Jeffrey T. Junig, MD, PhD

Sometimes I envy scientists and physicians from 100 years ago who took credit for the easy discoveries, sometimes even attaching their names to them. The Bernoulli Principle, for example, describes how the pressure of an inviscid material decreases as the flow of the material increases, and why the disgusting shower drape in cheap motels is pulled toward the person in the shower. I’m sure that I noticed that effect when I was about 6 years old, and had it not been already figured out, I know I would have come up with it eventually! But the days of simply thinking really, really hard and coming up with a “discovery” are long gone.Or are they? I have a good one, I think… and with the right presentation and help from readers, I might become famous. Or not. Either way, it’s worth a shot…. So, I’d like to introduce Junig’s Warm Coat Theory of Psychotropic Prescribing, or what I suggest the medical field refers to as the “JWCT” (I know—the title needs work!).

Back when I was an anesthesiologist, surgeons sometimes used the phrase “better is the enemy of good.” The point was that in some surgeries the best approach was to remove the infected or diseased tissue, stop the bleeding, close up ASAP, and get the patient back to the ICU. Spending another 4 hours picking at the tissue to make everything pretty risked a drop in the patient’s body temperature, a decrease in clotting and immune function, and an increased stress response, all in turn increasing the odds of a bad surgical outcome. I have to give credit where credit is due and note that the warm coat theory is similar in some ways to the “enemy of good” phrase that I have heard recited over the years. In fact, it is entirely possible that the unconscious parts of my mind stole the phrase and adapted it to psychiatry. If that is the case, I’m sorry for the actions of my unconscious—and I plead ignorance to the entire affair!

When prescribing medication for psychiatric conditions—for example, ADD or anxiety&mdash;the patient might note positive effects initially but then at some point ask, “maybe I’d do better with a higher dose; should we try a little more?” With any medication for any condition, there is a balance between positive effects of the medication and risks or side effects from the medication. Serotonin medications work well for depression and anxiety, but as their doses are increased, they will eventually cause sexual side effects. At still higher doses, they may cause drowsiness or nausea. The positive effects of a medication go up with dose, but the side effects increase as well. The goal for the patient and physician is to find the proper balance between positive effects and negative side effects. For example, if the patient has no interest in sex and doesn’t 

to be interested in sex, sexual side effects should not limit the dose. Nausea or sedation, on the other hand, may be barriers to dose increases. Different people have different concerns about risks and side effects, and different people have different needs for higher doses of medication. These differences, by the way, are why I maintain that psychiatrists should spend more time with patients than they do—but that’s another topic for another day.

Before we Wisconsin folks go outside in January, we take a look at the Weather Channel and dress accordingly. But we don’t dress for 14 degrees F; we dress for “pretty darn cold.” If I’m going to a Packers game, I’ll put on my long-johns (too much information?), jeans, and the snowsuit from Fleet Farm (that changed my life when I finally bought it, after suffering a few football seasons without it). I’ll also wear a stocking cap and maybe even a facemask, and of course a thick pair of gloves. At some point during the game, if the drunken guys squeeze in way-too-close on each side of me take off their shirts so their body heat radiates toward me and warms me up, I’ll take off my facemask and maybe my cap. By the end of the game, I might even have my own shirt off if the sun is out. Of course, the guys next to me might have enough of the game at some point and spend the rest of the game at the bar, just as the sun disappears behind a thick layer of clouds. Then, I’ll put the heavy stuff back on, and maybe rub my hands together or do some jumping around to raise my body heat. If I get cold enough, I’ll go inside and warm up for a few possessions. The point is that I don’t bring along a spring jacket to change into when I’m warm, and I don’t bring extra coats for when I’m cold. Instead I change my activity, my location, or make minor adjustments to my wardrobe.

According to the warm coat approach, I suggest that patients think of their psychiatric medications in a way similar to how I think of dressing for a Packers game in January. At the time the person wonders about a higher dose, he/she is getting a good response from the medication, usually with a low amount of side effects. At this point, “better” may be the enemy of “good.” The person is essentially wearing a warm coat in January. There is no need to run home and pick up a few more coats; the better action is to change behavior to fine-tune the degree of symptom relief. If the target symptoms are attention problems and the current dose of stimulant has taken the person 85% of the way, the correct action is to adjust behavior. Find a quiet location for studying. Get enough sleep. Come up with reminders and plan ahead, to avoid time crunches that interfere with performance. These are better approaches than increasing the dose of stimulant, which might raise blood pressure or lead to addictive problems. If the target symptoms are anxiety-related, work on positive self-talk and try to gain insight into why the anxiety is there in the first place. Learn to relax using deep breaths or by taking a walk to get away from the stressful environment.

If Junig’s Warm Coat Approach becomes big, some day you’ll be telling your grandchildren about the day you first read it, before anyone was talking about it. They’ll look up at you with big eyes and say “Wow!”   

Or not. Either way, I for one think the idea has legs!

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I'd like to introduce Junig's Warm Coat Theory of Psychotropic Prescribing, or what I suggest the medical field refers to as the "JWCT." 

Psychiatric Medication as a Warm Coat

Most physicians have heard the reference to ‘the elephant in the living room’. The phrase refers to an alcoholic in a family ruled by collective denial. References to ‘pink elephants in the living room’ are mixed metaphors; drunks classically ‘see pink elephants’, whereas the unseen living room elephant is just a garden-variety pachyderm. This latter point is only a pet peeve of mine, and has nothing to do with the rest of the story… so I’ll move on. 

 One nice thing about a ‘psychodynamic blog’ is that it can be about anything, since any issue involving humans will have a psychodynamic aspect. But when looking for a story about psychodynamics it is hard to find more content than a story about a drug addict. An impaired physician will be an even richer source of content. We might find, for example, a perfectionist who tried to temper his personal insecurities through academic accomplishment. When ‘tolerance’ took away pride in his accomplishments so even straight As felt inadequate, he faced the unconscious choice to either acknowledge his insecurities and become a ‘whole person’ made up of assets and liabilities, or to repress the uncomfortable feelings and develop a split to his personality where his perfect, outer, public side appears cocky and happy, and his inner, ashamed, insecure persona lives in hidden pain. A person in this condition is ripe for developing an addiction, as addiction makes such a split even more complete. The addict fancies himself as doing pretty darn well… except for that ugly, addicted part that is repressed and split off from his self-image. This repression is what we refer to as denial.

 When I look back on my own life I see that schoolwork always came easy to me, but I was socially inept and insecure. I ignored my loneliness and found solace in my accomplishments, but the positive feelings from my successes didn’t erase my core insecurities. If I set my mind to it I could learn almost anything, yet I felt naive and incompetent. I completed MD and PhD degrees in just six years of very hard work, but always felt like I wasn’t working hard enough. At 18 I travelled to Mexico to help build a church and at 19 I risked my life to save a drowning woman, yet I always felt guilty for sins I couldn’t remember committing. I found ways to validate myself, but at some point they all wore off—they ‘weren’t enough.’ And fittingly, I eventually become an addict.

 I’m explaining this because I don’t want to leave an elephant in my blog’s living room. As part of my recovery I constantly try to avoid the splitting of my personality—something that is a natural force for any addict with a public presence or image. It is tempting to hide my background and become only the perfect doctor with the record of accomplishment. Maintaining that persona is impossible, of course, in an era of search engines, but the danger of becoming that ‘perfect’ person is more acute for someone with my disease history. Addiction is a disease that limits insight, and the more I pretend that my illness doesn’t exist, the less insight I have to find my way back to the whole, imperfect person that I really am&mdash;and the person I must be in order to stay sober. I can’t be dismissive of my history even after 8 years of recovery. There is NO doubt in my mind that my addiction is a permanent condition; a potentially fatal disease for which, at this point, there is no cure.  

 The hard part for me is deciding in each situation the point where I disclose my history. If I point it out too soon, some people will envision elephant dung in my living room, consider me a fool, and never pay a visit. But if I point it out too late, some people will be angry that they didn’t hear about the elephant dung until after they stepped in it. For those who find metaphors challenging, by ‘elephant dung’ I’m referring to the consequences of my addiction for myself and others. For myself this includes the physical evidence of my addiction—old Board orders and National Practitioner Data Bank information&mdash;but also the personality characteristics that are common to those with addictions, and which (chick or egg) either came from or contributed to my addiction history.  For example, I can be quick-tempered at times&mdash;is that premorbid impulsivity, or is it a consequence of the self-centered grandiosity engendered by addiction? For others the ‘dung’ includes their conscious and unconscious attitudes toward addicts and addiction. When I mention my history to others I get a clue toward the amount of elephant dung they are carrying, which is largely a function of their past experiences with addiction.  Their reactions vary&mdash;surprise, contempt, sympathy, patronization, or in rare cases a hug, the secret handshake of recovery&mdash;but there are always reactions. These are the elephant reminders that I most dislike, as I have little choice but to accept them.

 At any rate, this is the disclosure of my elephant. If anyone is interested in more of the story, you will find it here and there on the Web; I tell my own version on one of my own Web pages (there is a link from 

, a forum I run for information about opiate dependence), and Men’s Health told a more graphic version a few years ago (Google ‘junig’ and ‘mens health’ and you will find that one). The Men’s Health write-up introduced a conflict in that I wanted to tell my parents that their ‘son the doctor’ had been discussed in a national, popular magazine… but something about the title made me hesitate. The article was entitled ‘The junkie in the O.R.,’ and featured a picture of a guy in scrubs injecting something into his ankle. The person in the photo wasn’t me, by the way—they apparently have junkie models, and didn’t need me. Who’d have thought?

 Most recovery stories have a hidden blessing, and I should share mine. Finding a ‘blessing’ from anything that lands one in the National Practitioner Data Bank is probably a transparent attempt to make sour lemons into overly sweetened lemonade, but I will let you be the judge of whether I am fooling myself or not. I loved anesthesiology, or at least I thought I loved it—periods of boredom interspersed with rare episodes of terror suited me fine, although in retrospect I probably had a couple bushels of repressed fear in my unconscious, and maybe a few acres of resentments growing toward those 3:00AM bowel obstructions. But being an anesthesiologist was quite lucrative and was rewarding in many other ways as well. I still vividly remember some of the more dramatic ‘saves’&mdash;the ruptured uterus in the OB unit that both mother and baby survived, the heroic intubations in the ER… there are no comparable experiences in psychiatry. But eventually the thrills were ‘not enough’ (do you detect a pattern?), and I became unhappy. I remember telling my partners that only a fool would ever leave such a job voluntarily. I am now more careful for what I wish for! If I had to name one thing that pushed my life off track, I would describe how at some point money became a way of keeping score for how was doing in life, and a source of security to the point where I almost considered money a source of immortality. I now understand the seductiveness and the fallacy of those thoughts.

 To explain the positives I have to provide just a small amount of background: my life came undone when I turned 40, and I entered treatment the following year, in 2001. Three and a half months later I completed the residential stage of treatment and found myself unemployed with what seemed like an impossible period of monitoring and aftercare stretching years into the future. But one day followed another, and I followed the good advice I received from other recovering people.  ‘Just keep doing the next right thing.’ ‘Take it one day at a time.’ And in my opinion the best advice:  ‘Be grateful.’ I eventually started doing things that I never would have done had my life stayed on track. I acted in several shows by our local Community Theater, after years of sitting in the audience and wishing that I could do that. Singing to the orphans as Mr. Bumble in Oliver as my son played the Artful Dodge rivaled any of my OR experiences, and gave me a sense of fulfillment that I had never had before. I replaced every beige wall in our home with a color (after consulting, of course, a book about colors and temperament). I began to write, and eventually established a regular column in Psychiatric Times and placed occasional articles in other publications. I spent more time with my children, and did my best to repair the damage I caused in our relationships. I appeared on TV in a story about addiction (a nicer presentation than my Men’s Health story!).  And I eventually struggled to learn humility as a new resident, this time in psychiatry. Residency was more enjoyable without the fear of learning IVs!

 I discovered that I love to teach, and I now teach at a nearby medical school and also in the residency program where I learned to be a psychiatrist. I have a radio show that I use to teach my local community about psychiatry and addiction. None of these jobs, by the way, pay a dime—yet they each make me feel like a million bucks. I am grateful for those who were willing to see me as more than ‘a junkie in the OR’, and grateful for second chances.  

 To end on a psychodynamic note, being a psychiatrist has taught me that we ALL have our outer projections of who we want to be, and we ALL have our shameful secrets. We are, of course, neither of those things, but rather we are all of them and more. I see too many people engaged in a battle that cannot be won, trying to be only one part of who they are. I also realize that people who seek happiness the most never seem to find it—those with addictions being at the top of that group.  

 I hope you all, the readers, will accept me elephant dung and all. I want to thank the folks at HCPLive for not dumping my blog after a background check. The new physician rating systems out there are relatively merciless for doctors like me, but that’s a story for another post. Until then… please do your best to keep your shoes clean.

One nice thing about a 'psychodynamic blog' is that it can be about anything, since any issue involving humans will have a psychodynamic aspect. But when looking for a story about psychodynamics it is hard to find more content than a story about a drug addict.

My Elephant

I wrote this introduction to readers of the Healthcare Professionals Network shortly after the tragic death of pop icon Michael Jackson. As I mulled over a topic and listened to the news reports, I realized that my professional experiences come together in such a fitting way in regard to his life and death that I had to make reference to the tragedy; I apologize for being opportunistic. 

 I am a psychiatrist with a psychodynamic approach to diagnosis and treatment. One goal in my work is to provide insight into maladaptive patterns in the way people go about their lives; one goal with the blog will be to take a look at the more obvious examples of psychodynamic principles as they play out in society. The unconscious mind lives in a fantasy world of ‘primary process thinking’ where constraints from time, money, and other ‘buzz-kills’ of mature thought wield no power. We each have our unconscious fantasies, often at conflict with the limitations imposed by adult reality.  Michael Jackson was in many ways a man living in a ‘primary process’ world, a ‘Peter Pan’ who never had to mature and face the facts, too wealthy and famous for anyone to stand in his way and say ‘you can’t have a merry-go-round—Grow up!! I will add the important caveat that I never met him, never even met someone who met him, so this is all just a guess. But we do a lot of guessing in psychodynamic psychiatry, so the point is still worth discussing.

 My second connection with the Michael Jackson story is that I have significant experience with opiate dependence, and the relationship between opiate dependence and the treatment of chronic pain. I expect (another educated guess) that opiates played a role in Mr. Jackson’s death. I know too well the world of desperate addicts who consciously or unconsciously manipulate others to keep drugs available and keep sickness at bay. And like many physicians who deal with chronic pain, I know the pressure one feels when a patient has paid money in order to receive respite, and complains of aches and pains from years of dancing, spinning, jumping, and kicking—a world that surely left Mr. Jackson with osteoarthritis and chronic pain. Michael Jackson, I would surmise (sounds better than ‘guess’), developed the misguided but common notion that narcotics were appropriate and helpful for such aches and pains, when in reality they are only a seductive pathway to misery and desperation, as tolerance demands higher and higher doses of the narcotics and dependence prevents going without the drugs for longer than a few increasingly-miserable hours.

 But there is more.  I am Board Certified in Anesthesiology (having taken the Boards back in the days of lifetime certification!) and I worked as an anesthesiologist and pain doc for almost ten years. I pushed a large amount of Diprivan (Propofol) ‘back in the day’, making me more of an expert than many of the TV docs who I heard refer to the milky induction agent as a ‘sleeping medicine’—kind of like calling Fort Knox a ‘piggy bank.’  And the final reason for my connection with Michael Jackson is perhaps the most significant reason:  I know how to moon walk. This last point alone puts me in a very select group of physicians&mdash;and was, I would again guess, the reason I was given the opportunity to write this blog.

 I cannot promise that every blog post will come together in such a fascinating way (just say it—oh puh-leaze!!), but my general approach will be to try to remind the field of psychiatry that even as we learn more about brain function, and even as we develop better medications to treat psychiatric illness, psychiatry will always be a field concerned with the mind. I have a PhD in neuroscience and was, in the 1980s, a ‘grind and bind’ guy;  tearing up rat neural membranes, spinning them down, and measuring the binding qualities of various radio-labeled chemicals, so I know the temptation for seeing the brain as a mass of chemical and electrical signals. But no understanding of neurochemistry will come close to explaining the thoughts and emotions of Michael Jackson, particularly in his last days, when he wanted so badly to turn off his brain that he resorted to using an anesthetic induction agent to quiet his thoughts at the end of the day. I have to wonder: were there no nice thoughts to focus on, to help tolerate the nighttime awake? Diprivan hurts when it is injected, and patients often wince in pain as they drift off to sleep in the operating room. But apparently the alternative was even more painful… which brings us back to an interesting thought.

 As I said earlier, we all have our unconscious, primary-process fantasies. Some of us fly; I used to have wonderful dreams of jumping so high that I was nearly flying, and in a primary-process world it never hurts to land. Some have fantasies of limitless riches, or perfect love. But a person who had perhaps the best opportunity to live in the world of fantasy—in a world where people only say  ‘yes’, and where pet monkeys are only a phone call away&mdash;was unable to tolerate such an existence. Why would that be? There is surely an important lesson for all of us in the tragic story of the boy living in Neverland; an ‘aha experience,’ or a moral to the story. I won’t spend any more of our time musing about the answers, since my answers would surely be different than yours. But the fun thing about psychodynamic psychiatry is that there is always a lesson, a story, or an ‘aha experience’ there for the taking for all of us, if we look for it.

 I look forward to talking with you again.

One goal in my work is to provide insight into maladaptive patterns in the way people go about their lives; one goal with the blog will be to take a look at the more obvious examples of psychodynamic principles as they play out in society.

Jeffrey T. Junig, MD, PhD

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