Danielle Victoriano interned at a non-profit mental health facility under the direction of Andrew Walsh. During some down time, she labored on a series of research projects and articles. This piece on Epigenetics is the second one to be published.

__________________________________________________________________

In recent years, the growing number of substance abusers in the United States has become a topic of national discussion. As the death toll from overdoses continues to skyrocket—with about 63,600 deaths in 2016, a number 21% higher than in 2015—substance abusers, family members, substance abuse counselors, and scientists are desperately searching for solutions that would help curb this national crisis. From all this turmoil has arisen a potential aid in the fight against substance abuse: epigenetics.

The topic of epigenetics cannot be breached without a better understanding of DNA, the material inside cells that serves as the language of life. DNA is the command center for why we look the way we look, and sometimes, why we behave the way we behave.

DNA or deoxyribose nucleic acid can be broken down to four bases: Adenine, Thymine, Cytosine and Guanine. Each of these bases are attached to a phosphate group and a sugar, and this combination of bases, sugars, and phosphate groups form the double-helix ladder that often comes to mind when we think about DNA.

However, this viewpoint is wholly incomplete. It must be understood that the DNA ladder also actually wraps itself around proteins called histones.  The tightness from the wounding around these histone proteins regulate which parts of the gene are expressed and repressed. The closer the histone proteins are to each other, the tighter the DNA is wound, and thus, the harder it is for the DNA-encoding machinery to access the DNA material. The further away the histone proteins are to each other, the looser the DNA is wound, which means that it is easier for gene expression to occur.

The distance by which histone proteins are from each other and the tightness of the DNA wounding around these proteins is determined by two chemical groups. Attachments of methyl groups on either the DNA itself or on the histone proteins are associated with repressing, or turning off the expression of a gene, while acetyl groups are associated with expression, or turning on the expression of a gene. Methylating the DNA and/or methylating the histone proteins tightens up the DNA-protein interaction, while acetylating the histone proteins opens up the gene and allows for expression.

To think about it more simply, imagine a flashlight that’s been turned on. Now, imagine a hand covering it. To open up the fingers over the flashlight means that light will pass through. To close the fingers over the flashlight means that light will not be able to pass through. This is similar to how epigenetic modifications to the human genome works. The light represents the fact that the DNA material will be there, it is whether or not the hand is open or closed that will factor in to if the gene is actually repressed or expressed. When the hand is open, there is expression, and when the hand is closed, there is repression.

Thus, epigenetics is the study of how the human genome is modified not through changes in the base pair sequence, but how the structure of DNA and protein is modified through attachments of chemical groups that alter the configuration.

The blossoming field of epigenetics has paved the way to discovery of epigenetic markers brought by substance abuse. By epigenetic markers, this means that genes have been identified to be methylated or acetylated differently from the norm.

One substance misuse disorder that is of high importance to public policy is the abuse of opiates. According to the Center for Disease Control, in 2016, around 66% of the 63,600 drug-overdose related deaths involved opioid use.

Researchers have found that in opioid addictive patients, there is more expression of a certain neuro-excitatory gene, GRA1, that would account for the addiction’s withdrawal symptoms such as restlessness, muscle twitching, and dilated pupils. This overexpression can be attributed to hyperacetylation of the neuro-excitatory gene. Hyperacetylation means that the gene is constantly being expressed, which leads to more expression than usual.

Alcohol is yet another substance misuse disorder that has been identified to have epigenetic markers. With alcohol use, researchers have found dysregulated amount of protein factors in the brain through abnormal methylation and acetylation patterns in some genes. In turn, during the active influence of alcohol, there is high concentration of the protein Arc, which is associated with decreased levels of anxiety and stress. This relationship results in alcohol-dependence to combat negative emotions that can be seen in many individuals with alcohol misuse disorders.

Knowing the existence of these epigenetic markers, and being able to identify and locate where they are in the human genome opens up a whole new realm of opportunity in terms of treatment options in substance abuse recovery. Potentially, the current rates of relapse that follow inpatient detoxification treatments could be curbed. As of 2015, it is reported that more than 85% of substance misuse patients relapse and return to substance use within a year following treatment. Since withdrawal symptoms are a trigger for relapse, imagine being able to control and limit those symptoms by targeting the epigenetic markers that caused the symptoms in the first place. Imagine being able to de-acetylate the neuro-excitatory gene, GRA1, that is constituently turned on in those with opioid abuse. This would most likely make early recovery easier, less painful, and less daunting.

Medications that are currently being examined to combat substance abuse are histone deacetylase inhibitors (HDAC inhibitors) and DNA methylation inhibitors (DNMT inhibitors).  These medications would attempt to re-regulate the imbalance that have been produced by epigenetic modifications in the body, by reversing or inhibiting the effects of methyl groups and acetyl groups.

Though research is still in its infancy, with no current research on how these medications affect humans, results have shown to be promising. One research study looked at the effects of having histone deacetylase inhibitors in rats with alcohol addiction and found that with HDAC medication, these rats are less likely to seek out or self-administer alcohol.

In terms of non-medication related treatments, there has been a promising finding that exercise can be used to reverse some of the epigenetic modifications made from chronic alcohol abuse. It has been found through rat studies that exercise has restored the brain physiology that has been altered by chronic drinking. Alcohol-addicted mice that were treated with regular exercise had improved memories and brain activities when compared to the non-treatment group.

Despite these success stories in controlled environments, there is still a lot more that needs to be done before this new technology can be used in humans. Currently, we simply do not have the technology to selectively choose genes that are specifically targeted by different addictive stimuli. However, we are hopeful that this new field will take off. With growing interest from research institutes in the national and global arenas, we can hope that the awaited future of epigenetics is not that far.

_________________________________________________________________

Danielle Victoriano is a member of the Princeton University Class of 2019. She studies Ecology & Evolutionary Biology and plans on going to Medical School. She can be reached at [email protected]

Daniel Shen interned at a non-profit mental health facility under the direction of Andrew Walsh. During some down time, he labored on a series of research projects and articles. This piece on Epigenetics is the first one to be published.

________________________________________________________

The National Suicide Prevention Lifeline is a 24-hour suicide prevention network that takes 1.5 million calls per year nationally, or roughly 4,000 calls per day[1]. Following the tragic deaths of celebrities Kate Spade and Anthony Bourdain earlier this June, this number rose by 65% for several days, an increase of more than 2,500 calls per day[2]. Such spikes are typical following media coverage of celebrity suicides; similar statistics were reported after musician Chester Bennington’s death in 2017, and in the months following actor Robin Williams’s death in 2014, national suicide morbidity rates increased by nearly 10% according to a recent study from Columbia University[3].

Regardless of the precise psychological and sociological factors behind the so-called “celebrity-suicide effect”, clearly these high-profile incidents seem to touch a painful hidden nerve within our nation. According to the National Institute of Mental Health, one fifth of all Americans, or nearly 45 million individuals, are currently struggling with some form of mental illness[4]. When news of Ms. Spade and Mr. Bourdain’s deaths broke, conversation within the media focused particularly on an alarming CDC statistic reporting a 30% increase in the national suicide rate since 1999[5]. (For reference, the national population grew by only 16% since then[6].) Yet despite the prevalence and severity of these illnesses, nearly 60% of suffering adults do not seek treatment, and if the caller volume spikes following Ms. Spade and Mr. Bourdain’s deaths are any indicator, this statistic likely suffers from under-reporting[7]. The minority that do seek treatment are nearly always prescribed medications that often come with a litany of adverse side effects – nausea, drowsiness, weight gain, and muscle tremors, to name a few – that add further stress to an already difficult situation.

Epigenetics is a growing area of biological research which has rapidly gained the attention of medical researchers within the past two decades and is now being considered as a potential strategy for devising effective psychiatric treatments. Promising developments have already begun in other arenas; recently elucidated epigenetic mechanisms behind some cancers have already led to the creation of novel cancer drugs, and similar progress is being made for many other non-communicable diseases[8].

In basic terms, epigenetics can be defined as the study of the biological mechanisms behind gene expression – that is, how cells can switch certain segments of DNA on or off in order to perform specific functions. For instance, although your skin cells and brain cells all contain the same DNA and thereby the same genes, your skin cells do not sprout dendrites and your brain cells do not secrete oils/sweat because both cell types have switched off the gene segments encoding for inappropriate and unnecessary features. Proper gene expression is essential for an organism’s growth and survival, and many diseases are the result of switches being in the improper state: some gene is turned off when it should be on, or vice versa. For example, many cancers arise when genes encoding for crucial DNA repair/proofreading proteins become switched off, leaving cells more vulnerable to cancer-causing mutations. This leaves medical researchers with a tantalizing prospect: if the onset of a certain disease is due to improperly switching on/off certain genes, could treatment simply be a matter of reversing the switches back to normal?

Psychiatric epigenetics research is based on the hypothesis that psychiatric disorders such as major depressive disorder (MDD) and schizophrenia have epigenetic markers – that is, these diseases are the result of either overexpression or underexpression of certain genes within brain cells, resulting in altered brain activity and behavioral symptoms. Furthermore, these markers can be either hereditary or environmentally triggered, and by reversing the pathological gene switches back to normal, the disease can be mitigated. Encouraging findings from cancer research and other non-psychiatric disciplines have already shown this to be a promising hypothesis⁸. MDD, schizophrenia, and generalized anxiety disorder (GAD) rank among the most common mental disorders in America, and consequently have been of primary interest for epigeneticists searching for markers[9]. Due to the sheer complexity of the brain, progress has been slower in the psychiatric realm compared to non-psychiatric arenas, as evidenced by the relative dearth of literature on the topic. Nevertheless, studies from animal models and post-mortem tissue studies have already yielded encouraging results; a few of these studies are highlighted below.

Major depressive disorder

Several lines of evidence have implicated brain-derived neurotrophic factor (BDNF), a protein responsible for healthy neuron function, as a key factor in the onset of MDD, with decreased expression of BDNF in the hippocampus being associated with depressive symptoms[10]. In 2009, a team from the University of Alabama used rat models to investigate whether or not the gene encoding for BDNF experienced any epigenetic alterations in depressed individuals[11]. They did so by subjecting a group of rat pups to abusive conditions such as social deprivation and maternal maltreatment to induce depressive behavior, then comparing their brain cells with those of a control group. What they found was that in the depressed rats, the BDNF gene exhibited signs of increased DNA methylation, a chemical modification of DNA that acts as an off-switch for gene expression. Furthermore, experimental treatments with a DNA methylation inhibitor, designed to undo this chemical modification, yielded promising results. Crucially, this epigenetic marker appeared to be heritable between generations as well: when female individuals from the depressed rat group were allowed to mate, their offspring also exhibited the same methylation patterns and the same behavioral symptoms. This suggests that epigenetics may offer a sobering framework by which the long-known hereditary aspects of mental illness can be understood.

Schizophrenia

 γ-aminobutyric acid, or GABA, is a neurotransmitter responsible for reducing neuronal excitability in the brain, among other functions. It has been hypothesized that for individuals suffering from schizophrenia, the mechanisms driving GABA production are defective in certain neurons, resulting in increased neural activity and pathological behavioral symptoms[12]. In 2005, a team of Harvard researchers looked for markers at the RELN gene within GABA-producing neurons, hypothesizing that defects in RELN production are a major factor behind GABA deficiencies[13]. Comparing post-mortem brain tissue between schizophrenic and non-schizophrenic individuals, they indeed found evidence of DNA methylation – an epigenetic off-switch – at this gene within brain cells of the frontal lobe in the schizophrenic samples. Moreover, their results were consistent with a previous study examining RELN expression in patients with bipolar disorder[14]. Given the similarity of psychosis symptoms between these two illnesses, this link suggests that epigenetics may provide a window by which the mechanisms behind these diseases can be better understood, leading to more effective treatments for a multitude of conditions.

Anxiety disorders

The hypothalamic-pituitary-adrenal (HPA) axis is a complex system consisting of the hypothalamus, pituitary gland, and adrenal glands and can be thought of as the “stress-system” of the body, forming the link between brain activity and hormone production. Corticotropin-releasing hormone receptor 1 (CRHR1) is a crucial protein that contributes to activating our bodies’ stress response via this system. A recent 2016 study from the Weizmann Institute of Science in Israel used rat models to investigate whether or not the gene encoding for CRHR1 was affected in rats with anxiety disorders (induced through various means)[15]. They found that for anxious rats, the CRHR1 gene was under-methylated compared to healthy rats, suggesting that this protein was being overexpressed in anxious individuals and resulting in overactivation of the stress response. When they treated the anxious mice with an experimental drug designed to restore methylation, they found that many of their symptoms subsided, demonstrating that epigenetics can indeed be a promising avenue for designing new pharmacological therapies.

Next steps

The above studies all present a positive correlation between specific epigenetic signatures and the onset of psychiatric disorders, suggesting that epigenetics research is indeed a promising direction for future diagnosis and treatment methods for these disorders. Nevertheless, the field of psychiatric epigenetics is still very much in its infancy, as evidenced by the relative dearth of literature on the subject compared to other disease studies like cancer. Moreover, all of the drugs that have been developed thus far (including the cancer drugs), promising though they may be, have been pan-inhibitors – that is, they affect the entire genome rather than specifically targeting one gene, raising concerns about potentially dangerous side-effects that are not fully understood. Reaching the point where epigenetic treatments can act with specificity and accuracy on single genes requires a more extensive understanding of our cells’ epigenetic mechanisms in all of their complexity, which is beyond our current knowledge. Given that our cells regularly erase and re-write epigenetic markers on their own as part of normal functioning, elucidating these mechanisms is certainly possible, and the moment we gain the ability to selectively modify epigenetic markers on single genes will herald a paradigm shift in medicine and human history.

______________________________________________________

Daniel S. Shen is a member of the Princeton University Class of 2019 and studies within the Department of Music. He is planning on going to Medical School. He can be reached at [email protected]

______________________________________________________

[1] Draper, J. (2015, January 05). National Suicide Prevention Lifeline: The First Ten Years. Retrieved July 05, 2018, from https://www.sprc.org/news/national-suicide-prevention-lifeline-first-ten-years

[2] Ravitz, J. (2018, June 13). Calls to suicide prevention hotline spiked after celebrity deaths, but what’s the next step? CNN. Retrieved July 5, 2018, from https://www.cnn.com/2018/06/12/health/suicide-hotline-increase/index.html

[3] Fink DS, Santaella-Tenorio J, Keyes KM (2018). Increase in suicides the months after the death of Robin Williams in the US. PLoS ONE 13 (2): e0191405. https://doi.org/10.1371/journal. pone.0191405

[4] Mental Illness. (n.d.). Retrieved July 05, 2018, from https://www.nimh.nih.gov/health/statistics/mental-illness.shtml

[5] Stone DM, Simon TR, Fowler KA, et al (2015). Vital Signs: Trends in State Suicide Rates — United States, 1999–2016 and Circumstances Contributing to Suicide — 27 States. MMWR Morb Mortal Wkly Rep 2018;67:617–624. DOI: http://dx.doi.org/10.15585/mmwr.mm6722a1.

[6] Population data retrieved July 5, 2018, from https://data.worldbank.org.

[7] Substance Abuse and Mental Health Services Administration, Racial/Ethnic Differences in Mental Health Service Use among Adults. HHS Publication No. SMA-15-4906. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015. Retrieved July 5, 2018, from https://www.samhsa.gov/data/sites/default/files/MHServicesUseAmongAdults/MH

[8] Allis, C., & Jenuwein, T. (2016). The molecular hallmarks of epigenetic control. Nature Reviews Genetics. http://dx.doi.org/10.1038/nrg.2016.59

[9] U.S. DALYs Contributed by Mental and Behavioral Disorders. (n.d.). Retrieved July 6, 2018, from https://www.nimh.nih.gov/health/statistics/disability/us-dalys-contributed-by-mental-and-behavioral-disorders.shtml

[10] Castren E, Rantamaki T. The role of BDNF and its receptors in depression and antidepressant drug action: Reactivation of develop- mental plasticity. Dev Neurobiol 2010;70:289–97.

[11] Roth TL, Lubin FD, Funk AJ, Sweatt JD. Lasting epigenetic influence of early-life adversity on the BDNF gene. Biol Psychiatry 2009; 65:760 – 769.

[12] Costa E, Chen Y, Davis J, Dong E, Noh JS, Tremolizzo L et al. REELIN and schizophrenia: a disease at the interface of the genome and the epigenome. Mol Interv 2002;2:47–57.

[13] Abdolmaleky HM, Cheng KH, Russo A, Smith CL, Faraone SV, Wilcox M et al. Hypermethylation of the reelin (RELN) promoter in the brain of schizophrenic patients: a preliminary report. Am J Med Genet B Neuropsychiatr Genet 2005;134B:60–6.

[14] Fatemi SH, Earle JA, McMenomy T. 2000. Reduction in Reelin immunor- eactivity in hippocampus of subjects with schizophrenia, bipolar disorder and major depression. Mol Psychiatry 5:654–663, 571.

[15] Evan Elliott, Sharon Manashirov, Raaya Zwang, Shosh Gil, Michael Tsoory, Yair Shemesh, Alon Chen. Dnmt3a in the Medial Prefrontal Cortex Regulates Anxiety-Like Behavior in Adult Mice. Journal of Neuroscience 20 January 2016, 36 (3) 730-740.

I follow 48 people or institutions on Twitter. It is an eclectic mix of comic book artists/writers, baseball analysts, public intellectuals, criminal justice groups, drug treatment advocates, comedians and a few that defy classification. Despite this menagerie, my feed was full of chatter about Press Secretary Sanders being asked to leave the Red Hen restaurant in Virginia.

A brief review of American law shows that:

(a) Restaurants can’t refuse service based on race (Katzenbach v. McClung, 1964). The Civil Rights Act of 1964 expanded this to cover religion and national origin as well.

(b) In June, the Supreme Court sided with a Colorado baker who refused to bake a cake for a gay couple, citing his religious objections. The decision was limited to just that case, so the right of refusing to serve the LGBTQ population based on religious objections is still murky.

(c) Businesses have a limited right to refuse service to people, but it is on a case-by-case basis and can’t be discriminatory on groups covered in point (a). It can often appear to be arbitrary. Cases of refusal that typically win in court are when the patron is causing trouble (loose definition here), overfilling the capacity, the kitchen is closed, accompanied by a large group of non-customers, or lacking adequate hygiene. Still, those cases can go either way and the restaurant can get some very bad press in the interim.

This past April, two black men in a Philadelphia Starbucks were asked to leave. They had not purchased anything, so they were not actual customers. Were they asked to leave because they were black males or because they had not purchased anything (or both)? Starbucks got a lot of bad press but there was never a court case; there was a settlement and a national closure of Starbucks on a day in May for training. I would have liked to have seen it go to Court, as there were a number of interesting questions.

In 2006, I was working at Hunterdon Drug Awareness in Flemington, NJ. It is an outstanding Intensive Outpatient (IOP) treatment program. I conducted an intake on a white male in his mid-20s. During our 90 minute conversation, he stated how much he disliked minorities and gay people. I pushed past this and evaluated his substance abuse problem. He needed treatment and could be properly served by our program. I set him up for 9 hours of group a week and 1 hour of individual counseling every other week. The clinician that performed the intake usually became the client’s individual counselor.

I did not want to work with him, based on his beliefs, which I found vile. I went to my supervisor and told him that I did not want to work with him because of his racist views. She said that it didn’t matter and that he deserved treatment. I told her I agreed he needed treatment but that I did not want to give it to him. She said I had to. Then I pulled out my ultimate card and said, “He hates gay people. He said so. Over and over” (my boss was/is a lesbian). I figured this would sway her.

She didn’t miss a beat and said, “I don’t care if he advocates for burning gay people at the stake. He needs treatment. We provide treatment. You will provide him treatment. And you will give him the same kind of care that you provide clients that you like. End of story.” And so I did.

My late friend Eric Arauz used to talk about our work in the drug and alcohol field as being apolitical. He waxed about firefighters and how they rushed into buildings and saved people. They don’t ask, “Who did you vote for in 2016?” or “What NFL team do you root for?” (I half-seriously think that Giants and Eagles fans would let each other die).

In the twelve years since that important lesson, I have encountered hundreds of patients who have uttered statements that I found embarrassingly provincial and uninformed, and sometimes vile and ignorant. This includes a number of soldiers and police officers. I have taught thousands of college students, many of whom have social and political views that are radical leftist and would both alienate a large swath of the population and hasten the financial bankruptcy of this country.

I provided service to all of them. I have counseled soldiers with alt-right views and I have taught students with revolutionary fantasies. Of course it was my hope that by being exposed to me, they would soften a bit and move towards the middle. But that was never part of the treatment plan or included in the syllabus. I had to focus on the job and the service that I was supposed to provide (I do have a bit more leeway in the college classroom, and I spend time in most of my classes discussing the importance of listening to those you disagree with).

Were the owners or manager of the Red Hen within their rights to ask Sarah Huckabee Sanders within their rights? Probably. I’m not a lawyer (though I did slay the LSAT), so that is a better question for a member of the bar.

Is the media attention a good thing for the Red Hen? Probably not. It has led to a lot of press, both good and bad, solely depending upon your political perspective. I know there was a restaurant in NJ with the same name that got a lot of angry phone calls. That is unfortunate collateral damage.

Do you like Sarah Huckabee Sanders? That is a question with no relevance, but I’ll answer it – no.

Do you think that refusing President Trump’s Press Secretary service in a restaurant is a good idea? A very strong no.

Will refusing Ms. Sanders get her to change her views or how she does her job or confront her boss? I highly doubt it.

Will refusing Ms. Sanders service likely cause Trump supporters to alter their beliefs and behaviors? Again, I highly doubt it. I believe that it will actually further entrench them in their positions and continue to divide Americans.

Where is the win here? There was no win. I think the Red Hen shouldn’t have done it. I think that Ms. Sanders tweeting about it inflamed it. I disagree with those who cheered the Red Hen and the I disagree with those who raged against the restaurant. Everybody lost here.

Who started it? Jesus Christ, that is childish question. If you are asking it, you are wrong.

Ok, Mr. Expert, Mr. Fucking High and Mighty, Mr. Soldier-Professor-Social Worker, what is your big time, arrogant, look down upon us all advice? Even if you disagree with someone, do not refuse them service. When having discussions, don’t interrupt them, curse at them, scream, insult, or lie about the facts. If you don’t like a policy, call your elected officials (a quick citizen test – name your Governor, both Senators, Congressional representative, state legislative representatives and mayor). Advocate. Vote.

Over the past week, I heard from a top NCAA baseball player, a high school senior who excels at lacrosse and an amateur Iron Man triathlete. All of them asked me a variation of the same question: “How do I get out of my head when things go wrong?” or “How do I avoid psyching myself out before hand?”

I hope those athletes find this helpful, but I also believe that everyday people can apply the suggestions here to their lives.

1) Recognize your negative self-talk. Most people talk out loud to themselves when no one is around. This does not mean that they are having conversations, but humans do tend to say a word or a phrase or a sentence out loud. They are speaking to themselves. For those that do not utter these lines, they almost certainly have a in-head commentary. These words could be said when we are driving our cars, walking to class, sitting in front of the TV, scrolling through our phones or some other occasion where we find ourselves alone. Here are some examples:

• I can’t do it
• That’s just great
• Living the dream
• Idiot
• Moron
• I’m a fucking loser
• I’m a piece of shit
• What was I thinking
• Fucking retard
• I’m going to fail
• No one likes me
• I’m always going to be alone
• I can’t win
• I always lose
• What’s the point
• Everyone is going to laugh
• I should quit
• I should kill myself

Anything we repeat out loud is powerful. Going to a 12-Step meeting and saying, “My name is XXX and I am an alcoholic” is extraordinarily significant, because it help break down one’s denial (even if they don’t fully mean the words). Since I was a teenager, I’ve been critical of having children recite the pledge of allegiance or repeat lines in houses of worship. This is not because I harbor anti-American or anti-religious thoughts, but rather that I want people to understand concepts before they have repeated lines hundreds or thousands of times.

2) Once you’ve recognized your negative self-talk, we have to work hard on stopping it. Each time you utter your word or phrase, you must work on catching yourself and say, “That’s not true” or “That’s not fair.” This takes a lot of effort. If someone needs additional help with this, I usually suggest putting a rubber band on one’s wrist and snapping it after each negative expression, followed by a “That’s not true” and then a positive affirmation. This can be tricky though, as some people just snap the rubber band during other moments. The rubber band snapping on the skin sends a physical signal to accompany the mental command to stop the behavior. It is basic behaviorism.

3) Reduce/eliminate the negative people from your life and add/accentuate the positive people. Surround yourself with people who support your goals and tell you that you can do it.

*Do not confuse this with surrounding yourself with sycophants or those that have no real basis in reality (if I announced that I was going to become a star ballet dancer, I am assured that the close people in my life would tell me that it was neither possible nor a good idea) .

4) Work on developing/improving/increasing your positive thinking and positive self-talk. Derek Jeter, Lebron James, and Katie Ledecky are all champions who, while having special physical skills, have excellent positive psychology. I encourage you to click on the links and read the articles about them. I also think that you should starting saying positive statements out loud in your down time, during practice and in the middle of competitions:

• I can do this
• I am worthy
• I am really good
• I am going to win this ball
• I’ve trained really hard
• People are rooting for me
• I am liked
• I am loved
• I am smart
• Try my best
• Champ
• Let’s go let’s go let’s go
• Do it
• Push through
• Next step
• Keep going
• This is fun
• This is fun god dammit

5) Engage in positive visualization. When I talk to people about this, they often say that they “feel silly” or “this is stupid.” Moving on. Sit down and close your eyes. Imagine the competition or event or aspect of the competition. See yourself on the field, court, track, playing surface or wherever else your event is taking place. Picture yourself trying hard and doing well. After you have done this a dozen times, you can take this to another level by writing down a few obstacles/challenges that might happen. Once again, close your eyes and picture how you will positively deal with those challenges.

6) Make a list of your major successes and difficulties overcome. If you quit smoking or drinking or drugging, that took a lot of work, discipline, will power and support. If you have already scored goals, completed a race, hit college pitching, climbed mountains, passed classes, changed a tire, successfully fought a ticket, or achieved some goal that you set out, you need to remind yourself that you have done that. Last year, I took a bunch of clients from a rehab hiking up Old Rag in Virginia. It is a difficult one day hike. During a very challenging part that was quite steep with huge drop offs, one client said to another, “We climbed Breakneck Ridge with Frank. We can do this.” I only heard about this after we completed the hike. I was thrilled and proud, as my client had used his past experience to develop his resilience and achieve the goal. I can not overstate the importance of doing this.

In March of this year, I made it to the summit of Mt. Kilimanjaro in a surprise and brutal snowstorm. I wasn’t nervous about the physical aspect of the climb, but I was deeply concerned about my ability to breath at 19,000 feet. I was in good shape, had the right equipment, had trained for the hike and I followed the directions from our guide. During the final ascent, I said the following lines:

• I can do this
• One step, one step
• I completed combat arms basic training
• I have run two marathons
• I made it to the top of Mt. Washington in the winter
• I don’t quit
• Very few people get this opportunity
• I can do this

On 4/24/2018, I testified before the NJ Legislative Black Caucus at the Second Baptist Church in Atlantic City, NJ. My written testimony (with ad-libs) is below.

______________________________

There is a long and ugly history of white experts lecturing black leaders. I do not want to have any part of that nasty history. I told my ex-wife that I was speaking before you today, and she said to offer up her condolences and that you should know that even people that love me find that their eyes glaze over when I go on and on.

My name is Frank Greenagel. I have taught at the Rutgers Center of Alcohol Studies since 2008 and at the School of Social Work and the School of Communication since 2011. I have served on the Governor’s Council of Drug Abuse and Alcoholism since 2011. I am the supervising therapist at the NJ Recovery High School in Roselle and also Direct the Family Program at College Recovery, a treatment program in New Brunswick. I am a consulting therapist for the NY State Troopers EAP and serve as a Medical Officer in the Pennsylvania Army National Guard. I am the co-chair of the Middlesex County chapter of the National Association of Social Workers, am a member of the National Association of Alcohol and Drug Abuse Counselors and serve as the Public Policy Chair of the NJ Society of Addiction Medicine. I have other jobs and associations, but for the sake of time I won’t keep listing them.

I have treated people who have used and abused marijuana since 2004. I have treated both genders, all races, all socioeconomic classes and people aged 13 to 79. I have treated veterans since 2004 and active service members since I was directly commissioned back into the Army in 2014.

I am someone who will make more money if marijuana is legalized in NJ. I will see more patients who have problems caused or exacerbated by their marijuana use, and my trainings for treatment programs and community speeches will be even more in demand. Despite the positive effect that legalization would have on my bank account, and unlike almost everyone else who would profit from the legalization of marijuana, I am completely against the legalization of this dangerous drug.

There are three major arguments that are given by the for-profit marijuana movement.

• It is a major revenue source.
• It is medicine
• Legalization is a civil rights issue and will reduce criminal justice disparities among minorities

I will point out the problems with each argument.

• It is a major source of revenue.
  1. Marijuana revenues have increased in Colorado and Washington over the last three years, but the revenues are not nearly as large as California has anticipated. This is partly because the illegal market in California and other states continue to thrive.
  2. Since legalization in Colorado, tax revenue from alcohol and tobacco has decreased. Economists call this an example of a substitute good.
  3. Economists, tax experts, public health officials and governmental bean counters all agree that alcohol and tobacco are revenue negative. For every current dollar that those drugs bring in, they cost between 7 and 10 dollars in the future. This is due to health care and criminal justice costs, which are easily measured. Workplace productivity costs are difficult to measure and family problems and their costs are very hard to measure. If we were able to figure out the workplace and family costs, tobacco and alcohol would be even more revenue negative.
  4. Because of health care costs and legal costs, marijuana is almost certainly a long term source of negative tax revenue. Remember, even with legalization, marijuana crimes will include underage use, public smoking, public intoxication, and drugged driving. Neither the American Government nor the American people seem to have a strong grasp of the concept of negative long term tax revenues.
  5. So-called medical marijuana is taxed at a lower rate than recreational marijuana. In March, Governor Murphy increased the number of diagnoses from 11 to over 30. Those new diagnoses covered included anxiety and chronic pain – both are quite common and are overdiagnosed and overmedicated. This will undercut the revenues brought in from higher taxed recreational marijuana as tens or hundreds of thousands of more people will seek low taxed medical marijuana as an alternative.
  6. Some politicians state that some of the marijuana tax revenue will go towards funding prevention and treatment programs. We heard similar arguments in the 1970s about casino tax revenues going to fund schools statewide and to rebuild Atlantic City’s infrastructure. I invite you to walk around outside and see if that promise was kept. I can assure you that most of the casino tax revenue was soon diverted into the general fund. I believe that marijuana tax revenue would similarly be diverted into a general fund. It is a false carrot meant to lull a too-trusting public and our officials into agreeing to this terrible public policy.
• It is medicine.
  1. I take no issue with people with AIDS, late stage cancer, or glaucoma that use marijuana to alleviate their symptoms or the side effects of various medications.
  2. I have no problem with the federal government moving marijuana from schedule I to schedule II in order to conduct studies.
  3. There have been almost no worldwide random controlled clinical trials on these 30+ diagnoses that it is approved for in NJ. There have been no RCTs in the USA.
  4. Major arguments about legalization have been made using veterans, and for-profit marijuana advocates love to offer up anecdotal evidence. I have treated hundreds of veterans over the years. I have many stories about veterans whose problems got far worse while using marijuana, including a veteran who recently completed suicide despite taking marijuana to treat his complex trauma. I am a veteran myself and rejoined the Army in 2014 after a 10 year break in service. This is a population that is incredibly important to me, and my actions easily support that claim. The VA reports that over 20% of veterans with a diagnosis of PTSD also have a substance misuse disorder (my experience finds that number to be much higher). Treating people with a substance misuse disorder with a dangerous drug that has not gone through random controlled clinical trials is terrible medical practice. It is the government’s duty to protect the public from untested substances falsely labeled as medicine.
  5. Medical professionals do not prescribe marijuana. They recommend it. This is an important manipulation of words. If they prescribed it, they would be liable to malpractice suits. By recommending it, they are not. It seems quite peculiar that people argue that it is medicine but that doctors will not prescribe it.
  6. This talk of both medicalization and legalization has caused a significant problem: it has lessened the stigma associated with marijuana. A Hazelden-Betty Ford poll found that 60% of people aged 18-25 believe that marijuana has no negative impact on the brain. With less stigma comes increased use.
• Legalization is a civil rights issue and will reduce criminal justice disparities among minorities
  1. Since legalization in Colorado in 2014, there has been an 8% drop in the arrest rate of whites under 21 for marijuana. Hispanics under 21 have been arrested at a rate 29% higher. Blacks under 21 are arrested 58% more.
  2. There are similar numbers in Washington state as well.
  3. Arrests involving marijuana in Washington DC are way down, but blacks are still arrested at a much higher rate than whites and Hispanics. While it is a good thing that there are fewer arrests, legalization has not changed the racial problems in the criminal justice system.
  4. Tobacco and alcohol are disproportionately sold in and disproportionately affect minority communities. Marijuana stores will almost certainly follow a similar pattern. In Denver, marijuana stores are much more prevalent in minority areas. If marijuana is legalized, I am certain that there will be no stores in Marlboro, Upper Saddle River, Alpine, Tewksbury, Montgomery or Bedminster. I am also certain that there will be a push for stores in Asbury Park, Atlantic City, Newark, Camden, Trenton, Patterson and Jersey City.
  5. Whites supported legalization about 20 points more than blacks in DC. This would be the first Civil Rights Issue that whites were more supportive of then blacks. I can assure you that this is not a Civil Rights Issue, and I strongly believe that calling marijuana a Civil Rights Issue is demeaning.

To be clear: I am opposed to the legalization of marijuana. I am in favor of decriminalization. I believe that any decriminalization (or legalization) bill should include a provision that addresses marijuana arrest records and provides for the release of prisoners who are solely incarcerated for marijuana use or possession, as well as adjusts the sentences of those who got longer sentences because of any historical marijuana convictions. If we lose and recreational marijuana is legalized in NJ, I beg of you to force municipalities to opt-in to growing, producing and selling it rather than make it an opt-out law where it immediately becomes legal in all 565 municipalities.

I really want to thank you all for your service to NJ and for holding these hearings. Thank you so much for patiently allowing me to testify. I am happy to answer any questions now or in the future.

My friend and colleague Eric Arauz died on March 24, 2018. I have been mourning and celebrating him. Since his death, I’ve written and posted photos of him everyday. I have professionally helped people with grieving for 15 years, and the best advice I offer them is to write about their dearly departed. I’ve followed my own advice and publicly shared my writing with others with the goal of helping them process Eric’s death. A few of the pieces that I have shared on Facebook were written by others, and when combined with my writing they paint a well-rounded portrait of that exceptional man. I want to provide a series of other perspectives with this collection of writings by my current seniors.

I have taught the final senior seminar (475) at the Rutgers School of Social Work since the spring of 2012. Starting in 2013, I have assigned Eric’s An American’s Resurrection to every section of that course. This photograph of my Rutgers seniors was taken on 4/11/18. Eric spoke to them on 2/28/18 (if you would like to hear the 80 minute discussion he had with the class, email me). They had just finished his book and they had no idea that I knew him or that he was coming to class. Eric and I always enjoyed watching their faces as they realized who was in the classroom with them.

The last time I saw Eric was four days before he died. He dropped of my students’ papers while I was working on my lawn (he spoke to my class while I was in Africa). We chatted very briefly, as he said he was in a rush. I did not begin to grade the papers until after he died. It took me a few weeks to get through them, as their reactions moved me and helped me celebrate Eric’s life.

I’ve distilled down the highlights of my students’ papers to share with you.

1) There is a great deal of stigma that addicts and individuals with mental disorders face, and their experiences are often not heard. Arauz is able to explain both of these dire issues in a clear way that spreads awareness on the dangerous consequences that can occur when people do not accept their conditions. He teaches readers that they should be empathetic and compassionate towards addicts and individuals with mental health issues. Therapist can play a key role in motivating these individuals to reshape their lives and seek intervention.

2) By recounting his journey with addiction and mental illness, Arauz exposes the reader to the vulnerable, and often ignored, population of veterans. Painted and masked by the brush of Uncle Same, Arauz exposes the myth of the invincibility by illustrating the struggles of veterans battling inner demons.

3) This book expresses the hells of the mental health system. Though without the maximum security VA mental hospital, his resurrection may not have been possible. The side-effects of the medication caused physical weakness, blood stained teeth, dry mouth and a loss of his sense of self.

4) A crucial difference between many of the staff members and his saviors was that the Virgils talked to Eric, asked him questions, and valued his presence even when he wasn’t able to respond.

5) Reading his story prepares future social workers and enhances traits of empathy and avoiding judgement.

6) With his own story written with conviction and honesty, he was able to give meaningful suggestions on what he believed the population of people with mental illness and those struggling with addiction genuinely need.

7) Arauz concludes for himself and the reader that personal connection is vital to a sense of self and recovery. Effective mental health treatment must incorporate, as a priority, personal relationships and a sense of community.

8) There may not have been a single chapter in the book that Eric does not talk about Bud, his mom, his sisters, or his wife.

9) Throughout the book there are many relevant themes and topics that relate directly to this course. The main themes of the book, which include years of suffering from child abuse, his battle with mental illness and addiction, and the stigma and treatment for his mental illness, resemble topics that were examined in this class.

10) Before enrolling in classes at Rutgers, Arauz’s future was uncertain. As he explains though, “…college, in general, is a great place to rebuild your life, to become self-aware…” (234). Arauz had a blank slate in front of him and took advantage of the opportunity.

These aren’t just enthusiastic readers, but burgeoning social workers who are going to be working with people that have similar diagnoses and problems as Eric. During his talk with my students, Eric said, “Without the book my story dies with me.” His experiences and teachings have touched and influenced tens of thousands and will continue to do so. I will assign Eric’s book for the rest of my teaching career and thus will ensure that his legacy and lessons thrive.

My name is Honeyah. I am currently a junior at Rutgers and I major in social work. I had Professor Greenagel for a public policy course last fall. He asked me to write about my experiences for his website.

My family moved to an upper middle class town in Central NJ when I was in second grade. It was easy for my sister and I to make friends. We knew most of the kids we went to school with and felt comfortable going to the usual hangouts within our community. On most days after school, kids from my elementary school would gather at the local park  to play tennis or basketball.

When I entered the sixth grade, the primary hangout moved from the park to the mall. Most of us dressed head to toe in either Hollister or Abercrombie; I jumped on that fashion trend. Like other girls my age, I also wore silly bands on our wrists and watched “Gossip Girl” religiously. In high school, most of us became obsessed with social media such as Instagram, Snapchat and Facebook (I was up to date on all the different platforms and apps).

There was a clear divide of students who prioritized their grades with those whom prioritized partying (I numbered among the former). Our school had a wonderfully positive and inclusive environment. Bullying was not really prevalent because of the significant diversity – no one really stood out or was considered a target. I was never bullied or made fun of throughout my time in elementary, middle and high school. I assume that this was because I was like other kids: I wore the same clothes, watched the same tv shows, and had the same social media accounts. Following trends made it seem as if I fit in with everyone else, however it was clear that I was and am different than most people living in the United States. This is due to the fact that I am a hijab (head covering) wearing Pakistani Muslim who was born and raised in America.

I started wearing a hijab in high school when I learned more about my religio and wanted to embrace it. Alhumdulillah (all praise to God), I was never bullied for this and had an overall positive experience in school because most of my classmates had known me for years and thought of me as Honeyah and not the “Muslim girl in the scarf.”

My experience at Rutgers has been positive. When President Trump announced the travel restrictions from the seven predominately Muslim nations early in 2017, there was a large protest at Rutgers. I was touched to see that most of the students who attended the march were not Muslim. There was a small counter protest – about ten Trump supporters came out holding signs anti-Muslim signs but they left after about half an hour. I feel welcome and safe at Rutgers.

——————————

My name is Iqra. I am Honeyah’s younger sister by two years. On January 20th, 2017, staff and students gathered around the televisions in our high school cafeteria to listen to President Trump’s inauguration speech. Many students clapped and cheered as the newly elected President spoke. Being a student in the same school district since kindergarten, I had grown accustomed to the way things worked in my district. After President Trump was elected, distinct changes started occurring in my school.

Although my hijab did make me an easy target for racist jokes, I was never really bullied for outwardly practicing my religion. During the last semester of my senior year, students who were previously quiet started openly uttering their anti-Muslim views to me. At one pep rally assembly (where students get together to support our sport teams), my classmates were shouting “Allahu Akbar” in a derogatory way. This was almost certainly done to make fun of the Muslim students in the bleachers.

Both the school newspaper and the local paper published stories about the bullying of Muslims at the high school, but they also detailed how we were not the only group that were being bullied. Many of the Jewish students were being targeted as well. Drawings of swastikas and Hitler, as well as comments directed at the Jewish students, were found on the desks at our high school. Although there were numerous other incidents, my school did little to alleviate the problem. Eventually, distraught parents and unhappy students, including myself, went to Board of Education meetings to express our disapproval and dismay of the way the school was handling the situation. Little was done.

I gave the Principal’s speech at graduation. The focus was on the importance of acceptance and diversity. Diversity is prevalent in the town I grew up in, which is a reason why many students in the school I attended were accepting of the differences among one another. However, it was unfortunate to note the change in the attitude and behavior of the students after Trump became President. I am now a Freshman at Rutgers and I have found that to be a very warm and safe environment.

I advocate on behalf and work in the addiction treatment industry. I do this despite that fact that very few programs are any good and most are horrendous. This is true for both in-patient and out-patient programs. They dress themselves up with fancy websites, glossy brochures, and friendly marketers. Back in the late 90s when I was a private first class (PFC) in the Army, Master Sergeant Spadoni occasionally told me that “You can’t polish a turd.”

I repeated this to one of my Rutgers students a half dozen years ago and he responded with, “Yeah, but you can roll it in glitter.” That is an apt description of the four most common marketing methods employed by treatment programs:

1. They have many photographs (maybe even videos) of their glimmering facilities.
2. They describe the extras they offer: gym memberships, yoga, equine therapy, whirl pools, sauna, music studios, and other shiny add-ons that sound impressive. Most of these offerings have little to no research to justify their presence in a treatment program but are there to jack up the costs (I’m pro-exercise, a huge fan of yoga, and can see the benefits of equine therapy, but they are just glitter if the clinical program isn’t solid).
3. They offer a heart-warming story about a successful client and/or provide quotes from happy parents and patients.
4. The owner or one of the head counselors or the marketer is in recovery, and they lead with that information to show that they “really understand” and “really care” and that this “isn’t about money.”

Over the last four years, I’ve written or edited a number of pieces that addressed a variety of the problems in the addiction treatment industry. You don’t need to read these to grasp the point of this article, but it will give you a much deeper understanding about my complaints.

1. Frank Jones and I wrote a piece about how insurance companies deny coverage to pay for treatment and how the industry uses it as an excuse to act badly.
2. Very few centers have a rigorous family program with a multi-family group. I’ve written about what multi-familly groups are and some basic advice for parents of young adults.
3. Andrew Walsh investigated the 1-800 numbers and the conman tactics that treatment programs use to lure clients. Mr. Walsh detailed how much attention he got with good insurance and how they quickly got off the phone if he didn’t.
4. Mr. Walsh wrote a piece about the lack of treatment beds for Medicaid patients. Substance abuse facilities are not interested in them. As a result, your chances of getting treatment depends upon your finances. It’s a true modern day civil rights issue.
5. The Florida model is the industry’s end-around move to get insurance to pay for seeming residential care when they reject it. The companies house clients a few blocks or miles from an intensive outpatient program (IOP) and shuttle them back and forth. In theory, it is a decent idea. The major problem is that the housing is not licensed or regulated. The staff often suffers from a lack of experience, education, training and supervision. I wrote a basic plan to address this.
6. Treatment centers brag about their CARF and Joint Commission certifications. These are non-government agencies that rate programs. Even terrible ones can get their approval, which makes the whole rating system virtually worthless.

Treatment program owners, directors, and marketers often call me or email me or try to connect with me on LinkedIn. I tell them I don’t really have clients to send them and that I am highly critical of the treatment industry. They respond that they have high standards too and push for meetings. Over the last few months, I’ve held court at Rutgers and had a number of colleagues and supervisees attend those meetings. We ask them a grueling set of questions and every single program has come up sorely lacking. Here are the three most important questions that you should ask:

1. Are all the therapists and workers supervised? How often do they get supervised? By whom? What are the supervisor’s credentials? What proof do you have of the supervisor’s expertise?
2. How much individual therapy do the patients get?
3. What data do you have to show the effectiveness of your program? Is it internally collected or do you have a neutral outsider do it? What metrics do you have to show how soon patients get a physical, visit the dentist and see a gynecologist? Do you measure stable housing and reduced involvement in the criminal justice system? What is the percentage that you help enroll in GED or vocational training or college courses? How many clients are set up in aftercare? How do you vet those aftercare programs?

Here is why those questions are important:

1. Substance abuse and mental health counseling are difficult to master and are quite draining. Staff needs to be well trained and supervised at least one hour a week (two hours is my base standard). This provides better care, reduces staff burnout, and results in fewer ethical problems.
2. Individual therapy is far more effective than group therapy, partly because most professionals that run group are not actually skilled in educating, room control, or handling a diverse set of people. Minimally, people should get one hour of therapy a week from a masters or doctorate level professional with a license (I’ll accept a masters level intern performing it if they are getting real supervision). The data is quite clear on this. Ideally, it is more than once a week.
3. Even the worst program has a success story. It doesn’t tell us anything about the quality of the program. Data does. Very very few have any kind of data.

Most programs have unsatisfactory answers to these three questions. They try to make up for it by rolling their shitty programs in glitter; hence the glossy brochures, glimmering facilities, touching stories of success, and assurances from owners/workers that are in recovery. All that glitters isn’t gold – in fact, it’s probably covering up a lot of shit.

_______________________________________________________________

This is from a brochure that was given to me by a marketer that visited us at the Rutgers Center of Alcohol Studies in January. We asked lots of questions, including the big three. I won’t go into what happened, because you could learn a lot by just calling them up and asking yourself. But their brochure had a statement in it that I haven’t come across before (Andrew Walsh pointed it out to me). The second and third lines celebrate the presence of a “12 Step guru” that helps the clients. It doesn’t state how much sobriety time the man has or if he has any education or credentials. I have never heard of anyone allowing themselves to be described as a 12-Step guru. The AA 12 and 12 book has a name for the guru types: bleeding deacons. From page 135: “At times, the A.A. landscape seems to be littered with bleeding forms.” In the same chapter, there is a stern warning against the professionalization of AA.

I am friends on Facebook with at least 32 people who have 20+ years of sobriety (I know a lot more than that though). None of them call themselves a guru or an AA expert. About a dozen of them work in the treatment field and do not advertise that they are in recovery; significantly, they have all been educated, trained, credentialed, and supervised (their expertise comes from that, not because they are in long-term recovery). Treatment programs continue to shock and amaze me.

John McCain has served in the Senate since 1987. He occupies the seat that used to belong to Barry Goldwater (a conservative who lost in a landslide in the Presidential election in 1964; Senator Goldwater would eventually repudiate a number of his ultra conservative policy stances from earlier in his life). Senator McCain is 81 years old and has been getting treatment for  brain cancer that was publicly announced in the summer of 2017. This piece is an appreciation for his service to the United States in both the Navy and Congress. A recent dual biography on the Bush Presidents is titled The Last Republicans, but that label fits Senator McCain much better (that said, even the latest Star Wars title shows that the “last anything” is probably hyperbole, except in cases like this or this).

John McCain was born in 1936. His father and grandfather were both four-star admirals in the Navy. Mr. McCain graduated from the Naval Academy in 1958 and became an aviator. He was shot down over Hanoi in October of 1967. His ejection from the plane broke both arms and his right leg. Those breaks were not properly set. During his captivity, he was tortured by the North Vietnamese, causing further injuries. Because of his family connections, he was offered an opportunity to be repatriated (swapped for other prisoners) before other Americans that were captured. Mr. McCain always refused such offers. His captors tried to break him, hanging him by his broken arms for hours (you can read about it in Robert Timberg’s The Nightingale’s Song). He was finally released in 1973. He was elected to the House of Representatives in 1982 and served two terms before successfully running for Senate.

In his masterful book on the 1996 Presidential Primaries and Election, The Losers, Michael Lewis met and fell for John McCain (to be clear, Lewis identifies as a liberal but deeply liked and admired the Senator anyway). The Senator was not running for President, but was serving as a surrogate for Senator Bob Dole. While Mr. McCain was imprisoned in the Hanoi Hilton, American anti-war protest speeches were broadcast into the prison cells in an effort to break the men. The leader of one of the protests was David Ifshin. In a story that wasn’t known until the Clinton Administration, Mr. Ifshin apologized to Senator McCain in 1986. During the 1992 campaign, Mr. Ifshin served as a legal counsel to Governor Clinton but did not immediately work in the administration. When Senator McCain learned that his Vietnam protests were holding up an appointment, he called an unprompted press conference to help Mr. Ifshin. Here is another telling passage by Mr. Lewis:

I visited him at his home in Phoenix and at his cabin in the Arizona desert. I came to know his wife and children. But — and here was the amazing thing — simply by being weirdly insistent on hanging around I came across all sorts of little habits he had that said something about who the man was. McCain was clearly ambitious as they come; even then you could see he was talking himself into running for president. Yet he had developed a trick to ward off the ill-effects of ambition on his soul: he did many things that were of no possible benefit to his political career. For instance, he made a habit, once a week, at the crack of dawn, of visiting the hospital bed of retired Arizona congressman Mo Udall. Udall, who was dying of Parkinson’s disease, was unaware he had a visitor. When he’d been in power everyone wanted to see him; now no one but McCain came to visit. There was no one to witness McCain’s gesture. The visit was McCain’s way of paying tribute to a man he had admired, and who had guided him early in his career. Since Udall no longer responded to visitors, the visits were of no possible benefit to him. McCain did it for himself: the trips were a tool for reminding himself of the transience of political success. (304)

Senator McCain would run for President in 2000, but he was defeated by Governor Bush in the Republican primary. Senator McCain had upset Governor Bush by 19 points in New Hampshire and had momentum heading into the South Carolina primary. Karl Rove convinced George W. Bush to “take the gloves off” and Mr. Rove engineered a series of false and disgusting attacks that would ultimately help Bush win South Carolina and the nomination. One was that his wife Cindy was a drug addict (she had abused pain killers after a surgery in 1994). Another was that McCain had slept with prostitutes and given his wife STDs. Yet another was that he was turned in the Hanoi Hilton and was now mentally ill. The coup de grace was that he had a Negro child out of wedlock. This played into the racism that strongly existed (and still exists) in South Carolina and was a twisted distortion of a wonderful story: the McCains adopted a Bangladeshi orphan with a cleft palet named Bridget in 1991 after Cindy McCain met her during a relief mission. I am extremely proud that I voted for Senator McCain in the 2000 Republican primary.

Senator McCain championed campaign-finance reform and worked across the aisle with Russ Feingold in 2002. During the next few years, he rebelled less against the Republican establishment and sometimes went against earlier positions. He did this in an effort to shore up his base to run for President in 2008. His running mate was Sarah Palin, an unmitigated disaster that he thrust upon the nation when his advisors discouraged him from naming Senator Lieberman (a conservative Democrat) as his running mate. Senator McCain has never spoken poorly of her in public, but Steve Schmidt, his campaign manager, has voiced both his opinion on Governor Palin and where the GOP has been headed in recent years. In the general election that year, I voted for the other guy. Over the next few years, Mr. McCain would return to his maverick ways.

Fast forward to June of 2015. Donald Trump said this about Senator McCain, “He’s not a war hero. He was a war hero because he was captured. I like people who weren’t captured.” In previous elections, such a statement about a decorated veteran would have been disqualifying. More so than anything else in 2015, that moment was the one that signaled shift in the Republican party and its voters. Numerous people that claim to support the military have twisted themselves with irrational verbal gymnastics in order to justify Mr. Trump’s anti-veteran statement about Senator McCain.

Just after his cancer diagnosis and treatment, the Republicans attempted to repeal the Affordable Care Act. Senator McCain ripped the Republicans for their terrible legislative process (no hearings, fast votes) and flew back to Washington to cast his vote. You can read about it here, but this video and picture say it all.

This December, there have been a number of moving moments and tributes. Vice President Biden appeared on The View, co-hosted by Meghan McCain. He was discussing his book about his son Beau, who passed away in 2015 from a similar form of brain cancer. Ms. McCain understandably was teary, and Mr. Biden moved over to console her. He said, “One of the things that gave Beau courage, my word, was John. You may remember when you were a little kid, your dad took care of my Beau. And Beau talked about your dad’s courage — not about illness, but about his courage.”

If you pay attention, you’ll see this over and over again in regards to Senator McCain. Political opponents having gracious and moving words to say on his behalf. Regardless of their fields, anyone who can garner such respect out of so many opponents is truly a special individual.

A few days later, Fred Hiatt, the Editorial Page Editor of the Washington Post wrote an opinion piece on Senator McCain and his role in U.S. global leadership, something that is very much lacking in the present:

Like many people, I’ve been alternately cheered and disappointed by McCain’s stances on domestic matters over the years — admiring when he helped save Obamacare a few months ago, disappointed when he went along with the Republican tax-cut bill this month. But McCain has never wavered in his support for democracy and human rights, and in his conviction that the United States needs to provide moral support to those who fight for freedom around the world. With President Trump often expressing more admiration for dictators than for democratic leaders, McCain’s advocacy has become lonelier — and more essential.

But he does not disguise how worried he is by the deeper currents that recall to him the darker movements of the 1930s: the nativism, the assaults on freedom of the press and the rule of law, the blaming of foreign competition for all ills, the rise of extremism. “I worry about the polarization that’s going on here, I really do,” McCain said. “The terms of the debate is what is really disappointing. The other day I was flipping the channels, and I saw Bannon just beating the crap out of Romney,” he continued, alluding to Bannon’s attacks on Romney for his service as a Mormon missionary in France during the Vietnam War. McCain, who more than did his part in Vietnam, made clear he didn’t share Bannon’s view. “I didn’t think there was anything wrong with serving your church. I had no idea that was a crime.”

Two days before Christmas, Larry Fitzgerald, a potential Hall of Fame wide receiver for the Arizona Cardinals, wrote a piece about Senator McCain for Sports Illustrated. Of the Senator, Mr. Fitzgerald said, “One of the reasons I admire Senator McCain is that he doesn’t always just vote his party. He votes his conscience, and that can seem like a rare quality these days.” The article is decent, though not nearly as good as the other ones I’ve referenced. It is further testimony to yet another impressive relationship that Mr. McCain developed.

I met Senator John McCain on Memorial Day in 2009. My ex-wife and I traveled to Arizona for the week around my 33rd birthday. We hiked the Grand Canyon (almost to the bottom), biked around Sedona, walked around Flagstaff, took in the Meteor Crater, and attended an Arizona Diamondback game in our quest to visit every MLB park (I’ve done them all and April is more than 3/4 through). Before the game started, I noticed Senator McCain sitting alone. No one had seen him. I felt conflicted. I like to give people their privacy (I sat next to Philip Seymour Hoffman at a steakhouse in NYC once and convinced April to leave him alone, despite the fact that Mr. Hoffman uncannily looked like my longest serving college roommate). Even back in 2009, after having just recently voted against him, I wanted to go over and shake Senator McCain’s hand. I went up to him and told him that I voted for him in the 2000 primary and that I appreciated his service in the Navy and his work in the Senate. I told him that I didn’t agree with him on a lot of issues, but that I had no question about his integrity. He was neither warm nor pleasant, but shook my hand and agreed to pose for the photo that begins this article. After our photo, a bunch of other people realized that someone famous was down behind home plate and they began to line up. I mouthed “sorry” to him but he didn’t respond (he is also known for being difficult and cursing a lot). Before the game, he appeared on the field with his wife and children, one of whom (Jack) was currently serving as a Naval Aviator. Mr. McCain stayed for most of the game and shook hands and signed programs for people that approached him. He never shooed them away.