workplace about the continuum of psychological difficulties, whether they be depression, anxiety, stress, trauma, and others, we need to have a language that separates and recognizes that continuum, and doesn't equate it all with the most severe level that necessitate much higher levels of care. We need to do this, frankly, from the perspective of our healthcare system and insurance. Understandably, an insurance industry relies on the fact that not everybody qualifies for the same treatment. It's not a problem if a surgery, a very expensive surgery was something that every patient could say, I need or want it. Of course, it's not the case. And so, in that case, insurance companies can manage cost. I haven't been as good at differentiating that in the psychological sense. So how do we create a system that cares for people at the most severe levels in appropriate circumstances, but doesn't minimize the distress, same time that someone with a lower level of symptoms has and gets them appropriate treatment in its place. And I don't solve that as a society. And I don't have an answer to that. But what I would suggest is one way that one thing that has to happen in order for those problems to be solved is, we have to find a way in our communities in our schools in our workplaces, to give people's privacy, avoiding stigmatization, acknowledging a level of normalcy, normalizing a certain degree of psychological symptoms. This is where I would argue that the notion of social emotional health really comes into play. And in the rest, this is a curriculum or a language that is taught even in schools for children as they grow up and in an increasingly sophisticated way, be able to talk about these ideas with each other with their teachers with their parents, in a way that they can work at this tentatively. Because what we know, and we've seen over and over again is that if you can address some of these issues early, and you can identify difficulties and not put them into a single category, but rather recognize that people can benefit from counseling, or talking or psychotherapy before it gets necessarily to the level of medication. But even if it does get to the level of medication, that it can be medication that's administered as an outpatient, even by a primary care doctor, and help a lot of people and prevent them from ending up in the more severe situation where they require intervention from a psychiatrist, and ultimately might even require a hospital or more intensive setting. It doesn't mean to say we can ever completely avoid that sometimes the illness will get worse, just as all the nutrition and exercise in the world doesn't prevent there from being some medical illnesses that do require a higher level of care. But we can't just say, we don't need to worry about nutrition and exercise because we have the hospital or the emergency room sitting there. These systems have to work together. And ultimately, they really need to work in what I would consider to be a true continuum. And this is really where I want to wrap up. And I see some questions coming through and I look forward to taking them, which is, if the system is disjointed, and if we have a totally separate system that is working and helping kids in school or individuals at work, which is separate from the system of therapists and psychiatrists in the community, which is separate from the system that is for the acute care and the residential care. And that is pretty much what we have in our society right now, highly fragmented, a highly siloed system, then our ability to act preventively and to keep things from getting worse, or to follow somebody who may have had mild symptoms early, which are now intensifying in response to whatever stresses from the environment or physiology. If that's too fragmented, we're going to fail. We have failed. And again, if we look at the opioid epidemic, if we look at the suicide epidemic, I would argue that we have seen the failure of a fragmented system. Unfortunately, I have relatively little hope that our large academic medical centers are able to provide that total continuum. They are too driven by financial pressures that have made this very difficult. It doesn't mean that excellent work can't be done in certain sections of the of the academic medical center, certainly worked at Columbia, we're now a Silver Hill is affiliated with Yale, and we see some wonderful things happening. But probably, some of the best things happening in our medical centers is research that then needs to be applied. And I would argue that the private nonprofit psychiatric hospital systems, like Silver Hill, like Austin Riggs and McLean and others, is an amazing opportunity for stitching these services together into a true continuum. This hasn't always been true in our past, but it is something that I and my colleagues and the other leaders at Silver Hill are working very hard to achieve. So I hope you'll hear more about that in the days and years to come. I think we can build a more holistic evidence based patient center continuum of care that provides both preventative help. And it doesn't have to be called treatment even but it's education, much like we're doing right now, but also in the schools and the workplaces, as well as a safety net for individuals who develop more severe difficulties. All of these interventions need to be multifaceted there is no one answer the era where we thought there was going to be some Deus Ex Machina and it'll be all solved by a new medicine, we're all solved by a new brain scan. We are pretty certain that is not coming anytime soon at least and maybe not ever. But by using many tools in a complex and thoughtful way, including a lot of what we're learning about wellness from outside psychiatry that is we're learning from meditation we're learning from nutrition we're learning from from religions we're learning from a whole range of different places, because after all these are, these are millennia old problems. I think we can we can do much better, and we can really start to solve some of these difficulties in our society. So I'm going to end there. Dan, I hope you'll come back and help me. Questions. Hey, how are you. All right, thanks everybody we got actually some really good questions and I'll just feed these to Dr Gerber and let him, let him respond. So the first question that was posted was with regard to medications. Do you think that since there's no longer as much of a stigma about them as they, as there used to be, it's led to over prescribing. And it's a great question and I think I think I would only change slightly one word I would agree but with one slide. I think what we have is misprescribing. I, I, I, there are certainly populations in which I still see some under prescription and other populations where I see over prescription. So I'm not sure that we necessarily the answer is necessarily across the board to reduce the amount of prescribing because I do think there are some populations still that could benefit from medications that don't currently. There are certainly some groups that that are are using medicine too much. The other part to this that that that really just just to put with that question is the use of psychotherapy. There is no question that psychotherapy is is a valuable effective treatment for almost all psychiatric conditions, not necessarily by itself. One of the areas of a past era was to imagine just as it's an error to think medications are for everybody. It's also an error to think psychotherapy solves all problems. But what we're increasingly learning is that judicious and thoughtful combinations of psychotherapy and medication are most often the most helpful to individuals and psychiatric illness. What are your thoughts on what appears to be a significant rise in the past couple of decades on diagnoses of ADD and similar conditions, were they always there and just am identified. Yeah. It's a great question. So I'm, I'm trained as a child psychiatrist. So, so this feels like a question that I got a lot. And I'll tell you what what my thought is on this. Is no question that attentional difficulties are increasingly spoken about. But the idea that there is a categorical division between people with ADD and those without which which sounds so much nicer it sounds so much simpler if we can just divide people into these two categories. I think that idea has led to a lot of problems, because what's essentially said is, well, if only I get the right diagnosis, I'll get put on the medicine. But in fact, the number of diagnoses of ADHD have risen dramatically. And I think that most of those individuals have some attentional difficulties that doesn't mean the medication was the right thing for them. And we failed as a society. And I don't, I partly blame psychiatrists for this, but I also blame our society as a whole for having the more nuanced description of when is it appropriate to use and helpful to use medications. And then our other interventional techniques, as if good if not better. And then the other piece, and we can spend the whole hour just talking about ADHD I would say, where does the amount of resources or socio economic status fit into it. I can tell you that it has grown much more common, for example, in in the inner city or in areas where people individuals being treated or predominantly have black or brown skin that medicines get used rather than psychotherapy, because prescribing a medicine is deemed cheaper than doing the psychotherapy. I don't think we should use medicines ever doesn't mean I think everybody should be on psychotherapy, but these are complex issues that have to be talked about as a society, and can't just be put off too well what is the diagnosis say that's that's not enough. This question is from Anne, who says that she is a recovery coach in Greenwich. And do you anticipate or have you already seen a spike in behavioral health concerns as a direct result of COVID-19. What's a great question and I'd be curious and what you're seeing. I'll tell you just just personally I have read data that argues both ways there are certainly those who are arguing that we have already started to see this anecdotally we're hearing more and more at the hospital of people who are very stressed by COVID. And the demand is certainly up that from where it was in February and March. On the other hand, in those of you may have read an article New York Times last week by Ben Kerry who's very thoughtful reporter here use the data is not fully in yet and that we can't tell. I would say that intuitively, I believe we are going to have more difficulties of a wide range, but exactly how they're going to present themselves and when they will present themselves. I don't know, I imagine this is going to be something we are going to see the consequences of for a long time to come, and it may be less about a large spike right now, and more about a long spread out stress trauma post traumatic stress situation that we're going to see for months if not years to come. And I think we're all going to have to work together to figure that out. Let's see here. What do you think of Medicare for all. Yeah, it's a great question and I don't want to stray too much into the political even though you probably figure out from some what I'll say. I think that from my perspective, it's very hard to imagine where a system of payment system as fragmented as we currently have is ever going to do justice for people with mental health difficulties that I can maybe see how it would work for some of our medical patients, but our folks with mental health difficulties need a single payer system. It's too complex, it's too multifaceted for these other systems to work. Whether Medicare for all is the right single payer system or not, I think all depends on how it's implemented. And I can tell you that the way Medicare is right now is terribly underfunded, even for people with Medicare in terms of their mental health, it would frighten me if we didn't increase the benefits, and then just generalized it to everyone. In fact, Medicare is one of the poor insurance reimbursers for mental health. On the other hand, it was beefed up and the benefits were made fair and better. You know, I don't, if you want to still call it Medicare for all and it's got better benefits, I would certainly be open to that. So I think it's all it's really going to hinge on the implementation. This is another, this is a question posted anonymously. I have been in and out of psychiatric care since college for an anxiety disorder, excuse me, and often on medications at that time. I feel I never had the full support of my parents because they didn't really understand what I was going through. What is your advice in terms of how to talk to people to make them understand the condition. Yeah, I really appreciate the question and I really commend you for asking it. What you describe is, is so common, and, and I think it's so hard to talk and ask about it. And I'm grateful to you for having the courage to raise this year. Like a lot of experiences, sometimes people who haven't been through them have a lot of trouble understanding what it means. And I think mental illness, like some other experiences are one of those things that some people have a very difficult time grasping. So how does one help, in this case your parents, understand better what you have been through and are going through. And if you're like other families that I've worked with, you've tried. And that doesn't necessarily mean obviously I don't know your parents. It doesn't necessarily mean that that they're bad people. It may mean that they haven't heard it in a way that they could understand. And notorious, it's notoriously difficult for family members, particularly when there is conflict to explain things to one another. So my recommendation is, and you may have tried this and if it hasn't worked, maybe there's a way to try it again. Get somebody else involved, whether it's a family therapist, someone your parents trust, someone you trust, some third party who can stand outside the family and say, I hear what you're saying, and I hear what you're saying, and try to translate and get people talking to one another again. One of the key components of virtually all the treatments that I do, as long as their families are in the picture, is some version of family meetings. You don't even have to call it family therapy if you don't want. I don't care if you call it therapy at all. But a family meeting, where everybody sits down together, or in this day and age, everybody's on Zoom together, and you have these conversations. And I have to tell you, I've seen families, not infrequently, who weren't able to do it on their own, just at the presence of a facilitator. And it's no tribute to me or anybody else doing it. Sometimes it's just the fact of a third person in the room kind of setting a level playing field and getting the conversation going that can really help. That's what I would hope for you. By the way, if I can be of service and you'd like to contact me, you know, I'm sure Dan will share my contact information or you can reach out to Silverhill Hospital, Google me, send me an email and I'd be honored to try to help you in any way I can. This question is from Victoria who is asking, statistically speaking, many adolescents experience their first onset of a mental health issue around age 14. For those individuals, can you provide any scientific data on what percentage recover to be able to lead adult productive lives and what percentage don't. So first, just to validate what you're saying that that almost all psychiatric illnesses or psychological illnesses developed in adolescence. And, you know, it's not all at once, but between let's say the ages of 13 and 20 something like 90 plus percent of psychiatric illnesses first appear doesn't mean they're diagnosed it doesn't mean they're treated, but in retrospect, that is what we believe. And it ties right on to what we know about brain development. That is the brain is really developing heavily during this period of time and adult identity and personality formation is taking place. So it makes sense from an herbologic point of view that this is when the machinery can go awry somewhat. It's also a time of enormous change and stress and and relationship conflict. So it makes sense. Now, any percentage that says how how many people go on into different categories, it's going to need cutoffs, because as I mentioned earlier, so much as a continuum so I'll speak in some in with the best cutoffs we have knowing that there is this continuum. Roughly 20% of the population has a diagnosable psychiatric condition through their adult life. If you think that of the entire population, not just people with difficulties. One out of five of them will have a persistent difficulty. And by the way, that doesn't mean they can't live a fulfilling life, it just means they're going to have some persistent difficulties that are going to require attention and some treatment. So if you figure that, let's say somewhere around half of adolescents suffer from some difficulties. Roughly, and I'm estimating a little bit here. A little more than half of those, it's going to resolve. But for a little less than half of those with difficulties and adolescents, it won't. It's not a foregone conclusion that if you have difficulties when you're 14 or when you're 18 that you're going to have in the rest of your life, but it's also not that unlikely it's not that much less than 50%. Now, the group that doesn't end up with a diagnosable condition will they still have some challenges sure everybody has some challenge. They don't disappear entirely, but they don't necessarily have to provide a huge problem. And to flip over into the group that doesn't have the psychiatric condition. Most of those people are going to live healthy and fulfilling lives with difficulties requiring some forms of treatment. So what percentage of the population is truly debilitated by their mental illness. That's less. Probably somewhere in the vicinity of eight or 9% 7% of the populations less than 10% are truly debilitated. And of course, most of them do present early on but it's a relatively small fraction of those adolescents that have some difficulty that will be truly debilitated for the rest of their lives There's a lot of hope. All the data suggests that the earlier you intervene, the more thoughtfully you intervene with high quality treatment, the better chances you have of not having a debilitating illness. So, help act quickly work collaboratively. And, and there's a lot of hope. The next question is, you spoke eloquently about the broken medical system caregivers are often lost and confused about how to navigate this system. The burden falls on the caregivers. How can we educate ourselves to better care for our loved ones. You know, it's such an important question and really grateful for that because it isn't something I spoke about but but something I feel really passionate about, which is, that's terrible what you know the truth of that statement really breaks my heart right families individuals who are in many cases at the worst times of their life right struggling with changes and frightening things and and just pulling whatever resources they can together to care for their loved ones are not the people that we should be now burdening with figuring out which call and which phone number and which hospital and doing a full analysis. I mean, you can pick up consumer reports and figure out what air conditioner to buy. Yet, there's no similar resource for figuring out how do you find adequate health care and I think it's a real tragedy and even crime that we have such a fragmented system that is putting families in that position. My dream here would be that this would be another thing that that private psychiatric hospitals like Silver Hill and others could really build and pioneer. It's part of that continuum that I was speaking about, because if you really want to facilitate getting to good treatment early, which I just spoke about right, you have to make this understandable and doable. And, you know, it, which, which I sometimes I've said this, you know, to more families that then I can count people with advanced degrees and, you know, who could navigate all sorts of incredibly complex systems. They're struggling. So what does this mean to a family that doesn't have those resources or doesn't have those that level of education right, it means it becomes virtually impossible. So we need to build those systems and we need to build them in a financially sustainable way, so that that again using the cross subsidization model, we're going to need some help from those who do have the resources to build these, and then make them available to others. There are some examples of this out there, but not enough. And certainly it's something that I would like Silver Hill to be known for in the future so stay tuned and I promise that's one of the things on our list. We have two questions on kind of a similar vein. Can we make schools more responsible and on a similar question, what kind of things can be done in the workplace. Yeah, to help. No, it's a great question and and I think the short answer is yes that I think there's a lot both schools and workplaces can do to be better. But as I'm sure you can all immediately agree. It's, it's not simple. I remember what one of the one of the things that that hit me once that I just hadn't ever thought about but it made so much sense was, I was part of a group and we were kind of being critical for a school system for not spending more attention and evaluating and then intervening on mental health. I remember being part of a group that was talking to the superintendent for this school district, and he's been very frank.  But it is not fair to put the entire burden on us and not give us the resources to do it well, because now we're already dealing with all sorts of difficult things in our society and in our system. Particularly with COVID right. If you're going to if you're going to ask us to help in this way, you've got to make the resources available and I couldn't agree more I think he was absolutely correct. I think sometimes schools resistance to doing this is misunderstood as being stigma, when it's really the failure of the system to provide adequate resources. It's not inexpensive it is not easy to to to help schools do this teachers don't get trained on this in in in regular teacher training. It requires you know those of us who spent, you know, literally a decade in schools of various sorts, learning about the different illnesses and then staying up. And if you're going to date with that and learning about the treatments, a lot of time and resources to get good at that. So for if schools are going to do this and I think they should be need to then be given the resources to bring in therapists and bring in counselors, and I think another area where schools really suffer is when the statistics get used against them.  If their statistics get published, they might end up looking like a worse school, because they're actually providing better services, this is known in the hospital world as well. I think we have to come up with unified systems across school districts or even across states. Won't even try for the whole country at this point but at least across states that that build systems incentivize schools for doing better. When I was in my training, you know you get to see these glimpses. At one point I worked in an inner city Manhattan school where they had embedded a clinic for kids inside the school and it was the most wonderful thing to watch. These teachers and therapists and psychiatrists collaborate around these students in ways that didn't stigmatize the kids, didn't label them, didn't insist they be even in separate classes, but joined forces. There are ideas like that out there that I think with more learning and with resources we could be doing. Workplaces are complicated too because of the issues around discrimination and stigma. We have to be enormously careful that mental illness or symptoms aren't used to identify the problem employee and therefore used either to fail to promote them or to fire them or somehow to discriminate against them. People have to be protected, but ultimately then also need to have the resources available. I'll tell you even at a psychiatric hospital these things are not simple. COVID has led to an enormous amount of stress on many hospital employees, including our own. And what we've learned is that there is no one size fits all that we have to make a number of different resources available to our staff and leave it really to their choice to privately choose what they want to use and what they don't. And I hope that we've been a leader in this. I do think other companies and institutions, I know Yale, for example, has been very thoughtful about how they're making resources available, but not all hospitals even are good at that. So we have to learn from one another. But thanks for a great question. Right. We have time for one more. So I'm going to ask kind of a broad question here that was posted, which is what is your idea for the future? So let's say that's a nice question because I can I can I can hear it the way I want to. So listen, my real idea for a future is institutions that can provide a real continuum of care and have both the flexibility to respond to a community's needs. But also the breadth to not be only good for one thing. It goes back to that earlier question about your families and crisis. How are they supposed to navigate the system? You can't ask people, you know, like, you know, to use a kind of crude analogy, you know, your vacuum cleaners broken and you got to go to a different store to replace the nozzle as you go to a different store to replace this part of the motor and this part of the wire. It's craziness. We wouldn't ask it for people fixing their vacuum cleaners. Why do we do that in mental health? So to me, my dream of the future is a system where you really have these more open systems that that provide different care. They have to be collaborative. I do believe they're going to come out of the nonprofit sector, rather than the for profit because they don't think there is a profit in this right now. And ultimately, I think government and insurance will learn from the successes of these institutions. I dream Silver Hill will be one of those happens to be nearby in your community. So I think I hope that's something that you can make use of. And I hope if you do need services for your family or for somebody, you know, you come to us because this is something that we're working very, very hard to build. Well, Dr. Gerber, thank you very much. This was really great. I do want to just reiterate for everybody watching and listening. As Dr. Gerber mentioned before, if you would like to contact him with a follow up question or if there's anything you feel you need to speak about, you can send us an email. The email address to use is programming at bedfordplayhouse.org, and we will make sure that Dr. Gerber gets those messages and relay them to him or we will share his email address with you. So you can contact him directly just whatever is whatever is most comfortable for everybody we're happy to do. And I hope I just say one last thing before you close, which is, you know, I hope this is obvious, but I think what you're doing at the bed for Playhouse by hosting events like this and having people like me and obviously there's many others like me out there is so important because it brings the message out to the community. It shows people that this is okay to talk about okay to ask questions about and it gets this question into the public discourse.  Thank you Dan for doing this. And if there's anything we at Silver Hill can do other doctors other therapists and so on to help with your efforts in the community. Please don't hesitate to ask. Thank you very much and we have some great volunteers who help with this program. And they're fantastic. And so we really appreciate you're coming on do this and hopefully next time we can do this again, actually in the theater. And on the stage with a little, a little bit of luck we can that won't be too far off. So thank you again, Dr. Gerber this is really, really fantastic and interesting. Thank you to everybody for watching. I hope you have a good night, and we'll see you again soon. Our next program in this series is coming up on July 12. We have and Dr. Andrew Solomon, who's going to be speaking about about COVID-19 and the effects of it so certainly no shortage of topics on. Yeah, he's, and you may know him is from far from the tree, and he's, he's spoken at the playhouse before, and we're going to have him online, unfortunately. There will be a recording of this which is going to go online for those if you know anybody who could benefit from watching it will be will be sharing that link in a couple of days. So please check back on the website then and thank you again. Really appreciate everybody's everybody's participation. Thanks everybody. Have a good night. Bye bye.


C is not object-oriented and so has no concept of classes, but it does have user-defined data types called structures. Unlike a class, a C structure has no notion of methods, a structure is just pure data. To declare a structure type, we use a reserved word struct, followed by a name, followed by a list of members and curly braces. Having declared this struct type, we can then create a variable of this type just as if we were creating a variable of a built-in type, except the type name is preceded by the reserved word struct. In fact, it's easiest to think of the word struct as if it's part of the type name. Once we have a variable of a struct type, we can access the individual members that make up the struct with the dot operator. So here, for example, we declare a type called struct cat with two members, a char pointer name and an int age. We then create a struct cat variable mittens and then assign its name member the char pointer value represented by the string m-i-t-t-e-n-s and then assign its age member the int value 5. We can assign one struct instance to another as we do here, assigning mittens to fluffy. This copies the value of every member of mittens to the corresponding member of fluffy. We can also create struct pointers as we can with any other type. Here we assign a struct cat pointer p and assign it the reference of fluffy, so p now holds a pointer representing the address of the struct cat variable fluffy. Somewhat surprisingly, we cannot compare struct values with the equality operators, so this expression is illegal. If you want to compare the corresponding members of two struct values, you have to compare them individually. Here, we use malloc to allocate a block the size of eight struct cats and we assign the result of malloc to a struct cat pointer. We then can retrieve the individual cats of this block using pointer arithmetic and the dereference operator and once we have an individual cat instance value, we can assign its members with the dot operator. So here we assign the string oscar to the name member of the first cat, the string kitty to the name member of the second cat, and the number four to the age member of the last cat. If we want a stack allocated block of cats, we can create an array instead of using malloc. We then use the array in the same fashion, but just keep in mind that the block of memory only exists for the duration of the local scope. So far, we've created pointers and arrays out of our base types and now also the custom struct types which we can create. But the general rule in C is that we can create pointers and arrays of any type, including other pointers and arrays. So we can have pointers to pointers, pointers to arrays, arrays of pointers, arrays of arrays, pointers to pointers to pointers, arrays of pointers to arrays, addInfinitem. For these complex types, a key thing to understand is that arrays of different sizes are considered different types. So say an array of five-ints is not the same type as an array of six-ints. So say when we create a pointer to an array of five-ints, that is a different type of pointer than a pointer to an array of six-ints. Here's a more elaborate example of a complex type. Because there exists in C an int type, we can also create arrays of int. For example, we can have an array of 12-ints type. And because that's its own type, we can create an array of that type. So we can have an array of four arrays of 12-ints type. And because that's its own type, we can create a pointer to that type, a pointer to an array of four arrays of 12-ints. And because that's its own type, we can create a pointer to that type, a pointer to pointers to arrays of four arrays of 12-ints. And because that's its own type, we can create an array of that type, so we can have an array of seven pointers to pointers to arrays of four arrays of 12-ints. Again, be clear that arrays of different sizes are different types. types. So here we have three pointer types, which all point to arrays of arrays of ints, but because the arrays are of different sizes, these are three separate types. Now you're probably trying to picture what these data types look like in memory. Well, pointers are the easy case. A pointer of any type always represents just a single address. For example, a pointer that points to an individual char is an address, a pointer that points to a pointer to a char is also an address, and likewise a pointer that points to an array of arrays is also just an individual address. As for arrays, an array of nx's is a contiguous block of nx's. So an array of seven doubles is a contiguous block that fits seven doubles. An array of 15 pointers to char's is a contiguous block that fits 15 pointers to char's. An array of four arrays of 12 ints is a contiguous block that fits four arrays of 12 ints, and each array of 12 ints is in turn a contiguous block that fits 12 ints. For illustration, here's an array of four arrays of three char's. The whole block is made up of four blocks, each of which is made up of three char's. Here's an array of two pointers to arrays of four arrays of 12 ints. What we have in memory is simply two pointers. The pointers point to arrays of arrays, but the pointers themselves as always are merely addresses. Here we have an array of two arrays of three pointers to arrays of 12 ints. Again, reading left to right, as soon as we're talking about a pointer, we're talking about just a single address, regardless of the type to which the pointer points. One thing that makes these complex types very confusing is that C programmers often use the words pointer and array as modifying adjectives rather than as nouns, and this ends up reversing the order of the components when we state a type. For example, instead of saying an array of 12 ints, we could say an int array sized 12. Even more confusing, we generally leave the array sizes unstated, so we would more commonly just say int array. The more complex our array and pointer types, the more confusion this creates. Instead of saying an array of four arrays of 12 ints, we commonly say an int array array, and instead of saying a pointer to an array of four arrays of 12 ints, we commonly say int array array pointer. Because it's awkward to include the array sizes in this way of expressing types, I find it less clear, even though it is less verbose. What you absolutely shouldn't do, however, is mix these two ways of expressing types. For example, instead of saying a pointer to an array of four arrays of 12 ints, or instead of saying an int array array pointer, which is equivalent, it would be valid English to say a pointer to an int array array, or say a pointer to an array of int arrays. But expressing types this way is horribly confusing. Sadly, many programmers use this manner of expressing types quite commonly. Just watch out for it and try to avoid using it yourself. If you're ever confused about a complex pointer or array type, put the component types in a consistent order, as I've demonstrated. Okay, so the next question is what syntax do we use to create these complex types? Well, before getting to the syntax, consider the nature of unary operators. For a moment, imagine if in the C language, dollar sign, number sign, and the at sign were all unary operators. They aren't, but just imagine this were the case. This use of the three operators on foo for example here would be applied from right to left. Now imagine if the at sign were post-fix rather than prefix, meaning it would be written after its operand rather than before. Now the order of operations depends upon the order of precedence. If the at sign had highest precedence, then this would be the evaluation order. If though the number sign had highest precedence and the at sign had second highest, this would be the evaluation order, and if the at sign had lowest precedence, then this would be the order. So the point is that when both prefix and post-fix operators are involved, we have to be concerned about the respective precedence. Now what do operators have to do with declarations? Normally we think of operations only existing in expressions, and the declaration is not an expression.  And just like in an actual expression, we can use parens to subvert this precedence. So in this declaration of an array, you should think of the square brackets as an operator on the name foo, but which has the effect of modifying the base type int to be an array of the size specified in the square brackets. So this is a declaration of an array of 12-ints. In this next declaration, we have another pair of square brackets containing the number 4. Because this pair is closer to the pseudo-operant foo, this is firstly an array of 4. So this is an array of 4 arrays of 12-ints. In this next declaration, we've added an asterisk and enclosed it in parentheses around foo. Without the parentheses, the square brackets would have higher precedence, but with the parentheses, the asterisk is applied first, so this is a pointer to arrays of 4 arrays of 12-ints. Lastly, we've added an asterisk outside the parens and moved the first square brackets to be inside the parens. So because square brackets have a higher precedence than asterisk looking inside the parens, this is an array of 4-pointers, and then looking outside the parens, these pointers point to arrays of 12-pointers to ints. So the general pattern of declaration syntax is that we start with a name and read the modifiers inside out going by the order of precedence, except where parens intervene. Now as for actually using these complex types, we need to cover a few rules. First, referencing a pointer type variable will return a pointer to that type. Here we assign the reference of int variable i to pointer to int variable json, and then in turn assign the reference of json to pointer to pointer to int variable Amanda. So the reference of json returns a pointer to pointer to int value. When dereferencing a pointer to pointer to x, we get back a pointer to x value. So here when we dereference Amanda, which is a pointer to pointer to int, we get back a pointer to int. If we use a dereference operator on Amanda twice, then we're dereferencing the pointer to int value returned by the dereference of Amanda, and so we get back a plain int value. As previously discussed, an array name is really a pointer value. Notice that I said pointer value and not variable because we cannot assign two array names. Here we can assign the array name foo to an int pointer variable, but we cannot assign the int pointer variable back to the array name. For this array of seven pointers to ints, the array name is itself a pointer to pointers to ints. For this array of seven arrays of four ints, the array name is itself a pointer to arrays of four ints. Normally we can only use the reference operator on L values, which as we discussed earlier are valid targets of assignment. A special exception though is made for array names. If you reference the name of an array of nx's, you get back a pointer to an array of nx's. So here we can assign the reference of foo to this pointer to arrays of seven ints. Again, as we've said repeatedly, the size of an array is an inherent part of its type, so this example fails compilation. A pointer to arrays of seven ints value cannot be assigned to a pointer to arrays of nine ints variable. Now here's the rule that's most surprising. Normally when we dereference a pointer to x, we get back the x value to which the pointer pointed. The exception is with pointers to arrays. An array is not an actual kind of value, so dereferencing a pointer to an array can't possibly return an array value. There's just no such thing. Instead, dereferencing a pointer to an array of nx's will return a pointer to x. So here dereferencing this pointer to arrays of seven ints variable bar returns a pointer to int, which we can assign to the pointer to int variable p.