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 The Intersection of
Behavioral Health,
Mental Health, and
Health Literacy

PROCEEDINGS OF A WORKSHOP

Joe Alper and Alexis Wojtowicz, Rapporteurs

Roundtable on Health Literacy

Board on Population Health and Public Health Practice

Health and Medicine Division

THE NATIONAL ACADEMIES PRESS

Washington, DC
www.nap.edu
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC
20001

This activity was supported by contracts between the National Academy of

Sciences and AbbVie Inc.; Aetna Foundation; Bristol-Myers Squibb; California
Dental Association; East Bay Community Foundation (Kaiser Permanente); Eli Lilly
and Company; Health Literacy Media; Health Literacy Partners; Health Resources
and Services Administration (HHSH25034011T); Humana; Merck Sharp & Dohme
Corp.; National Library of Medicine; New York University Langone Medical Center;
Northwell Health; Office of Disease Prevention and Health Promotion
(HHSP23337043); Pfizer Inc.; and UnitedHealth Group. Any opinions, findings,
conclusions, or recommendations expressed in this publication do not necessarily
reflect the views of any organization or agency that provided support for the
project.

International Standard Book Number-13: 978-0-309-48530-2

International Standard Book Number-10: 0-309-48530-4
Digital Object Identifier: https://doi.org/10.17226/25278
Epub ISBN: 978-0-309-48533-3

Additional copies of this publication are available from the National Academies
Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or
(202) 334-3313; http://www.nap.edu.

Copyright 2019 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

Suggested citation: National Academies of Sciences, Engineering, and Medicine.

2019. The intersection of behavioral health, mental health, and health literacy:
Proceedings of a workshop. Washington, DC: The National Academies Press. doi: h
ttps://doi.org/10.17226/25278.
The National Academy of Sciences was established in 1863 by
an Act of Congress, signed by President Lincoln, as a private,
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Learn more about the National Academies of Sciences, Engineering,

and Medicine at www.nationalacademies.org.
Consensus Study Reports published by the National Academies of
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For information about other products and activities of the National

Academies, please visit www.nationalacademies.org/about/whatwed
o.
 PLANNING COMMITTEE ON THE
INTERSECTION OF BEHAVIORAL
HEALTH, MENTAL HEALTH, AND
HEALTH LITERACY1

WILMA ALVARADO-LITTLE, Associate Commissioner, Director of

the Office of Minority Health and Health Disparities Prevention,
New York State Department of Health
MAY-LYNN ANDRESEN, Vice President, Quality in Health Care
Advisory Group
CATINA O’LEARY, President and Chief Executive Officer, Health
Literacy Media
STEVEN RUSH, Director, Health Literacy Innovations Program,
UnitedHealth Group
ALAN VANBIERVLIET, Extramural Program Official, National
Library of Medicine
TERESA WAGNER, Assistant Professor, University of North Texas
Health Science Center, and Senior Fellow, University of North
Texas Health Science Center Institute for Patient Safety

__________________
1 The National Academies of Sciences, Engineering, and Medicine’s planning
committees are solely responsible for organizing the workshop, identifying topics,
and choosing speakers. The responsibility for the published Proceedings of a
Workshop rests with the workshop rapporteurs and the institution.
 ROUNDTABLE ON HEALTH LITERACY1

BERNARD M. ROSOF (Chair), Chief Executive Officer, Quality in

Health Care Advisory Group, LLC; and Professor of Medicine,
Donald and Barbara Zucker School of Medicine at
Hofstra/Northwell
ANNLOUISE R. ASSAF, Senior Director, Global Medical Impact
Assessment, Pfizer Worldwide Medical and Safety; and Adjunct
Professor, Brown University School of Public Health
SUZANNE BAKKEN, Alumni Professor of Nursing and Professor of
Biomedical Informatics, Columbia University
AMY A. CLARK, Director, Cultivating Health Communities, Aetna
Foundation
GEMIRALD P. DAUS, Public Health Analyst, Office of Health Equity,
Health Resources and Services Administration
TERRY C. DAVIS, Professor of Medicine and Pediatrics, Louisiana
State University Health Sciences Center
CHRISTOPHER DEZII, Director, Healthcare Quality and
Performance Measures, Bristol-Myers Squibb
JENNIFER A. DILLAHA, Medical Director for Immunizations,
Medical Advisor, Health Literacy and Communication, Arkansas
Department of Health
JAMES DUHIG, Head, Risk Communication and Behavioral
Systems, Office of Patient Safety, AbbVie Inc.
ALICIA FERNANDEZ, Professor of Medicine, Director, Latinx Center
of Excellence, University of California, San Francisco; Zuckerberg
San Francisco General Hospital
LISA FITZPATRICK, Senior Medical Director, DC Department of
Health Care Finance; Professorial Lecturer, Milken Institute of
Public Health, The George Washington University
LORI K. HALL, Director, Health Literacy, Global Medical Strategy
and Operations, Eli Lilly and Company
LINDA HARRIS, Director, Division of Health Communication and
eHealth Team, Office of Disease Prevention and Health Promotion,
U.S. Department of Health and Human Services
NICOLE HOLLAND, Assistant Professor and Director of Health
Communication, Education, and Promotion, Tufts University School
of Dental Medicine
ELLEN M. MARKMAN, Lewis M. Terman Professor of Psychology,
Stanford University
JOHANNA MARTINEZ, Graduate Medical Education Director of
Diversity and Health Equity, Northwell Health
MICHAEL M. McKEE, Assistant Professor of Family Medicine,
University of Michigan Medical School
LAURIE MYERS, Global Health Literacy Director, Merck Sharp &
Dohme Corp.
CATINA O’LEARY, President and Chief Executive Officer, Health
Literacy Media
MICHAEL K. PAASCHE-ORLOW, Professor of Medicine, Boston
University School of Medicine
TERRI ANN PARNELL, Principal and Founder, Health Literacy
Partners
LINDSEY A. ROBINSON, California Dental Association
STEVEN RUSH, Director, Health Literacy Innovations Program,
UnitedHealth Group
OLAYINKA SHIYANBOLA, Assistant Professor, Division of Social
and Administrative Sciences, University of Wisconsin–Madison
School of Pharmacy
VANESSA SIMONDS, Assistant Professor, Community Health,
Montana State University
CHRIS TRUDEAU, Associate Professor of Medical Humanities,
University of Arkansas for Medical Sciences; Associate Professor of
Law, Bowen School of Law, University of Arkansas at Little Rock
EARNESTINE WILLIS, Kellner Professor in Pediatrics, Medical
College of Wisconsin
AMANDA J. WILSON, Head, National Network Coordinating Office,
National Library of Medicine
MICHAEL S. WOLF, Professor, Medicine and Learning Sciences,
Associate Division Chief, Research Division of General Internal
Medicine, Feinberg School of Medicine, Northwestern University
WINSTON F. WONG, Medical Director, Disparities Improvement
and Quality Initiatives, Kaiser Permanente

Health and Medicine Division Staff

LYLA M. HERNANDEZ, Senior Program Officer
MELISSA G. FRENCH, Program Officer
ALEXIS WOJTOWICZ, Senior Program Assistant
ROSE MARIE MARTINEZ, Senior Board Director, Board on
Population Health and Public Health Practice

Consultant
LAWRENCE SMITH, Dean, Donald and Barbara Zucker School of
Medicine at Hofstra/Northwell; Executive Vice President and
Physician-in-Chief, Northwell Health

__________________
1 The National Academies of Sciences, Engineering, and Medicine’s forums and
roundtables do not issue, review, or approve individual documents. The
responsibility for the published Proceedings of a Workshop rests with the
workshop rapporteurs and the institution.
 Reviewers

This Proceedings of a Workshop was reviewed in draft form by

individuals chosen for their diverse perspectives and technical
expertise. The purpose of this independent review is to provide
candid and critical comments that will assist the National Academies
of Sciences, Engineering, and Medicine in making each published
proceedings as sound as possible and to ensure that it meets the
institutional standards for quality, objectivity, evidence, and
responsiveness to the charge. The review comments and draft
manuscript remain confidential to protect the integrity of the
process.
We thank the following individuals for their review of this
proceedings:

ALFIEE BRELAND-NOBLE, Georgetown University

MCKENZIE HUGGIN, National Alliance on Mental Illness
Maryland
EMILY JONES, National Institute on Drug Abuse
CDR JACQUELINE RODRIGUE, U.S. Department of Health and
Human Services

Although the reviewers listed above provided many constructive

comments and suggestions, they were not asked to endorse the
content of the proceedings nor did they see the final draft before its
release. The review of this proceedings was overseen by HUGH H.
TILSON, University of North Carolina Gillings School of Global Public
Health. He was responsible for making certain that an independent
examination of this proceedings was carried out in accordance with
standards of the National Academies and that all review comments
were carefully considered. Responsibility for the final content rests
entirely with the rapporteurs and the National Academies.
 Acknowledgments

The sponsors of the Roundtable on Health Literacy made it

possible to plan and conduct The Intersection of Behavioral Health,
Mental Health, and Health Literacy: A Workshop, which this
publication summarizes. Federal sponsors from the U.S. Department
of Health and Human Services are the Health Resources and
Services Administration; the National Library of Medicine; and the
Office of Disease Prevention and Health Promotion. Nonfederal
sponsorship was provided by AbbVie Inc.; Aetna Foundation; Bristol-
Myers Squibb; California Dental Association; East Bay Community
Foundation (Kaiser Permanente); Eli Lilly and Company; Health
Literacy Media; Health Literacy Partners; Humana; Merck Sharpe &
Dohme Corp.; New York University Langone Medical Center;
Northwell Health; Pfizer Inc.; and UnitedHealth Group.
The workshop presentations were interesting and stimulated much
discussion, and the Roundtable on Health Literacy would like to
thank each of the speakers and moderators for their time and effort.
Speakers and moderators were Wilma Alvarado-Little, Zarita Araújo-
Lane, Jessica Black, Wilson Compton, Linda B. Cottler, Kate Farinholt,
Lisa Morgan, Joanne Nicholson, Catina O’Leary, Helen Osborne,
Michael Paasche-Orlow, Albert Park, Brandon Pate, Bernard Rosof,
Steve Rush, David Steffens, Teresa Wagner, and Michael S. Wolf.
 Contents

ACRONYMS AND ABBREVIATIONS

1 INTRODUCTION
Organization of the Proceedings

2 THE PERSONAL EXPERIENCE

A Personal Perspective on Effective Communication
What People Affected by Mental and Behavioral Conditions Want
You to Know
Discussion
References

3 SETTING THE STAGE

Defining Mental Health and Behavioral Health: What Is the
Difference?
How Cognitive Burden Affects Communication
Health Literacy, Cognitive Burden, and Health Care
Health Literacy Principles in Mental and Behavioral Health
Discussion
References

4 EXPLORING INNOVATIVE APPROACHES

Web-Based Resource for Individuals with Serious Mental Illness
Health System Integration of Mental Health into Primary Care
 Mobile Integrated Health Management
Using Large Social Media Data for Understanding Mental Health
Discussion
References

5 WHERE DO WE GO FROM HERE?

Discussion

6 REFLECTIONS OF THE DAY

APPENDIXES
A Workshop Agenda
B Biographical Sketches of Workshop Moderators, Speakers, and
Panelists
 Boxes and Figures

BOXES
1-1 Statement of Task
2-1 Communicating with Someone Who Has a Mental Illness

FIGURES
3-1 Conceptual frameworks to link cognition and health literacy

3-2 The characteristics of a health-literate organization

 Acronyms and
Abbreviations

AHRQ Agency for Healthcare Research and Quality

ASD autism spectrum disorder

CMS Centers for Medicare & Medicaid Services

DSM-5 Diagnostic and Statistical Manual of Mental Disorders,

5th Edition

EHR electronic health record

IMPACT Improving Mood-Promoting Access to Collaborative

Treatment

NAM National Academy of Medicine

NAMI National Alliance on Mental Illness
NIDA National Institute on Drug Abuse
NIH National Institutes of Health
NYS DOH New York State Department of Health

SAMHSA Substance Abuse and Mental Health Services

Administration

VHA Veterans Health Administration

 1

Introduction1

The field of health literacy has evolved from early efforts that
focused on individuals to its current recognition that health literacy is
a multidimensional team and system function. Health literacy
includes system demands and complexities as well as individual skills
and abilities. While communicating in a health-literate manner is
truly important for everyone, it can be especially important for those
with mental or behavioral health issues and for the systems and
teams that interact with them and treat these individuals.
“Although it may be self-evident, embedding health-literate
practices into systems requires practical and innovative applications
and practical and innovative solutions,” said Bernard Rosof, the chief
executive officer of Quality in Health Care Advisory Group, in his
opening remarks to a workshop convened by the Roundtable on
Health Literacy.2 “Mental health issues and behavioral health are
often not well understood by many primary care health care
providers and those in the public health community, yet, many with
chronic mental or behavioral health issues first access care through
the primary care system.” The same is also true of specialty care, he
added, though it is not often the initial portal for entry of the health
care patient.
The purpose of the workshop, which was held on July 11, 2018, in
Washington, DC, was to explore issues associated with effective
communication with individuals with mental or behavioral health
issues and to identify ways in which health literacy approaches can
facilitate communication. In particular, the workshop aimed to gain a
better understanding of how behavioral health and mental health
concerns can adversely affect communications between providers
and patients and their families (see Box 1-1 for the Statement of
Task).

ORGANIZATION OF THE PROCEEDINGS

The workshop (see Appendix A for the agenda) was organized by
an independent planning committee in accordance with the
procedures of the Academies. This publication summarizes the
discussions that took place throughout the workshop, highlighting
key lessons, practical strategies, and the needs and opportunities for
using the principles of health literacy to improve communication
among health care providers, individuals with behavioral health and
mental health challenges, and family members. Chapter 2 describes
the communication challenges experienced by those who have
behavioral health and mental health issues. Chapter 3 provides
background information on behavioral health and mental health
disorders, discusses the communication challenges that these
disorders create for individuals and family members, and describes
the principles of health literacy and how health literacy might
address some of those communication challenges. Chapter 4
provides some examples of innovative approaches for applying
health literacy principles to address communication challenges for
those with behavioral health and mental health disorders as well as
those patients’ families and communities, and describes how
improved health literacy can reduce disparities in care and foster
independence among older adults. Chapter 5 summarizes a panel
discussion on future steps and Chapter 6 presents the roundtable’s
reflections on the key lessons learned at this workshop.

BOX 1-1
Statement of Task
An ad hoc committee will plan and conduct a 1-day public
workshop that will feature invited presentations and discussion
on health literacy and mental and behavioral health. The
workshop may include presentations and discussion of issues
related to the particular health literacy challenges in mental and
behavioral health, possible approaches to overcome those
challenges, effective health literacy interventions in
patient/family care, and communication among providers. The
committee will define the specific topics to be addressed,
develop the agenda, select and invite speakers and other
participants, and moderate the discussions. Proceedings of the
presentations and discussions at the workshop will be
developed by a designated rapporteur in accordance with
institutional guidelines.

In accordance with the policies of the National Academies, the

workshop did not attempt to establish any conclusions or develop
recommendations about needs and future directions, focusing
instead on issues identified by the speakers and workshop
participants. In addition, the planning committee’s role was limited
to planning the workshop. This workshop proceedings was prepared
by workshop rapporteurs Joe Alper and Alexis Wojtowicz as a factual
summary of what occurred at the workshop.

__________________
1 The planning committee’s role was limited to planning the workshop, and the
Proceedings of a Workshop was prepared by the workshop rapporteurs as a
factual summary of what occurred at this workshop. Statements,
recommendations, and opinions expressed are those of individual presenters and
participants, and are not necessarily endorsed or verified by the National
Academies of Sciences, Engineering, and Medicine, and they should not be
construed as reflecting any group consensus.
2 This section is based on the presentation by Bernard Rosof, the chief executive
officer of the Quality in Health Care Advisory Group, and his statements are not
endorsed or verified by the National Academies of Sciences, Engineering, and
Medicine.
 2

The Personal Experience

The workshop’s first panel session featured two presentations that

provided an idea of the lived experience of a person with a
behavioral or mental health issue1 who may be trying to understand
and communicate with health care providers. The two speakers were
Lisa Morgan, an autistic adult who is the author of Living Through
Suicide Loss with an Autism Spectrum Disorder (ASD): An Insider
Guide for Individuals, Family, Friends, and Professional Responders
(Morgan, 2016) and a feature writer for the Spectrum Women
Magazine online magazine, and Kate Farinholt, the executive director
of the National Alliance on Mental Illness (NAMI) state organization
in Maryland. An open discussion followed the two talks.

A PERSONAL PERSPECTIVE ON EFFECTIVE

COMMUNICATION2
“I believe the start to good communication in health care is
listening, hearing, and seeing a person as an individual,” Lisa Morgan
said. “For me, as an autistic adult, communicating has been one of
the greatest challenges in all areas of my life, including health care.”
Indeed, she explained, one of the defining aspects of autism is
difficulty communicating and interacting with others socially, which
can hinder the ability to gain access to the health care, and, she
noted, access to health care is particularly important for individuals
with autism spectrum disorder because they live, on average, 18
years less than those who do not (Hirvikoski et al., 2016).
“Communication in health care is extremely important to me as an
autistic adult,” Morgan said, “and in my experience the lack of
understanding and huge gaps in communication between patients,
doctors, and behavioral health care providers can cause harm and
misdiagnoses, reduce the success of treatment plans, and ultimately
not address my actual health care needs as a patient.”
Along with health care concerns, many autism diagnoses come
with at least one, if not more, co-occurring mental health diagnoses
that are often complicated by such behavioral health issues as social
withdrawal and isolation, perseveration on negative thoughts, self-
harm, pervasive aloneness, poor social skills, and high levels of
anxiety. Many of those struggles, Morgan said, are all firmly rooted
in miscommunication between patients, their families, and health
care professionals.
To illustrate some of the challenges individuals with autism may
encounter, Morgan described several communication issues she has
experienced when trying to get help from physical and mental health
care providers. The first occurred when she went to her and her
husband’s primary care physician to get help for her husband, who
was experiencing increasingly severe depression and mood swings
and refused to get help himself. Morgan’s doctor agreed that he
would keep Morgan’s concerns in mind during her husband’s next
appointment, though he offered no support for Morgan as a
concerned caregiver. At Morgan’s next appointment, the doctor, who
had already examined her husband, told her that her husband had
presented “fine” and might feel better if she focused on being a
“nicer wife” by smiling more or retrieving his slippers for him. “I
could not even speak,” said Morgan. “I left the office that day and
never went back.”
 Morgan recalled that her doctor never asked her how she was
doing and provided no answers, referrals, or other form of help for
her. “Experiencing a doctor blaming me for something that ultimately
ended in my husband dying by suicide affected how I trusted any
doctor for a long time, and I still struggle to trust years later,” she
said. “I believe that doctor brought his own philosophy, his own
prejudices, and his own preconceived notions into our conversation
that day, which hurt me emotionally in the process.” That physician,
she added, neither referred her husband to any mental or behavioral
health care provider nor talked to her about any help she might
need to cope with her husband’s deteriorating mental health. “What
I sought when I first went to see that doctor was to communicate
my situation, get my husband some help, and relieve my anxiety,”
she said. “What I learned was communication must be a cooperative
endeavor between two or more people in order to work properly.”
In contrast to that experience, she said, the psychiatrist who
helped her through the last few traumatic months of her husband’s
life and subsequent death by suicide listened carefully to her when
they talked, which enabled her to keep her anxiety at a level
conducive to understanding, processing, and remembering the
information he shared with her. This psychiatrist accepted Morgan as
an adult with autism, was knowledgeable about autism, and was
open to learning how he could best communicate with her. She said
that she came to trust this psychiatrist and developed a comfortable
doctor–client relationship with him.
Unfortunately, when Morgan relocated to another state, she had
to start again to find a new doctor. Although her previous
psychiatrist tried to assist her, Morgan’s insurance required her to
see the behavioral health professional in the medical office of her
new primary care physician. Morgan arrived at her first appointment
with the new psychiatrist a bit nervous, but optimistic that they
“would connect in a positive way.” This hope diminished quickly, she
said, as the doctor spent most of the appointment telling Morgan
about her own background. The doctor abruptly informed Morgan
that she would need to answer a questionnaire, which would be
administered at a rapid pace, and that she had to answer as quickly
and honestly as possible. The doctor proceeded to ask Morgan about
her medical history, childhood, marriage, and past trauma. “She did
not look at me as she continued to fire questions at me,” Morgan
recalled. “She just typed and went to the next question as fast as
possible.” The doctor had warned Morgan that she was going to do
this, but her “processing speed is negatively correlated” to her level
of anxiety, which was getting “very, very high”:

I needed a minute to process my thoughts so I could focus on each

question, but they kept coming too fast. Meanwhile, I was answering as
honestly as possible, like she had requested, and as the questions brought
up more and more traumatic memories from my past, my anxiety
heightened to a level where tears came and I was trying to regulate myself
and still answer question after question.

Morgan pointed out that some people might question why she did
not ask the doctor to stop so that she could collect herself. “Due to
the neurologic makeup of my autistic mind, the more anxiety I
experience, the less I am able to talk,” she explained. “It’s during
those times I need the most help,” she added.
One barrier to receiving that help is that most physicians see her
as a non-autistic person displaying non-autistic behaviors, she said.
“I need doctors to know my behaviors will differ from a non-autistic
person. I need them to listen to me and believe what I am saying
about myself.” She also explained that the extreme anxiety she
experienced during the questionnaire resulted from the
posttraumatic stress disorder she had developed in the months after
her husband’s death. She felt as if she had just experienced
“multiple traumas all over again,” she said.
When the questionnaire was completed, Morgan said, she
expected the doctor to help her regulate her anxiety and help her
feel safe again. Instead, she looked at Morgan and told her she had
the authority to hospitalize her and keep her hospitalized until she
felt that Morgan was ready to leave. “She might as well have told me
she was going to put me in prison without due process and throw
away the key,” Morgan said. “I was horrified, and her words are
seared in my mind.”
Morgan explained that this appointment set her back significantly
in her “journey to health and healing” and said that she found it
difficult to trust anyone trying to help her. The encounter affected
her ability to regulate her anxiety, which was compounded by the
fact that she felt the doctor could take her away from her children at
any time and that there was no other practitioner available because
of her insurance.
Morgan had also recently begun to see a new psychologist, who
offered to help her by contacting the new psychiatrist to explain
Morgan’s unique communication needs. She later learned that the
psychiatrist’s perception of the intake appointment was much
different from her own. This knowledge did not particularly help in
Morgan’s preparation for her second appointment with the new
psychiatrist. The day of the appointment, she said, her anxiety was
high, and she was “extremely nervous about saying anything wrong
to her.” The appointment took a negative turn when the doctor’s first
question for Morgan was about whether she had taken a new
medicine the doctor had prescribed in the first appointment. Morgan
explained why she had not:

As an autistic adult, change is very difficult for me and I had not been able
to try the new medicine because it was a change, and I didn’t trust her at
that point. I had previously communicated to her that it would be difficult
for me, although I understood medicine is a tool for me to use to process
everything that has happened leading up to my husband’s suicide and the
aftermath.

The psychiatrist, Morgan said, replied that she was “not going to
go to [her] house and shove [the medicine] down [her] throat.”
Morgan noted that she felt unsafe again, her anxiety increased, and
she could only focus on the idea that the doctor made a comment
about coming to her house, so she withdrew from the conversation.
After Morgan left the appointment, she spent additional time
managing her anxiety so that she could safely drive home.
 Morgan concluded that her current psychiatrist and psychologist
have “diametrically opposed philosophies on how to relate” to her.
While her interactions with her psychiatrist have been fraught with
fear and anxiety, her psychologist communicates with her
respectfully as who she is, “an educated professional who has
experienced multiple traumatic situations.” The psychologist does not
patronize Morgan or treat her as though she is unable to help
herself. Her psychologist actively listens, offers guidance, and offers
space for Morgan’s autism. Her knowledge of autism allowed the two
of them to “communicate with each other instead of just trying to
communicate.” Her psychologist used her previous knowledge of
autism and conversations with Morgan around sensory needs to
create a safe and comfortable environment for their appointments.
Their patient–provider relationship is open, honest, and trusting,
Morgan said, and her psychologist is an “essential person I trust as I
continue on my journey toward health and healing.”
Morgan observed that she has had both positive and negative
experiences with different health care providers. The positive
experiences, she said, come with good communication.

A great place to start communicating is by listening to what I am saying,

hearing what I mean, and seeing me as an individual. Listening requires
putting aside any preconceived notions about me, accepting who I am as
an autistic adult, and having the doctor’s undivided attention for an
appropriate time.

“Hearing,” she noted, differs from “listening,” for “hearing” enables

contextualizing her medical history within her life. Additionally,
“seeing” is being able to recognize that she is an individual patient
and not just another appointment to get through. She concluded by
adding that gleaning a sense of the big picture out of the details
allows providers to ask the right questions so that patients can give
the right answers.
 WHAT PEOPLE AFFECTED BY MENTAL AND
BEHAVIORAL CONDITIONS WANT YOU TO
KNOW3
One in five people in the United States will be affected by mental
illness in their lifetimes, and suicide is the second-leading cause of
death in the United States for people 15 to 24 years old, Kate
Farinholt told the audience as a way of putting behavioral and
mental health issues in context. NAMI bases its approach to mental
illness in the belief that mental illnesses have a biological basis, are
no one’s fault, and that the experience of mental illness is itself
traumatic, both in the past and ongoing, for individuals with a
mental illness and their families. NAMI also operates from the belief
that the most effective treatments for mental illnesses jointly
address biological, psychological, and social elements and that the
gold standard of care is collaborative. “Most importantly,” she said,
“we believe that the lived experience of people with mental illness
and their families is absolutely essential in helping people in the
world to understand and think about how they might change
systems and programs and that our voice should be in the
conversation about how programs might be changed.” Farinholt said
that like most people who become involved with NAMI, she joined
the organization because she had a relative with a mental illness—in
her case a sister who developed schizophrenia at age 11.
There are many stereotypes about mental illness, including that
individuals with a mental illness are dangerous, irrational,
unpredictable, and incompetent; deserve blame for their condition;
have little hope for recovery; have no support network; and cannot
work or communicate with supporters. But perhaps the most
damaging, Farinholt said, is that people with a mental illness are
their mental illness. To the contrary, she said, a typical example of
someone with a mental illness is Deneice, NAMI Maryland’s program
specialist who happened to have developed a mental illness in her
thirties. At the time she developed symptoms, she had a job at the
U.S. Department of Defense. Eventually she lost that job, ended up
homeless, and would sleep under bushes when she was not in a
psychiatric hospital. At one point she walked into the NAMI office in
Baltimore, where she met and talked to Farinholt, who connected
her with a NAMI peer support group and eventually hired her as the
program specialist for NAMI Maryland.
There are stereotypes about families dealing with mental illness,
Farinholt said—that they are to blame; that they are enabling, pushy,
and controlling; and that they have no useful information about their
loved ones or resources to call on during times of crisis. Again, these
are not accurate. For example, Farinholt said that she knows more
about her sister than anyone and that she can identify the initial
signs that her sister’s illness is about to cause problems. Yet, for
years, Farinholt said, she could not get a psychiatrist or primary care
physician to understand that she knew her sister’s history and what
the indications of a problem were. Fortunately, her sister now has a
psychiatrist who gave Farinholt his cell phone number in case of
emergency. “We have never used it, but he is very inviting,” she
said.
Her sister’s mental illness also affects the non-psychiatric care she
receives. When she goes to primary care for a health issue, Farinholt
said, all the clinical staff sees is that she has schizophrenia, not that
she has a fungal infection on her foot. And the family is rarely asked
for what could be very useful information. “I might be the one who
often looks angry and aggressive when I am trying to advocate for
my sister,” Farinholt said. Similarly, years ago, if her sister had a
particularly bad episode and trashed the house, the only way to get
her sister to the emergency room would be by calling the police. Yet,
by the time the police arrived, her sister would have calmed down,
and Farinholt would be the one with wild eyes. As a family member
advocating for her sister, she said, “I have to work on presenting
myself as the calm one to, first, get them to recognize that my sister
is the person with the problem, but also to convince them that I
have some useful information, such as my sister is scared of people
carrying guns.”
 NAMI, she said, views mental illness as a catastrophic stressor to
the individual and to his or her caring family. A catastrophic stressor,
she said, is an unanticipated event that occurs with little time to
prepare (Figley and Kiser, 1989). It happens in an area where one
has little previous experience and few sources of guidance, and it
has a high emotional impact. “I can tell you that being told that your
sister has paranoid schizophrenia, that there is no hope, and you
might as well just give up, that is a huge stressor,” Farinholt said. For
the affected individual, receiving a diagnosis of mental illness can
also be a traumatic stressor, although, she added, it can also be a
relief to receive an explanation for the symptoms one has been
experiencing. Either way, she said, ongoing trauma is part of mental
illness, not just a trigger or potential risk factor.
Farinholt said that there are recognizable, predictable stages of
emotional reaction to the experience of mental illness and recovery
(see Box 2-1), which NAMI uses to help individuals and families see
what they need at particular points along their journey. She added
that while she now has to note on health forms that she has a
relative with a mental illness, she cannot remember a single time
when any health provider, except for her personal psychiatrist, has
ever asked how she is doing and how her sister’s illness is affecting
her.
One of the common problems that individuals with a mental illness
and their families encounter is that health care providers misread
their reactions to the ongoing and episodic trauma that accompanies
these diseases. Farinholt said that NAMI Maryland offers training for
providers to help them recognize the different reactions to these
traumas and learn how to accommodate them. While it is not
currently available in all states, NAMI offers a provider education
class that is designed to expand providers’ compassion for the
affected individuals and their families and to promote a collaborative
model of care. NAMI programs differ from one affiliate chapter to
the next, but many of these chapters offer classes for families and
individuals on topics such as the stages of adherence and recovery,
empathy and empathic guidelines, how to collaborate successfully
with the health care system, advocacy, and communication
strategies and skill building.

BOX 2-1
Communicating with Someone Who Has a
Mental Illness
Proceed to interact as you:
Remain calm and give firm clear instructions;
Assess the situation for safety;
Maintain adequate space between you and the person;
Respond to apparent feelings;
Respond to delusions and hallucinations by talking
about the person’s feelings rather than what he/she is
saying; and
Be helpful, encouraging, and supportive.

Avoid:
Reinforcing behavior related to the person’s illness;
Staring at the person—this may be interpreted as a threat;
Confusing the person;
Giving multiple choices—this increases confusion;
Whispering, yelling, ridiculing, deceiving, or touching
—this may cause more fear and lead to violence.

Someone with a So you need to

psychiatric illness might
Have trouble with reality
Be fearful
Be insecure
Have trouble concentrating
Be overstimulated
Easily become agitated
Have poor judgment
Be simple and truthful
Stay calm
Be accepting
Be brief and repeat
Limit input
Recognize agitation
 Be preoccupied Not expect rational
Be withdrawn discussion
Have changing emotions Get attention first
Have changing plans Initiate relevant
Have little empathy for you conversation
Believe delusions Disregard
Have low self-esteem and Keep to one plan
motivation Recognize as a symptom
Ignore and do not argue
Stay positive

SOURCE: Adapted from a presentation by Kate Farinholt at the workshop

The Intersection of Behavioral Health, Mental Health, and Health Literacy, on
July 11, 2018.

Families, she said, need to feel understood at a time when they

might have difficulty communicating. She noted that the Center for
Integrated Health Solutions, operated jointly by the Substance Abuse
and Mental Health Services Administration (SAMHSA) and the Health
Resources and Services Administration, lists nine core competencies
for an integrated behavioral and primary care workforce, two of
which concern interpersonal communication and collaboration and
teamwork. NAMI Maryland offers in-depth workshops on how to
communicate with a patient with a mental health condition who is in
crisis; these focus on determining if the patient is able to
communicate and provide information to the provider, if the patient
understands what the provider is saying, and if the patient needs a
supporter to assist them in reporting or understanding (see Box 2-
1). The key, Farinholt said, is that providers or crisis workers not
make an early assumption about whether (or how well) a patient is
capable of communicating but instead to observe how a patient is
behaving.
Farinholt’s final comment was that as a family member and her
sister’s supporter, she needs information—not about how her sister is
behaving at a particular moment but rather about what medication
she is on and what Farinholt should be watching for regarding side
effects or efficacy. She added that her sister lives in a group home
and attends a day program but that neither of those places
communicates with Farinholt even though she is a family member.

DISCUSSION
Bernard Rosof began the discussion by asking Morgan and
Farinholt what changes they would make to address the bad
experiences they have had. Morgan said that she would create an
interpretation book similar to a foreign language phrase book that
would allow for free-flowing communication between her and her
health care providers. Farinholt said that she wants to see all health
care professionals trained in basic communication skills and taught
about the various mental illnesses so that they communicate
effectively with someone who is having a behavioral health issue.
Catina O’Leary from Health Literacy Media asked the two panelists
what had allowed them to be brave and continue searching for the
right provider who could communicate effectively with them. Morgan
said she kept searching because she knew she needed help from a
professional and that there are providers out there who are good
communicators. She added that it does not take much for a provider
to make a huge difference in the life of someone with a mental
illness or behavioral health illness. “It takes seeing the person for
who they are because everybody is so different, and just listening
and making that connection,” she said. Farinholt said that the
wonderful psychiatrist who has stuck with her sister has decided to
retire and let the family know a year in advance. “We are concerned,
and I am a little tired and also getting older,” she said. She has
trained her three sons and hopes that between the three of them
they will find a way to advocate for their aunt when Farinholt is
gone. “But right now,” she said, “the concept of having to find
another psychiatrist who will go the extra mile is really concerning. I
do know that there are a lot of really great primary care and
psychiatrists out there. The question of how to find them is a little
harder.”
Lawrence Smith from Northwell Health said that as a primary care
physician his perception is that many psychiatrists are not interested
in getting information from the referring doctor or family members,
which he blames on a deep-seated cultural characteristic of that
particular medical specialty. “They [psychiatrists] simply want to take
care of the patient in a separate, secret box and tell no one about
what happens for fear of the stigma if it gets out that that patient
has a mental illness,” he said. Smith said that this attitude is
epitomized by the fact that if he goes to a patient’s electronic health
record (EHR), he cannot find any record of anything that happens in
the department of psychiatry because that information is hidden in
the electronic record. “Until we are all willing to take a little bit of a
risk that we believe that behavioral health has a biologic basis, and
this is just another set of problems that we should not be afraid of
telling people we are dealing with, we cannot solve this problem,” he
said. Smith acknowledged that U.S. society may not be ready to
consider mental illness as just another biological illness, but he
countered that having HIV/AIDS was de-stigmatized in a very short
period of time. “I think we can face this challenge and do it,” he
said.
Farinholt and Morgan both agreed with Smith that record sharing
is an impediment to care for those with a behavioral health disorder
or mental illness. Farinholt added that health systems are changing
how they include those issues in the medical record. She noted that
her own medical record now includes an incorrect note from her
primary care physician about depression, and, as a result, her
neurologist now asks her how her depression is doing even though
her thyroid problem, which was the issue, has been resolved. But, it
is also another example of seeing the patient as their illness, she
said—as soon as the neurologist saw that the primary care physician
had noted that Farinholt denied having depression, that was the
question her [former] neurologist focused on.
Michael McKee from the University of Michigan Medical School
pointed out that the burden of mental illness is high among patients
with various types of disabilities, and he called on medical schools to
do a better job training physicians on basic communication
principles, particularly regarding communication with populations
that may need more clarity and openness from their health care
providers. He then commented on the difficulty of finding providers
who are good communicators and suggested that some
organizations should consider developing tools or resources that
would help patients with this difficult task. For example, the
organization help.org established a list of providers who are fluent in
American sign language. McKee said that he is hopeful that insurers
will start identifying providers who have specific skill sets, such as
second language fluency, that would help patients.
Farinholt replied that the disability community and mental or
behavioral health organizations such as NAMI are now being invited
to the table to discuss this very issue. She said that NAMI Maryland
does not refer people to specific providers but that people in its peer
support groups are absolutely sharing the names of good and bad
providers. Morgan added that the autism community relies on
grassroots, word-of-mouth approaches to identify good providers.
Johanna Martinez from Northwell Health said that she tries to
teach her students that the patient’s voice is the most important. “I
think in every other field outside of health care the consumer has so
much to say on the product that is being delivered or how that
product is being delivered, and yet, in health care we have a lot of
room to grow in that area,” she said. Noting that there are efforts to
increase the patient’s voice in medical practice, she asked the
panelists if they had any ideas on how to more systematically
include the patient voice in the process of delivering care, in addition
to the personal experience in receiving care. Farinholt said that
SAMHSA has funded a program on the integration of mental health
and behavioral health into pediatric care that has a focus on patient
and family involvement and engagement in system and program
changes and design. Now, thanks to the Pediatric Integrated Care
Collaborative at the Johns Hopkins Bloomberg School of Public
Health, there is a toolkit that includes a focus on increasing the
patient voice in care delivery.4 Farinholt said that making health care
practices trauma-informed and inviting family engagement are both
important. Morgan added that physicians need to listen to the
parents of the children they treat. “There is a high percentage of
doctors that I have gone to for my children who do not think I know
them at all,” she said. “Listen to moms. It is a great beginning.”
Farinholt seconded that message.
Christopher Dezii from Bristol-Myers Squibb commented that he
was struck by the fact that there are still communication problems
involving mental health and primary care providers after many years
of dealing with this issue, and he wondered if there is even sufficient
access to mental health professionals. Farinholt said that in Maryland
access to psychiatric health care is “very difficult.” This is particularly
true for children, she said, given that there are large parts of the
state where there are no child or adolescent psychiatrists. The
state’s Behavioral Health Integration in Pediatric Primary Care
program is attempting to address this shortage by making child and
adolescent psychiatrists in the Baltimore and Washington, DC, area
available immediately via telemedicine in response to a call from a
pediatrician.5 She said that psychiatrists may get paid far less than
other specialists, so there may not be as much incentive for people
to go into this field.
Responding to a question from Rosof as to whether the nation’s
health care system is prepared to address the relationship between
communication problems and how physicians are educated and how
care is delivered, Smith said that his institution teaches psychiatry
and neurology as a single entity and that mental health disorders are
biological diseases. “Our students then go into a clinical world where
they are stunned that no one thinks or behaves that way,” he said.
“It is very difficult to sustain learning that is never reinforced in the
actual care delivery space.” In his opinion, he said, attitudinal
change has to start with the people already in practice who are the
role models of the next generation of physicians. Earnestine Willis
added that health care professionals need to do more work on de-
stigmatizing mental and behavioral health, both within their ranks
and out in the community. Martinez said that, in her experience,
medical educators are prepared to meet this challenge, but she
added that physicians in training also need to learn that the social
determinants of health and behavioral health, not biological factors,
are probably the biggest predictors of health outcomes. She agreed
with Smith that new physicians are not getting the lessons they
learned in medical school reinforced by their mentors in practice.

REFERENCES
Figley, C. R., and L. J. Kiser. 1989. Helping traumatized families. San
Francisco, CA: Jossey-Bass.
Hirvikoski, T., E. Mittendorfer-Rutz, M. Boman, H. Larsson, P.
Lichtenstein, and S. Bolte. 2016. Premature mortality in autism
spectrum disorder. British Journal of Psychiatry 208(3):232–238.
Morgan, L. 2016. Living through suicide loss with an autism
spectrum disorder (ASD): An insider guide for individuals, family,
friends, and professional responders. London, UK: Jessica Kingsley
Publishers.

__________________
1 At the workshop, speaker Wilson Compton defined “behavioral health” as an
overarching term that includes mental health diagnoses, substance abuse and
addictive disorders as well as behaviors that affect health, such as medication
adherence (see Chapter 3). In this proceedings the term “behavioral health” is
used as a general term and “mental health” is used more specifically, when
appropriate.
2 This section is based on the presentation by Lisa Morgan, the author of Living
Through Suicide Loss with an Autism Spectrum Disorder (ASD): An Insider Guide
for Individuals, Family, Friends, and Professional Responders (Morgan, 2016) and a
feature writer for the Spectrum Women Magazine online magazine, and the
statements are not endorsed or verified by the National Academies of Sciences,
Engineering, and Medicine.
3 This section is based on the presentation by Kate Farinholt, the executive
director of the National Alliance on Mental Illness in Maryland, and the statements
are not endorsed or verified by the National Academies of Sciences, Engineering,
and Medicine.
4 For more information, see https://picc.jhu.edu (accessed September 7, 2018).
5 For more information, see http://mdbhipp.org (accessed September 7, 2018).
 3

Setting the Stage

The workshop’s second panel, as well as a separate presentation later

in the workshop, provided background information on behavioral health
and mental health disorders, on the communication challenges that
these disorders create for individuals and family members, and on the
principles of health literacy and how health literacy might address some
of those communication challenges. The speakers who addressed these
topics were Wilson Compton, the deputy director of the National
Institute on Drug Abuse (NIDA); David Steffens, a professor and the
chair of psychiatry at the University of Connecticut Health Center;
Michael Wolf, a professor and the associate vice chair for research in
the Department of Medicine at Northwestern University’s Feinberg
School of Medicine; and Catina O’Leary, the president and chief
executive officer of Health Literacy Media. A discussion was moderated
by Steven Rush, the director of the UnitedHealth Group Health Literacy
Innovations Program.

DEFINING MENTAL HEALTH AND

BEHAVIORAL HEALTH: WHAT IS THE
DIFFERENCE?1
 After agreeing with the comments of the last session that training in
communication issues for health care providers is “woefully
inadequate,” Wilson Compton said he hoped this workshop would
generate some actionable items to address that issue, whether during
training, through continuing education, or through system-level
approaches that would influence behavior, such as Yelp-like reviews or
financial incentives. He added that incentives and rewards do not have
to be large to change behavior, something that research at NIDA has
shown.
Commenting on what he heard in the first session, Compton said he
was impressed by how much stress can impede good communication,
and he added that while individuals with a mental illness may have a
particular problem with stress, those without a mental illness can have
similar issues. For example, someone who has just received a cancer
diagnosis may be very stressed and unlikely to remember much of what
else the physician says from that point forward. “While we are focusing
on mental illness and mental health issues today, some of these issues
are generic across all the health literacy field,” he said, adding that he
hoped that the lessons from other areas of health and could be applied
to the area of behavioral health. Another lesson he took from the first
panel’s presentations was that health care providers might need some
instruction on basic etiquette. “I was impressed that an awful lot of
what was missing was just basic kindness and basic respect,” Compton
said.
Turning to the subject at hand, he explained that behavioral health is
a global term used as shorthand for a broad range of conditions and
that, like all shorthand, it has severe limitations in that it does not
provide the nuance or detail needed to make complex care decisions.
To him, he said, behavioral health includes mental illness as well as
substance abuse and addictive disorders. He added that topics such as
medication adherence, which is a behavioral issue, are related subjects
but are not generally included in the term “behavioral health.” Because
behavioral health is such an overarching label, it is important to define
the term, particularly in publications. “We may not agree on what the
boundaries are around it, but if you define it, I can at least accept what
you mean when you use that term,” said Compton.
 Behavioral health issues are extremely common, he noted, with some
46 percent of Americans meeting the criteria for a diagnosable mental
or substance use disorder at some point in their lives. The annual
prevalence of a mental health issue is 18 percent, Compton said, with
some 4 percent of Americans meeting the criteria for a serious mental
illness over the past year and 8.1 percent meeting the criteria for a
substance use disorder. Approximately half of all mental disorders begin
before age 14, and 75 percent first appear before age 24.
Comorbidity is common as well, he said, with some 8.2 million adults
having both a substance abuse disorder and a mental illness. “One of
the key issues for taking care of patients with these conditions is that
when you discover one of them, you need to very carefully explore for
other disorders,” Compton said. Too often, physicians forget to ask their
patients with major depression or schizophrenia about their alcohol or
tobacco use. “Just by paying attention to comorbidity, we can improve
care,” he said.
While mental illness may be a more specific term, it, too, includes a
broad category of disorders—autism and autism spectrum disorders,
childhood behavioral conditions such as conduct disorder and
oppositional defiant disorder, Alzheimer’s disease and other dementias
in older adults, and major mental illnesses such as depression, bipolar
disorder, or schizophrenia. “Each one of those deserves some separate
attention and some nuance,” Compton said, “so I remind us that even
as we think in these broad categories we need to pay attention as well
to the individual needs within each of those diagnostic groups, because
while there will be a few similarities, there will be nuances in terms of
the specific disorder.” The Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition (DSM-5) defines a mental disorder as “a
syndrome characterized by clinically significant disturbance in an
individual’s cognition, emotion regulation, or behavior that reflects a
dysfunction in the psychological, biological, or developmental processes
underlying mental functioning.” Mental disorders, he added, are usually
associated with significant distress in social, occupational, or other
important activities.
Substance use disorders, he explained, occur when the recurring use
of alcohol or drugs causes clinically and functionally significant
impairment, such as health problems, disability, and a failure to meet
major responsibilities at work, school, or home. According to the DSM-
5, a diagnosis of substance use disorder is based on evidence of
impaired self-control, social impairment, the risky use of alcohol or
drugs, and certain pharmacological criteria. Compton said that
substance use disorders follow a particular development course and
have multiple causes, which include environmental and biological
contributors.
Compton pointed out that a key feature of many mental illnesses and
substance use disorders is disordered thinking and that this can impede
communication in a direct manner. “You have somebody who, because
of their brain condition, just cannot hear what you are saying,”
Compton said. In addition, behavioral health patients can display
behaviors that they are unable to control, further getting in the way of
good communication. This communication impediment exists over and
above any impairments that result from the stress of the clinical
experience, he added. Stigma also impedes communication, both
directly and indirectly, and it affects patients, families, and even
clinicians. In the addiction field, stigma exists among policy makers and
in the criminal justice system, and as such, notations of a substance
use disorder in an EHR can become an impediment for those seeking
care. While Compton agreed that it is important to integrate care, he
said that it is also important to recognize the potential for such
integration to backfire in some circumstances.
One place where stigma is playing out today is in the nation’s
response to the opioid epidemic, Compton said. Despite the fact that
there are proven, medication-based treatments for opioid addiction that
can help people improve their functioning, regain their lives, and
become pro-social, active members of society who are not breaking the
law or putting their own lives at risk, too few people have access to
these treatments because there are not enough clinicians in many parts
of the country who can provide care. Even where treatment programs
exist, only about one in four such programs will offer medication-
assisted treatment (Knudsen et al., 2011). “I think that is because of
some of the internal stigma that medication-assisted treatment faces
within the treatment providers themselves,” Compton said. He did
applaud the change in philosophy toward medication that has been
adopted by programs such as Betty Ford and Hazelden, stalwarts of 12-
step approaches to addiction, when shown the data that their patients
were unsuccessful when not offered medication and that they were not
continued on medication in the longer term.
Concerning approaches to address these issues, Compton said he
believes it is possible to change attitudes, reduce stigma, and tailor
communication to patients with behavioral health and mental health
disorders. For example, clinical programs that participated in research
on buprenorphine, one of the medications used to treat opioid use
disorder, were more likely to adopt medical treatment in their programs
going forward. “The ability to practice with [buprenorphine] was useful
for long-term change,” he said. It is important to change providers’
attitudes toward medication-assisted therapy because research has
shown that provider attitudes about the effectiveness of this approach
and its morality affect whether the therapy is offered and used (Bailey
et al., 2013; Uebelacker et al., 2016). Compton noted that he has seen
attitudinal changes over the past few years that are bringing more of a
public health and population health focus—rather than a purely law
enforcement issue—to the issue of opioid addiction.
There are ways of reducing stigma through the use of language, he
said. For example, referring to an individual as “a substance abuser”
rather than “having a substance use disorder” can bias clinician
attitudes about whether these individuals are culpable, threatening, or
deserving of punishment (Kelly and Westerhoff, 2010). Compton
concluded his presentation by highlighting what the U.S. Surgeon
General had to say about substance use disorders, which was that
everyone has a role to play in changing the conversation around
substance use in order to improve the health, safety, and well-being of
individuals and communities across the nation. “I think the work of this
roundtable on communication issues fits in nicely with what the
Surgeon General highlighted,” Compton said. Although the Surgeon
General was speaking specifically about substance use disorders,
Compton said he believes that this message applies more broadly to all
behavioral health conditions.
 HOW COGNITIVE BURDEN AFFECTS
COMMUNICATION2
To begin his presentation, David Steffens reported that when the
University of Connecticut Health Center worked with EHR vendor Epic
on the design of its new system, it made the strategic decision to make
all of its psychiatric notes available to other physicians in the system.
There was debate within the psychiatry department involving concerns
about stigma, but in the end the decision was made to open the record
as far as symptoms, course of treatment, and medications. “I think the
field is moving to be much more integrated,” he said.
“When it comes to cognitive concerns,” Steffens said, this is not an
issue just about primary cognitive disorders such as Alzheimer’s disease
and other dementias or mild cognitive impairment. People with acute
medical issues, such as heart attack and pneumonia, as well as with
chronic disorders such as chronic obstructive pulmonary disease, sleep
apnea, and Parkinson’s disease, may have cognitive problems as well.
These cognitive impairments, which are under-recognized in the
medical community, can affect both an individual’s level of function and
his or her ability to communicate effectively.
From a neuropsychological perspective, cognition refers to memory,
attention and concentration, information processing, visuospatial
perception, language abilities, and executive function—the ability to
reason, plan, problem solve, and multitask among other actions—with
memory, attention and concentration, information processing, and
executive function being the most relevant to mental illness. Steffens
said the signs and symptoms of executive dysfunction include trouble
grasping the main idea of something, struggling to weigh benefits and
risks, general difficulty making decisions, problems holding onto a
several-step mental process, trouble initiating lists or making new goals,
and a lack of flexibility. Executive function control resides in the brain’s
frontal lobes, the same brain region involved in a wide variety of mental
illnesses and substance use disorders (Arnsten and Rubia, 2012).
Steffens said that executive dysfunction, which can persist despite
improvements in other psychiatric symptoms, can make it difficult for
people to comprehend complex verbal or written communication and to
weigh one choice against another.
Steffens explained that the capacity for communicating and making
decisions about health care has four dimensions, each of which can be
affected by executive dysfunction (Palmer and Harmell, 2016):

1. understanding the nature as well as the risks and benefits of

treatments and alternatives;
2. appreciating and applying the relevant information to one’s self
and one’s own situation;
3. engaging in consequential and comparative reasoning and
manipulating information rationally; and
4. expressing a clear and consistent decision.

Memory problems can be present in disorders other than dementias,

Steffens said. The hippocampus is the key brain region involved in
memory formation and retrieval, but the temporal and frontal lobes play
important roles as well. The signs and symptoms of memory problems
include difficulty learning, storing, retaining, and retrieving information.
Older adults, he said, may have early dementia with memory problems
that are masked by the presence of depression or anxiety, and people
with traumatic brain injury can also have memory problems. Steffens
noted that of the four dimensions of capacity for communicating and
making decisions about health care, memory problems can affect the
ability to understand the nature as well as the risks and benefits of
treatments and the ability to express clear and consistent decisions.
Attention and concentration, which together refer to the ability to
stay awake and alert, maintain focus, and hold onto a train of thought,
can also be affected in individuals with a mental illness. The brain
structures involved in attention and concentration include the posterior
parietal lobe and the frontal lobe, Steffens said, and attention and
concentration problems are often present in depression, mania,
psychoses, anxiety disorders, posttraumatic stress disorder, and
attention deficit and attention deficit–hyperactivity disorders. He
explained that the signs and symptoms of attention and concentration
problems include difficulty staying alert as a result of not having enough
mental energy to fully engage with people or things in the environment;
difficulty focusing attention and being easily distracted by external or
internal stimuli; and losing a train of thought or forgetting the point in a
conversation. Of the four dimensions of capacity for communicating and
making decisions about health care, impairment in attention or
concentration may affect understanding, reasoning, and expression of
choice.
Information processing, the fourth aspect of cognition that comes
into play in mental illnesses, refers to the ability to take in
environmental stimulation through the five senses, interpret it, and
respond to it. Information processing, Steffens said, relies on cortical
and subcortical connections in the brain, and it is a fairly typical
symptom in those with moderate to severe depression. The signs and
symptoms of slowed information processing include slowed thinking
speed and response times, the tendency to absorb only fragments of
information, and social inappropriateness resulting from difficulty
interpreting and making sense of social cues and the body language of
others. Of the four dimensions of capacity for communicating and
making decisions about health care, slowed information processing can
affect understanding and reasoning, he said.
Steffens said that it is striking how many of the people with
depression that he sees demonstrate poor understanding of important
concepts. A person with depression, he said, can parrot back words on
a consent form without really demonstrating any effort or the ability to
put what they read into their own words. Similarly, manic patients may
understand in general what their illness is and how much treatment can
help the symptoms, but they may not have much insight into why that
information applies to them. This causes difficulties in collaborative
health care decision making. Impaired reasoning comes into play when
a person with schizophrenia articulates a decision to refuse
antipsychotic medication, not because of a concern about side effects
but out of a delusional belief that the drug is a poison. Steffens
explained that people with severe anxiety and depression may be so
overwhelmed that they cannot decide or express a choice. “If the goal
is collaborative care with the patient, these can be frustrating for all
concerned,” Steffens said. “Knowing that part of the underlying
condition that somebody has may actually impair their abilities is
important.” He added that while this is something he tries to teach
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as many have, experienced incomparably more pain after the birth of
the child than before it. This is all unnatural and wrong, and would
not be, if human beings had from the first always obeyed the physical
laws. But is there no method by which these pains—terrible and
persistent as they often are—may be prevented? Certainly, if the
experience of thousands may be taken as a guide. No drugs can do it.
Suppose we give strong opiates, as some few of the more stupid
practitioners may yet sometimes do, we may allay the pains
somewhat for the time. But who does not know that the pains are in
the end made worse? And what havoc does such treatment make
with the nervous system? But, fortunately, physicians have, as a
general thing, abandoned this practice.
In this case we helped the patient into the wash-tub, having the
back elevated two or three inches by a block of wood, she sitting in it
with the feet outside, and there being a couple of pails of tepid water
in it. She was rubbed for a long time—say fifteen or twenty minutes—
until all pain was removed. A large, heavy sheet was then folded both
ways, making it four double, and laid upon the bed; on this she was
placed, after which it was folded about her, reaching from the arms
to the knees. The application caused a good deal of shivering, but as I
told her, the more shivering the less pain, she bore it patiently. She
was covered, so as to make her in a reasonable time comfortable, and
there was, I believe, moderately warm applications made to the feet.
This being at about one o’clock in the night, I directed that if the
pains should again come on, as they probably would, she should be
rubbed as before a long time in the shallow-bath, have the wet-sheet
renewed, use the wet towels about the abdomen and genitals, as we
always do, without exception, in such cases, and to repeat these
processes without any reference to hours or time of day, as might be
needed to keep off the pains. Once only before morning was it
necessary to repeat them, and she enjoyed, on the whole, a good half
night’s rest in the folded wet-sheet. In the morning another bath was
taken, when she found herself very comfortable, and, withal, strong.
This patient being at a considerable distance from my home, I saw
her, I think, but twice after the birth. She bathed three or four times
daily, used the wet compresses freely, and took injections according
to need, and suffered almost nothing with after-pains. She kept her
strength well, and sat up to rest herself more or less every day.
 The third or fourth night—the latter, I think it was—she was a good
deal wakeful from fever. Seeing her in the morning, I directed the
bath and folded wet-sheet as before, which at once subdued all
unfavorable symptoms. Had she resorted to them in the night time
as often as the symptoms might have demanded, she would have
obtained a good night’s rest.
All things considered, our intelligent patient found a vast
difference between water-treatment and that to which she had been
before subjected; and she was well rewarded for the heroism, self-
denial, and perseverance which she manifested at and before the
time of her confinement.
Case XIV.—November 10, 1850.—This is a case of an intelligent
young lady of this city, of apparently delicate health, and, I should
judge, twenty-two or twenty-three years of age.
Having been recently married, she spent the winter of 1849–50
probably in too much excitement for the health of one in her state.
Her home besides—a fashionable boarding house—was not one at
which the proper food could be obtained; in short, she lived too
freely, and that upon food of improper character.
In the month of May she experienced a severe attack of bilious
fever, and also, comparatively unacquainted with the water-
treatment, she had the good sense to determine at once to submit
herself confidently to the new method; she had, indeed, no
confidence in any other, and her intelligent husband coincided with
her in opinion, while the other friends objected strongly to what they
considered a piece of fool-hardiness.
By the freest use of packing sheets, of short duration, shallow-
baths in the wash-tub, the wet girdle and tepid clysters frequently
repeated, together with entire abstinence from all food, she was
completely cured in a few days.
Here let it be remembered, that such attacks of fever, as indeed of
all severe acute diseases, are far more dangerous when they occur
during pregnancy.
After recovering from this attack, our patient went for a time to the
country, and followed all along a good course of bathing, with more
attention to diet. Her health improved constantly up to the close of
her period.
 She came to labor the night of November 10, 1850. It lasted only
about six hours—rather a quick one for the first—natural, and on the
whole easy. Her child was a fine healthy boy.
Cold wet compresses were used freely, as ordinarily in such cases.
She suffered little or nothing from after-pains.
The lady was inclined to take only a moderate course of bathing
during recovery, and I did not regard it best to urge her. Two or three
times a day, however, she had an entire ablution of some sort. I think
she sat up more or less every day. She had all along a good appetite,
slept well at night, felt cheerful and contented, and in a few days
found herself in all respects quite well.
This case, although not of very marked character, is yet an
instructive one, when we take into consideration all of the
circumstances connected with her pregnancy.
Case XV.—A laboring woman, who had been deserted by an
intemperate husband, applied to me in the summer of 1850 for
advice. She was poor and melancholic, and knew not what to do. Our
house was too full to receive her at the time, but a benevolent lady of
the city gave her a good home, and some small wages, for what light
work she was able to perform, but on the condition that she should
find some other place in which she should be confined.
This was her second pregnancy, her first child having died at birth.
She was now debilitated, and had worn her clothing a good deal too
tight. I endeavored to persuade her to do all she could under the
circumstances toward the restoration of her health, and especially, to
avoid the great evil which I have mentioned.
On the 18th of November, 1850, the patient having been some days
an inmate of our establishment, gave birth to an apparently healthy
male child, weighing nine pounds. During two days she experienced
pains, more or less. Being very much busied at the time myself, my
worthy friend, Dr. Wm. E. Rogers, of Waymart, Wayne county, Pa.,
superintended the delivery in a faithful and skillful manner. With his
own hands he changed the wet cloths every few minutes, during the
period of four hours. These, of course, aided very materially in
warding off after-pains, and all other evils incident to the puerperal
state.
 The patient having no nipples, could not nurse her child. They had
been countersunk, as carpenters would say; that is, they had been
driven into the breast, doubtless by the patient having been in the
habit of wearing too tight clothing upon them. This not unfrequently
happens with those who unwisely attempt to improve upon the form
which nature has given them.
No milk whatever could be obtained from the breasts; they were
inflamed considerably, three or four days at first, but, by appropriate
treatment, the difficulty soon ceased.
Previous to entering our establishment, the patient had never in
her life taken an entire ablution, that she could remember of. After
the birth, she had, in connection with the compresses, one towel-
bath a day. Three days after the birth, that is, on the fourth morning,
she found herself sufficiently strong to enable her to go down five
flights of stairs without assistance, and twice went out of doors. The
next day she worked in the kitchen, and by following up the daily
bathing, with care and diet, she was very soon fully recovered.
It will be seen that this patient had comparatively but little general
treatment. The persevering use of the cold fomentations, adopted at
the first after delivery, must have operated powerfully in warding off
heat and other inflammatory symptoms, which tend so much to
reduce the strength.
Considering the fact of the inflammation of the breasts, and that
no milk whatever could be obtained, it was rather remarkable that
she was carried through it without having them suppurate and break.
Case XVI.—December 20, 1850.—The patient was, I judge, about
twenty-five or twenty-six years of age; apparently of scrofulous habit;
eighteen months before, gave birth to her first child. At that time she
was kept in her room three months constantly, with a broken breast.
This time she resolved to avail herself of the water-treatment, with a
hope of avoiding the awful sufferings which she had before endured.
She bathed pretty freely and daily during this her second period,
following the advice laid down in the work entitled “Water-
Treatment in Pregnancy and Childbirth.” She kept also busy about
household duties, which aided her a good deal in maintaining good
general health.
 On the evening of the above-mentioned day, December 21st, 1850,
the patient was confined, pregnancy having lasted only 265 days, 15
days short of the usual time; the labor was, on the whole, an easy
one, and ended between 6 and 7 o’clock in the evening.
Usual treatment, with cooling compresses, was followed faithfully,
and after the patient resting a little, a thorough ablution in the wash-
tub was given. She slept well during the night.
The patient had long been troubled with piles, and, as usually
happens under such circumstances, she experienced a good deal of
trouble from the affliction at the time of the former birth. So also, at
this time, it came on so bad as almost wholly to prevent her sitting
up.
With the view of checking it as soon as might be, we commenced
the next morning with the cold packing-sheet, twenty minutes. She
had four baths in all during the day and evening, the water pretty
nearly cold. She felt all along perfectly well, and would have been
able to sit up a good deal the first day, were it not for the
troublesome ailment mentioned.
The second day, and onward through the first week, the treatment
followed was the cold pack in the morning twenty minutes, and the
bath after it; bath in the wash-tub before dinner; the cold pack and
bath again toward evening; the bath again before going to rest; and
cold compresses most or all of the time, night and day.
At the end of the week the patient was so well that she could go
about the house, take charge of her infant herself, and had already
dismissed her nurse. She had suffered no feverishness, no pain, nor
any restlessness at night. Nor was her strength scarcely at all
impaired.
It is now more than two months since the birth of her child, and I
have often heard from her, as being in all respects well.
Two important circumstances helped very much in this case; the
patient herself is a very intelligent and assiduous person, and had
studied faithfully and understandingly the method of treatment
which, in her good judgment, she chose to adopt. Her husband, too,
had a good understanding of the matter, and was himself a most
faithful nurse.
 Case XVII.—A young lady, just married, emigrated from the city of
Edinburgh, Scotland, early in the summer of 1850. She had been
pregnant one month before starting. She was of delicate health, small
stature, of fair hair and complexion, and, as we would say, of
scrofulous tendency. She had always been sedentary in her habits,
and was occupied, for the most part, sitting and within doors. She
had, in short, had but poor opportunity for the development of her
physical powers, and had contracted a bad lateral curvature of the
spine.
The ship’s passage across the Atlantic was a long and boisterous
one of eight weeks; she was a good deal seasick, and after the first
week was compelled, for want of strength, to remain in her berth
night and day; thus she continued for six entire weeks; the eighth,
and last week of the passage, she was able to be out a little.
The patient, together with her husband, took up her residence in
the very heart of this, in the summer, hot and unhealthy city. She had
always been accustomed to a much cooler climate, and now became
necessarily a good deal debilitated. She had lived for a time mostly,
or altogether, upon the vegetarian principle, in the old country; but
in this city she adopted a different course, using coffee, and perhaps
tea, and some other articles not altogether friendly to health.
She consulted me, however, some ten or twelve weeks before
confinement. I advised her at once to avoid flesh-meat, to drink only
cold water, and to bathe and exercise much more than she had been
in the habit of doing; the advice was followed faithfully, and with the
happiest effects.
December 29, 1850.—Sunday morning, at 4 o’clock, her labor
ended. For fifty hours, without intermission, it had continued,
depriving her of rest almost wholly, three nights. Of all the examples
of fortitude and patience which I have ever witnessed under such
circumstances, this was the most remarkable. Notwithstanding the
great length of time the labor lasted, the patient did not at any
moment despond, nor did she, to my knowledge, utter a single word
of complaint. At times she would recline; then again she would sit
up, walk about the room, or engage in some light work. She bathed
also repeatedly, as the pains were progressing, and the ablutions
appeared to refresh the system, and support her strength materially.
I repeat, this very worthy lady’s fortitude and resignation were
remarkable, and such as I shall not soon forget.
This, as I have remarked, was her first child. Under such
circumstances there is usually but slight loss of blood. But in this
case, owing perhaps, partly to the patient’s constitution or state of
health, and partly to the severity of her labor, considerable flooding
succeeded the expulsion of the after-birth. To check this, she was at
once raised and put in the cold sitting-bath. The effect was as sudden
and as favorable as could be desired.
The patient had something of after-pains, but not a great deal.
Three and four baths were taken daily, and the cooling compresses
were freely used.
There were circumstances in this case which caused me some
trouble in anticipation; no urine was passed for full thirty-one hours
after delivery. Considering how much had been done in the way of
bathing, water-drinking, and wet compresses, it was singular that
such should have been the case. But no harm whatever occurred in
consequence of the renal secretion being so long prevented.
Day by day, the patient gained strength; it was against her recovery
somewhat that she was obliged to remain in the same room—and a
rather small one—where the family cooking and other work was
done. Still, through great faithfulness and perseverance in the
treatment, she recovered in all respects remarkably well.
The notes I made of the case at the time are as follows:
“First Day.—Patient was sponged over in bed a number of times,
whenever the cooling compresses were not found sufficient to check
the after-pains. Slept considerably during the first night, but, as is
common after the rest has been broken a number of nights in
succession, the sleep was somewhat disturbed. The compresses were
changed very often. She was not raised up for a bath, as it was
thought that, in consequence of the severity and great length of the
labor, she was too weak.
“Second Day.—Bath in the wash-tub three times, and body
sponged in bed two or three times besides. Urine was passed thirty-
one hours after the birth. Patient sat up to-day in bed.
“Third Day.—Bath in the tub four times; the water cold as usual.
She preferred this; it gave her nerve. It made her shake a good deal at
the time, but this circumstance is attended with no danger. Sat up an
hour and a half at a time to-day. Appetite good.”
It was remarkable in this case, that the pulse remained at 100 and
upward for a number of days after delivery; yet the recovery was
certainly highly favorable.
Within the second week the patient was able to go out and walk in
the open air.
In eighteen days she brought her infant in her own arms to my
house, a distance of about one mile, and returned again home,
experiencing very little fatigue.
About six weeks after the delivery she met with an accident, which
caused her considerable suffering. She received a blow upon one of
the breasts, not very severe, but sufficiently so to cause an
inflammation, which ended in abscess, or broken breast, as it is
usually termed. By following up the water processes faithfully, that
is, by taking frequent ablutions, packing-sheets, with compresses
constantly upon the breasts, sometimes tepid and at others cold,
according to the feelings of comfort, she passed through the period of
healing much better than is usually the case with broken breast.
Considering the patient’s constitution, her voyage across the
Atlantic, her residence in the heart of a hot, unhealthy city, the
length and tediousness of her labor, her recovery was remarkable.
Case XVIII.—This is the case of a young married lady with her first
child. She is of rather nervous temperament; too active naturally for
the good of her system.
January 11, 1851.—She was confined after a seven hours’ labor.
Two or three days before, she had evidently overdone at ironing and
other household duties, which she was too fond of performing. Her
full period would, I think, have been six to seven weeks later, the
birth being premature, in consequence of the over-exertion alluded
to. The child, however, was above the average weight—a daughter—
but did not seem to possess its full share of vitality.
The usual treatment of ablutions three and four times a day, with
cooling compresses, the wet girdle, clysters, etc., was practiced, and
with the happiest results. The patient sat up, day by day, and
recovered, not quite so rapidly as some, but in all respects well.
 Case XIX.—A lady, thirty-eight years of age, recently married,
came to her confinement the 4th of March, 1851. For two months
only she had been bathing, with reference to her expected time; her
health has generally been very good, and all along, during the period
of pregnancy, she attended personally to her household matters,
rendering her little habitation as perfect a specimen of order and
cleanliness as could be conceived of.
All this tended powerfully to preserve health of body, and
cheerfulness and contentment of mind, circumstances never more
important than during the period of pregnancy.
We would expect, naturally, that a patient at this age would suffer
the first time a severe and protracted labor. But in her case it was far
otherwise. True, for two days previous to delivery she experienced
some symptoms of labor, but was able to be about, and slept
considerably nights. At 10 o’clock, A. M., on the 4th instant, labor had
fully commenced; at 4 P. M., delivery took place; making labor only six
hours, on the whole a short one.
Not long after the birth, the patient was helped into the tub for a
thorough wash. She would have been able, I think, to perform the
ablution herself alone; still, it was thought best that she should make
no effort at the first bath.
It is now the third day since delivery, and the patient has had three
or four ablutions daily in water at 70° Fah. She has used the
compresses freely; the wet girdle much of the time, which she finds
to strengthen her back. She sat up more or less every day, usually
after the bath.
The third from the birth, she was going about her room, putting
things in order, feeling in all respects well. The milk was secreted
freely, and she has had no trouble from the breasts, from
feverishness, or any other cause; the infant doing also as well as the
mother.
On the sixth day, the patient went from home, taking her infant
with her, on a visit to a friend residing in another street.
 LETTER XXXVIII.
CONCLUDING REMARKS.

Hysteria—Its Prevention and Cure—Leucorrhea, or Whites—Falling of the Womb.

There are two or three topics connected with the diseases of the
sex, respecting which volumes might be written, concerning which I
will here make some practical remarks.
 HYSTERIA.
This affection takes its name from hyster, the womb. It appears
under such a variety of forms, imitates so many other diseases, and is
attended with such a variety of symptoms, which denote the animal
and vital functions to be considerably disordered, that it is difficult to
give any thing like a rational description of it.
Hysteria attacks usually in paroxysms or fits. “These are
sometimes preceded by dejection of spirits, anxiety of mind, effusion
of tears, difficulty of breathing, sickness at the stomach, and
palpitation at the heart; but it more usually happens that a pain is
felt on the left side, about the flexure of the colon, with a sense of
distention, advancing upward till it gets into the stomach, and,
removing from thence into the throat, it occasions, by its pressure, a
sensation as if a ball were lodged there, which is called globus
hystericus.” At this time the patient feels as if she were actually in
danger of suffocation, grows faint, is affected, perhaps, with stupor
and insensibility, while at the same time the body is turned to and
fro, the limbs are thrown into motion, and wild and irregular actions
take place, with alternations of laughter, crying, and screaming.
There is also frothing at the mouth, eructations of wind from the
stomach, hiccough not unfrequently, and in some cases a transient
delirium is experienced. The limbs may also become so rigid that it is
not possible for the patient to bend them.
Treatment.—If the paroxysm be only a slight one, it is as well to
leave the patient quite to herself; but if the fit be a severe one, the
shallow-bath, in a wash-tub, for instance, or the dashing of cold
water, and rubbing the surface well with hands wet in cold water, will
be highly serviceable. If the patient can drink a sufficiency of warm
water to make her vomit, she will experience great relief. The clyster,
freely administered, is also a valuable help.
In regard to the prevention of this disease, all that I have said or
can say concerning the means of fortifying and invigorating the
general health, would be as appropriate in this as in any other place.
May I not hope that when you consider, each and any one of you,
how troublesome this disease is, and how bad a state of things it
indicates, that you will use your best influence upon those around
you—that by a correct, systematic course of living, its attacks may be
warded off. It is far easier, as well as more desirable, to prevent
hysteria than to cure it.
 LEUCORRHEA, OR WHITES.
This is a very common affection among females, few arriving at full
womanhood without experiencing it. It consists in a puriform
discharge from the vagina, varying in color in different cases, but
more commonly it is of a yellowish white. It always denotes a
deteriorated state of the health, and if allowed to proceed too far, is
apt to end in some worse malady.
The water-treatment is peculiarly adapted to the cure of this
ailment. The great object should be to fortify the general health. For
this object, a good course of hydropathic treatment will in many
cases be necessary. The vaginal injections—not too cold—and sitting-
baths are valuable means.
 PROLAPSUS UTERI.
Falling of the womb has latterly become too much a fashionable
complaint. A great many women suppose they have it, merely in
consequence of some unpleasant feeling, and because it is so much
talked about.
I cannot here enter into a lengthy description of this disease; but I
desire, most earnestly, to impress upon your minds the great value of
the water-cure as a means of remedying it. Prolapsus is a disease of
general debility, and hence the good effects of the new method in
treating it.
Do not depend too much upon local and mechanical means; these
are too much in vogue at the present day. True, vaginal injections,
the wet girdle, sitting-baths, and in some cases the pessary, are all
good in their place; but the restoration of the WHOLE SYSTEM,
remember, is the great thing.
Those who have this complaint, should be careful not to overdo in
walking or other exercise.
 INDEX.

Abortion, 143
Abortion unknown among Indians, 27
Abortion, consequences of, 146
Abortion, causes of, 145
Abortion, prevention of, 147
Abortion, recurrence of, 149
Abortion, evils of, 152
Abortion, cases of, 153
Abortion, dangers of causing, 158
Acute disease in pregnancy, 165
After-pains, 328
Age, marriageable, 34
Air and exercise, 122
Amenorrhea, 61
Austrians, habits of the, 32

Barrenness, 224
Bathing after delivery, 287
Bible account of midwifery, 19
Binder, the, 288
Bladder, the, 232
Blisters, 218
Bloodletting, 220
Breast, inflammation of, 370
Breasts, pain of, 195
Breathing, difficult, 190

Cases of childbirth, 383

Cases of abortion, 153
Catamenia, the, 40
Catamenial discharge, the, 40
Change of life, 55
Change of life, remarks on, 60
Childbirth, cases of, 383
Child, management of the, 292
Child, washing the, 307
Childbed fever, 342
Childbirth among the Indians, 27
Chlorosis, 65
Chlorosis, causes of, 66
Chloroform, 258
Clothing, remarks on, 110
Coffee, 150
Compresses, uses of, 288
Constipation, 173
Courses, the monthly, 40
Costiveness, or constipation, 173
Costiveness, treatment of, 174
Cramp of stomach, 186
Cramp of lower limbs, 195

Delivery, management after, 285

Delivery, bathing after, 287
Diarrhea, 175
Diet in pregnancy, 123
Diet, vegetarian, 127
Difficult breathing, 190
Disease, exposure to, 197
Drink in pregnancy, 129
Dysmenorrhea, 84
Dysmenorrhea, treatment of, 86

Emetics, 219
Ether, 258
Exercise in pregnancy, 122
Exercise in pregnancy, remarks on, 150

Fainting in pregnancy, 139

Fainting, symptoms of, 140
Fainting, results of, 141
Fainting, treatment of, 142
Fallopian tubes, 238
Falling of the womb, 430
Feather beds, 149
Fetus, anatomy of, 243
Fetus, effects of food on the, 124
Fright, effects of, 215

Genital organs, itching of the, 193

Headache, 179
Headache, treatment of, 180
Heart-burn, 169
Heart-burn, treatment of, 170
Hemorrhage, uterine, 162
Hemorrhage, uterine, cases of, 162
Hemorrhage from the stomach, 184
Hemorrhoids, 176
Hemorrhoids, treatment of, 177
History of midwifery, 19
Hysteria, 195
Hysterics, 195

Imagination, the, 207

Indians, childbirth among, 27
Inflammation of the breast, 370
Itching of the genital organs, 193

Jaundice, 189

Labor, 253
Labor, divisions of, 254
Labor, signs of, 260
Labor, stages of, 261
Labor, advice concerning, 280
Lacing, 111
Leucorrhea, 429
Leucorrhea, treatment of, 429
Light, solar, effects of, 118
Limbs, swelling of, 194
Liquor amnii, 264
Lochia, the, 337
Lochial discharge, the, 336
Longing, 204

Marks and blemishes, 208

Marriageable age, 34
Menorrhagia, 81
Menorrhagia, treatment of, 83
Menses, age at which they appear, 37
Menses, names of, 40
Menses, source of, 42
Menses, nature of, 43
Menses, quantity of, 46
Menses, cessation of, 49
Menses, check of, 61
Menses, water-treatment in, 64
Menses, danger of checking the, 79
Menstruation, history of, 34
Menstruation, age at which it commences, 37
Menstruation, symptoms of, 40
Membranes, the, 273
Mental despondency, 201
Midwifery, cases in, 383
Midwifery, history of, 19
Midwifery, Bible account of, 19
Midwifery, American history of, 24
Midwives in France, 23
Midwives in Bible times, 20
Monthly discharge, the, 40
Monthlies, the, 40
Milk-tubes, the, 371
Miscarriage, or abortion, 143
Miscarriage, prevention of, 147
Miscarriage, recurrence of, 149
Morning-sickness, 133, 136

Nausea and vomiting in pregnancy, 132

Navel, healing of, 300
Nervousness, 200
New Zealanders, habits of, 30
Nipple, the, 371
Nipples, sore, 362
Nursing, 308
Nursing, rules for, 310