Danger to Self

on the front line with an er psychiatrist

The psychiatric emergency room, a fast-paced combat zone with pressure to match, thrusts its medical providers into the outland of human experience where they must respond rapidly and decisively in spite of uncertainty and, very often, danger.

In this lively first-person narrative, Paul R. Linde takes readers behind the scenes at an urban psychiatric emergency room, with all its chaos and pathos, where we witness mental health professionals doing their best to alleviate suffering and repair shattered lives.

As he and his colleagues encounter patients who are hallucinating, drunk, catatonic, aggressive, suicidal, high on drugs, paranoid, and physically sick, Linde examines the many ethical, legal, moral, and medical issues that confront today's psychiatric providers. He describes a profession under siege from the outside-health insurance companies, the pharmaceutical industry, government regulators, and even "patients' rights" advocates-and from the inside-biomedical and academic psychiatrists who have forgotten to care for the patient and have instead become checklist-marking pill-peddlers.

While lifting the veil on a crucial area of psychiatry that is as real as it gets, Danger to Self also injects a healthy dose of compassion into the practice of medicine and psychiatry.



Excerpts: danger to self

From the Preface:

I love my job when I'm not there. I'm a doctor in the psych emergency room at San Francisco General Hospital (SFGH). One reason I work there is that when I'm not there, I'm not there. I have a decent shot at separating out my job's trauma and drama from the rest of my life. But in my workplace, there's nowhere to hide.

This psychiatric job requires a certain amount of physicality. I am on my feet a lot, trying to soothe the jangled nerves of the weary, the sick, and the stressed-the latter category often includes the staff. I occasionally situate myself in front of the nursing station between the shift's charge nurse and the doors of our four seclusion rooms. I am one part bouncer, one part traffic cop, one part standup comedian, and one part maitre d'. Sedative anyone?

If you try to make sense of the place, you'll lose your mind. If you don't sweat the details, you can get a patient in trouble. If you do sweat the details, you'll run out of time.



Reviews and Press

Danger to Self— The Combat Zone of the ER Mental Crisis Ward
The Bright List | Aretha Bright | October 09, 2012

This is an ER psychiatrist's story from the front lines of mental illness and acute situations. This book reminded me why I got my psychology degree in the first place— It should be the next doctor soap on TV.

Linde's book consists of ten case studies drawn from 17 years of working in the high-pressure atmosphere of the Psychiatric Emergency Service at San Francisco General Hospital.

Linde's use of a combat metaphor isn't accidental. The mental health pros at SF General deal with a flood of patients who are hallucinating, drunk, catatonic, aggressive, severely suicidal, high on drugs, paranoid, and physically sick. I couldn't believe some of the stories. Their decisions need to be made as quickly as any physician's, and making the wrong call could have consequences just as lethal as in surgery.

This is the Wild West of medical dramas—and it's all true.
--Aretha Bright

"Danger to Self feeds our fascination with the world of medicine and our interest in the lives of others. . . . Linde's fast-paced but well-detailed accounts supply the wild, loud, chaotic, smelly and dangerous but also mostly moving "scripts" that could easily be a TV show." Read the full review
Herbert Schreier, Special to The Chronicle | Sunday, January 3, 2010

In this moving book, Linde (psychiatry, Univ. of California; Of Spirits and Madness: An American Psychiatrist in Africa) relates the challenges, joys, and potential gut-wrenching errors of his work as an emergency room psychiatrist at a public hospital, who is encountering those on the margins of society in the midst of illness. Few of the many recent books on therapy, psychoactive medications, and American mental health services put human faces on their subjects as Linde does. He writes with grace, honesty, and humility about the psychiatrist's task of judging the mind and heart of another human being while remaining convinced that medicine can play a role in restoration and healing. VERDICT: Those who enjoy the writings of Oliver Sacks and Sherwin B. Nuland will be enlightened by Linde's compassion and carefully wrought prose. Students of health policy, counseling, and psychology will find insight here as well.
Aaron Klink, Duke Univ., Durham, NC | LIBRARY JOURNAL, November 15, 2009

Linde (Of Spirits and Madness), clinical professor of psychiatry at the University of California-San Francisco medical school, performs a remarkably successful balancing act by presenting both the theory and practice of emergency room psychiatry in a compelling manner. He personalizes his cases and demonstrates how essential the human dimension is in high-quality care. Using 10 fascinating case studies from his 17-year career-with patients manifesting symptoms from suicidal behavior to catatonia-Linde discusses the medical, legal, philosophical and ethical implications of treatment options. He brings the reader along as he is forced to make almost immediate diagnoses and determine courses of treatment, including incarceration, that have the potential to shape (or end) these patients' lives. It becomes abundantly clear that there are rarely simple, straightforward answers. Linde quotes a professional bromide: "[t]he only thing that two psychiatrists can agree on is that a third one is wrong." He's a talented writer and a compassionate doctor who understands what works best for him and his patients: "while my head works pretty well, my real strength as a physician comes from the heart."
Publisher's Weekly | November 2, 2009

"Linde's Danger to Self is a warm, candid and appealing account of being an emergency room psychiatrist. Linde captures the non-conformist, hard-boiled style of the psychiatrists who work in this setting."
Tanya Luhrmann, Professor of Anthropology, Stanford University, author of Of Two Minds: An Anthropologist Looks At American Psychiatry

"Linde illustrates academic points with his personal experiences quite deftly. He comes across as a warm-hearted, thoughtful, dedicated physician doing a difficult job as best he can. His book offers an authentic behind-the-scenes look at how a psychiatrist thinks and practices."
Frank Huyler, ER doctor and poet, author of The Blood of Strangers: Stories from Emergency Medicine and Right of Thirst: A Novel (P.S.)

"In this provocative first-person account, Danger to Self, psychiatrist Paul Linde takes us to the troubling front lines of America's mental healthcare crisis. With one in three people experiencing some form of mental illness in their lifetimes, this is a story that needs to be told. Linde waves a red flag that can't be ignored."
Kemble Scott, author of SoMa and The Sower

"Danger to Self is an excellent account of treating acute mental illness; Dr. Linde presents powerful stories of disturbed minds and circumstances, of lives in upheaval due to psychosis, addiction, and despair. It is also the story of a psychiatrist who tends those ill enough to warrant treatment in a psychiatric emergency room. Well-written, compassionate, and worth the reading."
Kay Redfield Jamison, author of An Unquiet Mind and Nothing Was the Same.

Danger to Self: Table of Contents

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