How To Address the Opioid Crisis Without Gunboat Diplomacy

 

The United States is currently suffering through the self-inflicted crisis of electing an authoritarian administration.  Civil, legal, international, and diplomatic standards are routinely ignored and there seems to be no clear overriding strategy other than promulgating the autocracy.   271,000 government employees were fired, many leading experts in fields that ran counter to the autocratic myths, but most were loyal career government employees dedicated to serve the public.  USAID – a government agency providing technical assistance and medical care in the developing world since 1961 was officially shut down by the Trump administration in 2025.  USAID was credited with saving 92 million lives over 20 years and there is currently a tracker in place that estimates how many people will die as a result of the closure.  It is clear the Trump administration is not afraid to be directly responsible for the deaths of tens of thousands if not millions of people.  It might fit their American first narrative if there was any possible benefit to Americans.  Their political calculus apparently ignores any goodwill effects of helping people and a national image unlike the usual totalitarian regimes.

Trump’s version of the War on Drugs, is smaller in scale but probably much more deadly.  Trump began sinking boats in the Caribbean and the Pacific Ocean that he alleged were carrying drugs in September 2025.  Since then, 35 vessels were struck or sunk killing 123 people (1).  There is ongoing debate that this is not standard drug interdiction where drug smugglers are stopped by the Coast Guard, arrested, and stand trial.  This is unlawful killing of suspected drug smugglers where the public is supposed to accept that the alleged intelligence about whether they were smuggling drugs is accurate.  Given this administration’s honesty track record there is no way that should be accepted at face value.  The Coast Guard’s own statistics suggests that 25% of the vessels they board for the same reason are not carrying drugs. Even if they were this is essentially executing people without due process for what are non-capital crimes in the US.

In addition to the strikes that are seen as criminal there have been 2 incidents suggesting additional war crimes.  In the first, survivors of the first strike were killed while they were swimming in the water.  In the second, a strike was made by a plane disguised as a civilian plane.  According to the Geneva Convention it is a war crime to feign protected status and then attempt to kill, capture, or injure an adversary.  This is known as perfidy and it is accepted by the US.  Like most activity from this administration there appears to be no clear rationale for all this activity and despite the outcry over potential war crimes – the actions continue unabated.

I had plenty of experience teaching diverse groups of students about the opioid epidemic from about 2008 to 2020.   Overdose deaths were a proxy for the epidemic.  The initial part of that curve was due to excessive prescribing that was associated with a pain as the fifth vital sign initiative.  There were excessive and escalating prescriptions for the treatment of chronic pain.  In many cases there were diversions of these drug supplies for non-prescription use.  In some cases, there were pill mills that specialized in writing opioid prescriptions in great numbers.  They resembled medical practices from the turn of the 20^th century that maintained people in addiction rather than treating any specific medical problems. As more prescription opioids were diverted it was more cost effective to purchase heroin and that was the first significant change in consumed opioid composition.  By 2014 synthetic opioids (fentanyl and carfentanyl)  were introduced into this landscape.  They had much higher potency than the usual prescription opioids and that led to more drug overdoses.  Countermeasures were introduced including intranasal naloxone and fentanyl test kits.  These are effective measures if available but there is some misunderstanding by the public, who sees opioid users as risk averse.  They are not risk averse but both countermeasures are useful in saving lives.  The most effective life saving measure is MOUD or medication for opioid use disorder including buprenorphine, methadone, and naltrexone.

That brings me to a paper on the sudden reduction in overdose deaths beginning in mid-2023 and extending into 2025 in both the US and Canada.  During that time the overdose death rates dropped by 30%(3).  The graph of that reduction is shown below.  The data is a combination of confirmed data by the CDC and provisional counts and projections by NCHS for the last two years.  It is very similar to the graphs generated by the authors in their report.

 

 The authors used a novel approach to investigate the idea that supply shock accounts for the decrease in overdose deaths.  During treatment it is common for people using non-prescription controlled substances to report shortages and changes in the drug supply as well as price changes to their treatment providers.  The authors used the number of drug seizures and opioid concentration estimates of those seizures to estimate fentanyl shortages.  They also searched a popular social media site (Reddit) for any mention of the term fentanyl or a reasonable facsimile and drought or shortage or a facsimile.  The Reddit data was compromised from January to July of 2024 by moderation on the basis that these posts about fentanyl shortages violated terms of use.

Both groups of indicators of decreased drug supply (drug seizures and concentration and social media posts indicating a drug shortage) correlated with a drop in drug overdose deaths.  By the end of 2024 the opioid overdose death rates and concentrations has fallen by about 30% (see graph).  The original paper plots both fentanyl concentration in pills and powders as well as death rates).

What caused these drops?  The authors suggest several possibilities.  First, China acted against the manufacture and sale of fentanyl and the precursors starting in late 2023. That included online platforms.  There was a meeting between President Biden and Xi in November 2023 that focused on law enforcement cooperation in this area.  The authors suggest this is a low-cost opportunity for China to get leverage in negotiations with the US. Second, US drug interventions in Mexico may have reduced the supply, but the authors point out that the DEA would have paradoxically claimed no credit in their reporting but did credit the lack of precursors from China.  These factors are strong arguments for supply chain disruption as a cause of the drop in opioid overdose deaths.  

Could this be a generational effect?  From a demographic standpoint, the 25-plus year opioid epidemic represents an entire generation.  The succeeding generation has seen the toll of these drugs as both mortality and morbidity.  The younger generation has been noted to have some sober initiatives and they are consuming less alcohol than their predecessors. Is it possible that this subcultural movement is extended to other intoxicants?  The 0-25 year age group typically has the lowest number of overdose deaths and by itself is unlikely to account for the decrease.

The authors suggest three implications of their paper.  First, that dealer level interdiction on the street may not be necessary to reduce drug trafficking.  Presumably that intervention has been constant over the course of the recorded data and it has had minimal impact. It is also high risk and places certain demographic groups at higher risk.  Second, this may be a transient effect.  Drug traffickers can adapt as noted by the difference in how fentanyl makes it to the streets in the US compared to Canada.  Finally, if this was in fact the effect of diplomacy those efforts should be increased rather than decreased. India is a source of precursors and in some cases direct to consumer shipments of controlled substances.  Diplomatic efforts could yield further disruptions in the supply chain and less problems with opioids on the streets of the US.       

There is now a fourth implication and that is that gunboat diplomacy and the questionable use of the US military against boats suspected of carrying drugs is unnecessary.  It also highlights that the Executive order to declare war on cartels was also unnecessary.  There was a substantial drop in overdose deaths before any of these measures was employed and it may be an indication that diplomacy is the way forward.  If I was a conspiracy theorist, I would suggest that Trump wants to get credit for the drop in fentanyl trafficking that occurred in the Biden administration.  According to the authors of this paper we do not know if this is a long-term trend or not. Since most fentanyl trafficking does not originate in Venezuela or the countries surrounding the targeted areas it is unlikely to have a big effect.  

That 30% decrease in mortality cannot be ignored and a closer examination of the Biden negotiations is warranted.

 

 

 

George Dawson, MD, DFAPA

References:

1:  Watson B, Peniston B.  The D Brief: ‘Perfidy’ in boat strike?; Pentagon’s new AI plan; Venezuela’s broken air defenses; Quantum space cameras; And a bit more.  Defense One.  January 13, 2026.  https://www.defenseone.com/threats/2026/01/the-d-brief-january-13-2026/410643/

2:  Tait R. Killing of survivors sparks outrage – but entire US ‘drug boat’ war is legally shaky.  The Guardian.  December 4, 2025.  https://www.theguardian.com/us-news/2025/dec/04/venezuela-boat-strikes-legality-hegseth

3:  Vangelov K, Humphreys K, Caulkins JP, Pollack H, Pardo B, Reuter P. Did the illicit fentanyl trade experience a supply shock? Science. 2026 Jan 8;391(6781):134-136. doi: 10.1126/science.aea6130. Epub 2026 Jan 8. PMID: 41505547.

Graphics:

1:  Lead graphic is from the CDC and is in the public domain: https://www.cdc.gov/overdose-prevention/about/understanding-the-opioid-overdose-epidemic.html

2:  The graph of fatal overdose deaths per year shows the number of fatal opioid overdose deaths in the United States from 2000 to 2025.  The data from 2000 to 2023 consists of final and reported figures from the Centers for Disease Control and Prevention (CDC) and the National Institute on Drug Abuse (NIDA). The figures for 2024 and 2025 are based on provisional counts and projections released by the CDC's National Center for Health Statistics (NCHS) as of January 2026.

3:  Graphics 2 and 3 were designed with the assistance of Google Gemini.

The Problems With AI Are More Readily Apparent

 

Note:  This essay is written by an old human brain that was writing essays and poetry decades before there was an Internet. No AI was used to create this essay.

Artificial Intelligence (AI) hype permeates every aspect of modern life.  We see daily predictions of what group of workers will be replaced and how AI is going to cure every human disease. It is no accident that the main promoters of AI will make significant profits from it.  Vast amounts of money are being invested and gambled on AI on Wall Street.  Educators are concerned that students are using it to write the essays that took us hours or days to write in college – in just a few minutes.  That application leads to the obvious questions about what will be the end product of college if all the serious, critical, and creative thought has been relegated to a machine. 

Apart from sheer data scraping and synthesis of what amounts to search inquires - AI seems to be imbued with magical qualities that probably do not exist. It is like the science fiction of the 20^th century – alien beings superior to humans in every way because they lack that well know weakness – emotion.  If only we had a purely rational process life would be much better.  The current promoters tend to describe this collective AI as making life better for all of us and minimize any risks.  The suggested risks also come from the sci-fi genre in the form of Terminator type movies where the machines decide it is in their best interest to eliminate humans and run the planet on their own. There are the usual failed programs to preserve human life at all costs or to destroy humans only if they are carrying weapons. 

But AI thought experiments do not require even that level of complexity to create massive problems.  Consider Bostrom’s well known example of a paper clip making machine run by AI (1).  In that example PaperClip AI is charged with the task of maximizing paperclip production.  In a case of infrastructure profusion it “proceeds by converting the Earth and increasingly large chunks of the observable universe into paperclips.”   He gives several reasons why obvious fixes like setting a production limit or a production interval would probably not work and leads to infrastructure profusion that would be catastrophic.  The current limitation on this kind of AI is that it does not have control over acquiring all these resources.  It also lacks the ability to perceive how correct production in an fully autonomous mode.   Bostrom also adds characteristics to the AI – like motivation and reinforcement that seem to go beyond the usual conceptualizations.  Where would they come from?  If we are not thinking about programmed algorithms what kind of intelligence has its own built-in reinforcement and motivation schedule independent of the environment?  After all – the task of producing just enough paperclips without consuming all of the resources on the planet is an easy enough task for a human manager to accomplish.  Bostrom suggests that it is an intuitive task for humans but not so much for machines.

A couple of events came to my attention in the past week that make the limitations of current AI even more obvious – especially contrasted with the hype.  The first is the case of a high-profile celebrity who has lodged a complaint against the X(formerly Twitter) AI called Grok.  In it, she points out that the AI has been generating nude or semi-nude photos of her adult and teen-age photos. I heard an interview where she mentions that this practice is widespread and that other women have contacted her about the same problem.  This practice is in direct contrast with the X site use policy saying that users doing this will be banned and referred for prosecution. She has not been successful in getting the photos stopped and removed.

The second event was a Bill Gates clip where he points out that what he considers a sensitive measure of progress – mortality in children less than 5 years of age - has taken a turn for the worse.  He predicts the world descending into a Dark Age if we are not able to reverse this change. That new release comes in the context of Gates predicting that AI will replace physicians, teachers, and most humans in the workplace in the next 10 years.  Of course he was promoting a book at the time.  In that same clip he was optimistic about the effects of AI on health and the climate despite the massive toll that AI creates on power generating resources to the point that some companies are building their own municipal sized power plants. 

What are the obvious disconnects in these cases?  In the first, AI clearly has no inherent moral decision making at this point.  That function is still relegated to humans and given what is being described here that is far from perfect.  In this case the complainant has some knowledge of the social media industry and said that she thought that any engineer could correct this problem quickly.  I am not a computer engineer so I am speculating that would take a restrictive or algorithmic program. But what about the true deficit here?  It could easily be seen as a basic deficit in empathy and an inability to apply moral judgment and its determinants to what are basic human questions.  Should anyone be displaying nude photos of you without your consent?  Should identified nude photos of children ever be displayed?  AI in its current iteration on X is clearly not able to answer these questions in an acceptable way and act accordingly.

The second contrast is only slightly more subtle. Conflict of interest is obvious but Gates seems to not recognize his described descent into the Dark Ages based on an increasing death rate in children 5 years of age and younger depends almost entirely on human decision making.   It runs counter to the decades of medical human decision making that he suggests will be replaced. Basic inexpensive life-saving medical care has been eliminated by the Trump administration.  This has led to the predictions that hundreds of thousands if not millions of people will die as a direct result. Is AI going to replace politicians?  What would be the result if it did?  Cancelling all these humanitarian programs is a more complicated decision than not publishing nude photos of non-consenting adults or any children.  It is a marginally rational ideological decision.  Is the AI of different politicians going to reflect their marginally rational ideology or are we supposed to trust this political decision to a machine with unknown biases or ideologies?  How will that AI decision making be optimized for moral and political decision making?  Will AI be able to shut down the longstanding human tendency to base decisions on power over morality?  If politicians allow AI to replace large numbers of workers, will it also be able to replace large numbers of politicians and managers?  It can easily be argued that the decisions of knowledge workers are more complex than that of managers.                                    

A key human factor is empathy and it requires emotional experience.  You get a hint of that in the best technical description of empathy I have seen from Sims (2):

“Empathy is achieved by precise, insightful, persistent, and knowledgeable questioning until the doctor is able to give an account of the patient’s subjective experience that the patient recognizes as his own… Throughout the process, success depends upon the capacity of the doctor as a human being to experience something like the internal experience of the other person, the patient: it is not an assessment that could be carried out by a microphone and a computer.  It depends absolutely upon the shared capacity of both the doctor and patient for human experience and feeling.”  (p. 3)

The basic problem that machines have is that they are not conscious at the most basic level.  They have no experience.  In consciousness research, early thinking was that a machine would be conscious if a human communicating with it experienced it like another human being.  That was called the Turing Test after the scientist who proposed it.  In the case of computerized chess – there was a time several years ago when the machine was experienced like it was making the chess moves of a human being.  The headlines asked “has the Turing Test been passed?” It turns out the test was far too easy.  There are after all a finite number of chess moves and plenty of data about the probabilities of each move made by top players. That can all be handled by number crunching.

What happens when it comes to real human decisions that require the experience?  And by experience I mean the event with all of the integrated emotions.  Is AI likely to recognize the horror of finding your nude photos on the Internet,  or scammers trying to blackmail you over a fictional event, or the severity of your anxiety from being harassed at work, or the devastating thoughts associated with genocide or nuclear war?  Machines have no conscious experience.  Without that experience how can we expect a machine to understand why the sexual exploitation of children and adults is immoral, wrong, or even anxiety producing?

It is also naïve to think that AI will produce ideal decisions.  Today’s iteration may be the crudest form but everyone is aware of the hallucinations. The more correct term from psychiatry is confabulation or making things up as a response to a specific question.  When you consider that today’s AI is mostly a more sophisticated search engine there really is no reason for it.  As an example, I have asked for an academic reference in a certain citation style and will get it.  When I research that reference – I find that it does not exist.  I have had to expend considerable time finding the original journal and looking for the reference in that edition to confirm it is non-existent.  Explanations for these phenomena extend to poor data quality, poor models, bad prompts, and flawed design.  The problem is acknowledged and many AI sites warn about the hallucinations.  A more subtle problem at this point is how AI will be manipulated by whatever business, government, or political body that controls it. That problem was pointed out in a book written about a decade ago (3) illustrating how algorithms applied to individual data can reinforce human biases about race and poverty and promote inequality. I have seen no good explanations about why AI would be any different and in fact it probably makes the financial system less secure.

As I keep posting about how your brain and mind work – please keep in mind it is a very sophisticated and complex process. It is much more than looking at every available reference and synthesizing an answer.  There are the required experiential, emotional, cognitive, value-based, and moral components.  Superintelligence these days implies that at some point machines will always have the correct and best answer.  That certainly does not exist now and I have a question about whether it will in the future. It is a good time to take a more realistic view of AI and construct some guardrails.     

      

George Dawson, MD, DFAPA

 

 

References:

1:  Bostrom N.  Superintelligence: Paths, Dangers, Strategies.  Oxford, England: Oxford University Press, 2014: 150-152. 

2:  Sims A.  Symptoms in the Mind: An Introduction to Descriptive Pathology.  London, England: Elsevier Limited, 2003: 3.

3:  O’Neil C.  Weapons of Math Destruction. New York City, USA; Crown Books, 2016

 

Threads and Why Post-Apocalyptic Art Is Not A Deterrent To An Apocalypse

 

I watch a lot of post-apocalyptic television series and movies.  In fact, I watch so much of it that Netflix categorizes my favorite genre as “Extreme Survival In Twisted Worlds”.  That is an actual category.  I have also read the survivalist literature and literature on extreme survival shelters. You can call a company and have one delivered that they will sink in your back yard.  Some include sophisticated features like cooling your shelter exhaust so it cannot be picked up by infrared detectors.  If you have several million dollars to spend you can get a deluxe survival condo located in an old missile silo.  That assumes that you have adequate warning of the impending apocalypse to travel there. The standard post-apocalyptic fiction seems to assume that there will be significant numbers of survivors, that they will be well prepared, and the only worries will be ruthless leaders and defending yourself and your resources from them. The only exception I can think of is the movie version of Cormac McCarthy’s The Road, that is focused on the grim post-apocalyptic existence of a man and his son. But even in that story there was a relatively happy ending.

A week ago, I was watching clips from Jason Pargin.  He is an author who offers insightful sociocultural commentary on various topics.  The one I saw was about this topic in general. He observed that most post-apocalyptic movies and television series are inhabited by attractive people who don’t seem to be in that much distress.  They all seem to have survival skills and are getting along famously.  The only exception seems to be when they need to use their survival skills in physical confrontations with roving hordes of zombies or rival camps trying to steal their food or personnel.  Even then they prevail.  He suggested the 1985 film Threads as a counterpoint.  The movie is about a nuclear attack on the United Kingdom.  His point was that this was probably a much more accurate depiction of post-apocalyptic survival and it is grim – even decades after the event.  

On that recommendation I was able to find the movie on a streaming service and watched it from beginning to end.  It starts off in a couple of cities in the UK, and we focus on a few familiar people and their routine.  There is background news that the US has started some kind of military operation in Iraq and Russia is starting to respond.  There are some antiwar protests about it in the UK.  Eventually it escalates to a single nuclear device attack from Russia responded to by a single nuclear weapon from the US.  Tensions increase and eventually a high-altitude nuclear weapon is exploded over the UK as an electromagnetic pulse (EMP) that knocks out communication. That is followed by nuclear attacks on major cities.  We witness the mushroom cloud, anxiety, and panic.  There are a massive number of deaths from the initial blast and burn injuries.  There are an equal number of people exposed to radiation and injuries that nobody can treat.  There are no medical systems left that can treat or triage the massive number of injured.  That should be intuitive for anyone who lived through the COVID epidemic because at one point the mass casualty systems in many countries were overwhelmed by that respiratory infection.  By comparison a nuclear attack in any major city would produce hundreds of thousands to millions of injuries.  Most of these people would die without care. 

Removal of dead bodies was another problem.  There was insufficient manpower and fuel left to bury or burn them. There were scenes of bodies everywhere.  They were burned from radiation and decomposing.  Sanitation was a problem with no clean water, sewage, or garbage disposal.  Rats and dogs were everywhere spreading contamination and disease.  People had to seek shelter in partially demolished buildings that could not protect them from radioactive dust.  In the days following the blast more people came down with and died from radiation poisoning.  At one point the public officials who were supposed to be managing the disaster just gave up.  The landscape was littered with survivors wearing dirty clothing, shivering in the cold, with nothing to eat or drink.  Diseases that has been gone for centuries due to improved sanitation were back and killing survivors.

The confrontations depicted in the usual post-apocalyptic movies were still there but on a much smaller scale.  It was no longer village versus village. It was two people against one and all three significantly debilitated.  As the nuclear winter set in from debris blown into the atmosphere – there was some cooperation manually harvesting crops that were still in the ground.  It was a slow process due to the poor physical health of the survivors, a lack of food, and the lack of operable farm equipment.  Once those sparse crops were harvested there was not much hope for a planting season.

Threads does highlights at several intervals after the nuclear attack. About 20 years after the attack, they estimate that there are about 1.0 - 1.5 million people left in the UK or about the number that were there in Medieval times.  In 1985, there were 56.6 million people in the UK.

Threads accurately depicts the catastrophic changes that are likely to occur after a nuclear war.  The imagery in the film is much grimmer than I am describing in this essay. I found the final scene so gruesome that I am not mentioning it here. I don’t think it is necessarily important to watch it all.  It does not take much imagination to think about what will happen if suddenly the power goes out, municipal safe water systems shut down, and you no longer have a safe food supply or medical care.  More importantly – you no longer have the hope that any of these systems will ever be restored.  One of my concerns has always been – what happens to the people who are taking life saving medication every day for chronic problems.  What happens to the millions on CPAP for sleep apnea? Most of them will encounter very serious problems in the next 1-3 months and that assumes they were able to save their current supply of medicine. 

How does Threads compare to other films in this genre?  The closest approximation is probably The Day After a 1983 American movie that depicts similar levels of mayhem and destruction but alludes to the severity of the destruction at the end saying an actual attack would be much worse than what is depicted.  There is apparently is a 2025 film called Nuclear Winter that I cannot find anywhere.  There are several films that leave the results of a nuclear attack up to the imagination of the viewer.  Fail Safe is a classic film demonstrating the catastrophic consequences of mistakes with nuclear weapons but the viewer only experiences the anxiety and fear of the government and military officials.  The recent Kathyrn Bigelow film A House of Dynamite uses a similar approach while pointing out the folly of anti-missile systems.  There are scores of survival manuals available from government web sites that describe is detail what happens during a nuclear attack and what you need to protect yourself.  None of them say anything about what it will be like when all the services and infrastructure that you need every day to live is permanently gone. There are certainly glimpses of this from conventional weapons.  The devastation in Palestine is a recent example.  But even the horror of what happened in Palestine seems to be minimized and sanitized on a daily basis as if it can be argued away.

The scariest prospect of living in the 21^st century is that there are no peace movements anymore.  The only realistic prevention strategy is to maintain the peace and international relationships and there are few people who talk realistically about that.  All the current world leaders seem poorly equipped for that task.  Many seem to adhere to the Athenian precedent from 415 BC when they ignored an appeal from the Island of Melos based on their neutrality.  Instead, they attacked and massacred all the men and enslaved the women and children.  In today’s world we see the dynamic of power over morality being played out on a regular basis.  A related issue is the people in power are old men with questionable values and motivations. They have no stake in the future and the immediate goals of many are self-enrichment and fictional legacies.  Many of them are convicted criminals or have been charged with war crimes.  Many clearly have no interest in averting a climate apocalypse that will amplify the power over morality dynamic that has been present since prehistoric times. That is hardly a group I would assemble to prevent nuclear war. It seems that modern man has very advanced destructive technology being managed by the same primitive brain.

A significant portion of the general populations of each country do not seem much better. Instead of recognizing the sanctity of the universal struggle for existence and all that involves they tolerate megalomaniacs and, in many cases, seem to worship them.  In the United States, billionaires and an impending trillionaire are all considered geniuses and given privileges (most notably lower taxation rates) that the average citizen does not have.  The media hangs on the predictions of this elite group as if they are accurate. While this group profits from taxpayer supported subsidies and contracts, many of the people paying the taxes can’t afford food, housing, child care, or healthcare. In the US, the people and the Congress representing them seem powerless to change the recent more malignant course of power over morality. Much of that powerlessness comes from new trends in negating reality and science by politics and rhetoric.  It is easier to listen to an antivaxxer rant than contemplate a burned-up world with nothing left to sustain human life.  It is as if the zombie apocalypse has already happened and the people have become a slow-moving herd of the undead, watching their little screens while the world burns.  

None of this makes me very hopeful about the future. If you can deny that vaccines have been the single most significant mortality reducing medical achievement in history you can deny a nuclear winter with tens of millions of dead bodies littering the landscape.   

And remember a nuclear war is not "winnable" or containable based on geography.  It is much more likely the end of civilization and probably our species.  

 

George Dawson, MD, DFAPA

Graphic Credit:

Palestinian News & Information Agency (Wafa) in contract with APAimages, Public domain, via Wikimedia Commons.

Description: Damage in Gaza Strip during the October 2023 - 29

 https://commons.wikimedia.org/wiki/File:Damage_in_Gaza_Strip_during_the_October_2023_-_29.jpg

Creative Commons License CC B-Y SA 3.0 Attribution-ShareAlike 3.0 Unported

Stream of Consciousness - The Artistic Side

 

 

I have several posts on consciousness on this blog and consider myself to be a student of the phenomenon.  That is not easy because the experts even to this day will say at some point that we don’t really have a good definition.  They do tend to agree that conscious states differ and to use a famous example: “My experience of the color red is not your experience of the color red.”  If you think about that simple statement long enough it can mean a lot of things. 

Psychiatry has had an ambivalent relationship with consciousness.  Over the decades, psychiatry has gone from attempts to study psychopathology at the gross neurological level, to classifications based on clinical course, to phenomenological studies at the individual level and back to purely biological and psychological models.  Most of these models whether they are DSM based or psychotherapy model based – leave out the individual unique conscious state.  The closest we can probably come are phenomenologically based interviews relying on self report and psychotherapies that assume varying levels of conscious awareness.

From the humanities we have stream of consciousness art that reflects the artists spontaneous thoughts, feeling, memories, associations, and perceptions and translates that into an art form.  James Joyce and Virginia Wolfe are two writers famously associated with the term, but it can be found in any medium.  The poetry of Emily Dickinson and the abstract expressionism of Hans Hoffman color block style of painting are additional examples.  In current times, stream of consciousness is most likely described in movies and I will be focusing my comments on two that I recently watched – Railroad Dreams and The Life of Chuck.      

Before getting to the movies let me list a few properties of stream of consciousness.  First and foremost is non-linearity.  There is no clear beginning, middle, and end.  They are often juxtaposed or at times completely missing. This is the way most people think.  I used to get up in the morning, get in the car for the commute, and on the drive, I would be transported somewhere forward or back in time.  At times what I was thinking about was so intense, I did not recall much of the drive. There are currently debates about time – whether it exists or what the true function of time is.  One of the explanations is to create timelines for all our conscious experiences.  Stream of consciousness thought has been described as chaotic but I would see it as semi-chaotic since most of the associations should be familiar.  Exceptions might include sleep transitions with vivid random imagery, fantasies, and other imaginations.

Internal and external monologues are another feature.  At times the thought processes are accessed through an independent narrator.  The art translates these monologues into narrations, flashbacks, and voice overs. The viewer gets access to that part of consciousness that is typically hidden in real life with all the emotion, fantasy, and association.   Highly personal memories and fragments of memories come through. What the protagonist is focused on in the environment (visions, sounds, sensations) is presented.  The most famous image and connection to me occurs in Citizen Kane when at the end we learn that Rosebud was the name of Charles Foster Kane’s childhood sled and we see it being thrown into a fire as he is saying that name.

In movies if the images need to convey asynchrony - techniques are used to indicate the surrealism of dreams, spiritual, experiences, flashbacks, or memories. Historical context is used to reorient the viewer.  For example, in the Life of Chuck – 3 different actors play him at various stages in his life and as the film progresses we jump to progressively younger ages.  In Train Dreams, the director uses a bridge and narration as an anchor point to orient the viewer to where we are in the main characters life. Memorable people from many points in life are present in both films – just like the memorable people we all tend to think about in our everyday lives. Some of those memorable people become attached to other thoughts from different points in time.  In Train Dreams one of the main character’s co-workers drops dead as they are loading a horse-drawn wagon and the narrator says: “He died of a heart condition that if he was born 25 years later would have easily been discovered and cured…”  All part of how our conscious state recalls memories and modifies them based on our current experience.

In Train Dreams, Robert Granier is the central figure (played by Joel Edgerton).  It is all about his life in Idaho.  We see glimpse of his early life arriving by train in Idaho.  We see him encounter a man who has been fatally injured and is lying in the woods.  He gets that man water by filling a boot with water in a nearby stream.  Grainer is a loner leading an isolated existence until he meets Gladys Olding in church.  They marry and have a daughter Kate.  To provide for the family, Granier needs to work at a distance from home in the dangerous occupations of railroad construction and logging.  We witness his coworkers being killed by accidents, racists and vigilantes. We see his interactions with Gladys and Kate and the plans they make for the future. During his last season as a logger he comes home to find the area engulfed in a wildfire and Gladys and Kate are gone.  He is devastated and camps on the ashes of his old cabin, hoping they will reappear.  At times he hears the voices of Gladys and Kate in the woods.  His friend Ignatius Jack comes out to visit him when he is in bad shape.  Ignatius Jack shoots an elk and helps him rebuild his cabin. 

Along the way he sees flashbacks of incidents that occurred with his family and his coworkers.  Among them is Arn Peeples (played by William H. Macy). Arn is a philosopher of sorts and is focused on the connectedness of nature and how man’s existence plays out in unpredictable ways. We also witness an incident where Grainer encounters a logger who he worked with years before.  That logger is no longer doing physical work but attending to some of the machinery.  He has obvious memory problems and has difficulty tying his bootlaces.  Grainier assists him with the bootlaces and at that time makes the decision that he is done logging.

He returns home and eventually established a hauling business with two horses and a wagon.  It increases his social contact and in a most interesting encounter he meets Claire Thompsen (played by Kerry Condon) a bright, charismatic, and attractive forestry worker.  He discloses to her that he still hears the voices of his wife and daughter and asks if this makes him crazy. She normalizes the experience and says that she also lost her husband.  The have one more encounter when she invites him up to the top of her fire tower.  

At one-point Granier thinks his daughter Kate has returned as a teenager.  He finds her outside of his cabin lying on the ground.  He takes her in, notices that she has a broken leg and sets the leg.  In the morning the cabin door is open and she is gone without a trace.  The scene is surrealistic and the viewer is left with the impression that it did not happen.  He continues to live alone in the cabin.  The narration tells us that he dies alone in the cabin at age 80 while he is sleeping.  Before that we see him take the train to Spokane.  He witnesses the first moon landing on a storefront television and takes an airplane ride in a two-seater biplane.   We are left with the impression that he has finally seen meaning in what is portrayed as an isolated, tragic life.  We don’t have to look too hard to see that there were ups and downs.  That at times he was loved and cared for despite the horrific incidents and that his life was probably not that much different from ours. 

In The Life of Chuck is a drama based on a Steven King novella about the life of  Charles “Chuck” Krantz (played by Tom Hiddleston).  The movie is in three acts – in reverse chronological order.  The early view of Chuck in Act 3 is his image placed on multiple billboards and ads that all say: "Charles Krantz: 39 Great Years! Thanks, Chuck!".  The main character in this act is Marty Anderson (played by Chiwetel Ejiofor) – a middle school teacher.  He and his students are attending to what seems to be a climate change driven apocalypse.  His ex-wife calls and they discuss the end of the universe.  He travels to her house.  Before that both the Internet and television stations have failed except for the Charles Krantz ad   Along the way he encounters a young girl roller skating and an older man who is an undertaker.  The streetlights go out and Chuck’s image is projected onto the windows of surrounding houses and they do not know what to make of it.  The predominate affect is anxiety and fear.  Anderson finally reaches his ex-wife’s house.  They both fear that the end is near.  As they are watching the sky in the backyard – stars and planets start to disappear.  The scene is interleaved with Charles Krantz sick and dying in his hospital bed.  His wife and teenage son are there.  They are both tearful and his son says: “Only 39 years.”  His mother replies: “39 Great years.  Thanks Chuck!.”  Chuck dies and we are left pondering a tremendous metaphor. 

Act 2 begins with narrator Nick Offerman introducing the major players. A busker drummer sets up her drum kit and starts playing for donations from passersby.  It is a large intersection of several roads resembling an outdoor mall.  There is only foot traffic.  We learn that she dropped out of Julliard and has not told her parents yet.  We are introduced to a young woman who just received a break-up text from her boyfriend.  Finally, we see Chuck Kranz walking.  He is dressed in business attire.  We hear all about his business background, reason for being in the city, employer, and opinion of his fellow accountants.  We learn that he does not know about his condition and that he will be dead in 9 months.  No diagnosis is mentioned but from the description of the symptoms it is a severe progressive neurological problem.  In a critical piece of narration, we learn how Chuck will eventually assess the severe pain he endures with the disorder compared to what he will do that day in the street. 

As he walks across the area where the drummer is set up – they both make eye contact.   She thinks he will just walk by – but he puts his briefcase down and slowly breaks into dance following her beats.  She modifies the tempo and he continues to follow.  He notices a girl who has just broken up with her boyfriend is moving to the music and he pulls her out to dance.  A crowd gathers and it is a joyous scene – the crowd cheers them on. It is a vigorous dance number and at one point Chuck pauses and appears to be in pain.  He brushes it off and competes the dance – but declines to continue dancing.   The busker points out they were very successful and could probably do it for a living.  As they are debriefing after the scene, the busker asks Chuck why he stopped to dance and in a narrative highlight – we learn what he could have said but decided not to.   

Act 1 begins in Chuck’s childhood and we learn he lost his parents in an automobile accident.  He is living with his grandfather Albie and grandmother Sarah. His mother was pregnant at the time of the accident. Albie is an accountant and he has a drinking problem.  The house where they live has a turret with a padlock on the door and Chuck is forbidden to go in there.  His grandfather alludes to unusual things happening in there.  Through a series of comments, it seems that Albie claims he saw some distressing incidents that happened in the future while he was in that turret.     

There are two fantastic scenes in Act 1.  In the first, Chuck notices his grandmother is dancing to rock and roll music while she cooks. She is slender, athletic, and moves like a dancer.  She invites him to join her and she teaches him a lot about dancing.  He eventually joins a dance club in high school where he is a great dancer but his partner is significantly taller than he is.   The second scene is in English class.  Everyone is talking and moving.  We learn the young teacher is “a hippy dippyish woman with no command of discipline and would probably not last long in the public education system.”  She is trying to recite Walt Whitman’s Song of Myself.  Chuck appears to be the only student who is listening.  After the class disperses, Chuck approaches the downtrodden teacher and asks her what Walt Whitman means when he says: "I contain multitudes”.  She is invigorated by the question, approaches him and places her fingers on each side of his head and asks:  “What’s between my hands.?”  In the dialogue she points outs: “All the people you know.  Everything you see. The world. And as you age that universe gets bigger and more complex."  She encourages Chuck to “fill it.” 

In the last part of Act 1, we see glimpses of Chuck in the hospital.  We learn a glioblastoma is killing him and it is having effects on his cognition.  In this act we learn that his grandmother died suddenly in a store in her mid-60s. He inherited his grandparents’ home and eventually uses the proceeds to transition though college and then into the home where he moves after his marriage. In the final scene, he is in his late teens and has been given his grandfather’s possessions.  He uses the key to go into the turret.  While there he sees an image of himself in a hospital bed on a monitor.  The narrator makes the connection between what Chuck’s grandfather had seen in the room and that the waiting he referred to was the period that elapses between current time and when the image of the person’s death occurs.   

One of the most interesting aspects of stream of consciousness art is the impact on the observer.  You realize that the author is doing more than telling a story. In many ways it is a projective test for your own conscious experience.  How many times have you thought about dying?  How many times have you seen gross injustice and not corrected it – only to be haunted by it for the rest of your life?  How many people who you have encountered in your life do you think or dream about every day?  How many times have you lost important people who changed your life?  How big is the universe in your head?  The author’s associations are also your associations and they have significant emotional impact.   

The movie presents so much information about the players that even when they do not have an answer you can speculate about what it might be.  When Chuck starts dancing in the street, his initial hand movement is identical to the one his grandmother used when he first saw her dancing to rock and roll music in her kitchen.

There are no easy solutions presented in either movie.  Granier does not suddenly fall in love with the forestry worker and regain his martial bliss.  Chuck does not forget about his accounting job and become a busker.  His joyous, wonderful grandmother dies horribly in public.  Existence moves inexorably on.

I found both movies exhilarating – not just for the stream of consciousness approach but the stream of consciousness within the stream of consciousness.  I hope it will help people focus on the universe in our head and how it operates.

 

George Dawson, MD, DFAPA

 

1:  Train Dreams.  Santa Monica, California:  Black Bear Pictures; 2024.

2:  The Life of Chuck.  New York: FilmNation Entertainment; 2024

Graphic Credit:

Graphic:  Cosmic Calendar originally invented by Carl Sagan that maps the time of the Universe (13 billion years) onto a 12-month calendar.  Man and civilization does not appear until December 31st at 10:30 PM on this calendar.  This visualization is from physicist Emma Chapman and the Royal Society

The Royal Society, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons

Page URL: https://commons.wikimedia.org/wiki/File:Cosmic_Calendar_%E2%80%93_deep_time_and_cosmic_history_as_one_year_(time-lapse_and_annotations;_50MB_version).gif

This graphic is used twice in The Life of Chuck most importantly in scene 3 when Marty Anderson is trying to reassure his ex-wife that the end may be much longer than she expects.  

Enthusiasm Is A Plus...

 

 

I am currently writing an opinion piece on the medical skills necessary for current and future psychiatrists.  I designed a table and sent it to my favorite internist for feedback – my brother.  He was concerned about my level of intensity and wrote back:

“In an ideal world this sounds good. In my experience most psychiatrists do not have your zest for medical knowledge. Enthusiasm is hard to teach.”

His response got me thinking about the enthusiasm factor in academics and medicine.  Is it teachable or can it be transmitted some other way?  What about the issue of authenticity?  Is the observable really enthusiasm or is it something else appearing to be enthusiasm?  Competitiveness is probably a good example and it is legendary in pre-med and medical school courses.  There appear to be plenty of people who adhere to the old adage about escaping a bear attack: “I don’t have to be faster than the bear – I only have to be faster than you.”  When I was in med school these people were known as gunners because on rounds with attendings they were gunning for you.  They would attempt to elevate their status by trying to make you look bad. In some cases that took on the appearance of just trying to look more interested than you.  I never really understood the mentality because after all we were in the presence of an attending who could make all of us look bad – and typically did.

My interaction with professors and attendings was the first real sign that true enthusiasm exists.  In college at every level there were professors with vast knowledge of their subject material.  At times they would interject their personal excitement about the subject matter into the lectures.  Anecdotes about the organic chemist who famously said that God consults him about molecules, the inscription on Boltzmann’s grave, or the mathematician who discovered group theory and then died in a duel at age 20 and the implications. Some of these professors would read the room and try to inject humor to invigorate the class and create some enthusiasm. And there were the obvious sacrifices like hanging in there as a professor or adjunct at a liberal arts college for substandard pay and benefits for the love of the academic field and the ability to practice it.

In medical school, it was even more obvious.  Most of the people med students interact with are attending physicians on clinical rotations who teach but also have their own productivity demands.  Physicians rounding on patients with a teaching team have their clinics or surgeries in addition to supervising trainees. They need an academic level of expertise in their field to maintain the teacher-student hierarchy.  A pediatric endocrinologist told me: “I must know the most about any endocrine subject in the room (referring to the mix of specialties on our ward team).  It is no accident that I know all about adrenal steroidogenesis.  I have to know it cold.”

Was that still about competitiveness and one-upmanship?  Possibly but highly unlikely.  After all an attending physician is not competing against trainees or anyone else.  If there is any competitiveness it comes down to internal standards.  As an attending for me that came down to a series of questions:

1.  Am I missing anything?

2.  Am I doing an adequate job?

3.  Am I covering everything that is important to cover and am I communicating what that is?

4.  Are there any problems with the staff or trainees that need to be addressed?

Competitiveness does persist post training and it is a largely undiscussed problem.  I once witnessed a confrontation between two very high-level academics where one commented that he would never be beaten by the other.  The rejoinder was: “I think the field is big enough for both of us”.   In the current American system, it is encouraged among front line physicians using several metrics like productivity (number of patients seen not papers read) and various scapegoating techniques in the corporate employee assessment. But I think most senior physicians get to the point where they welcome collegial discussion and consultation.  If you discussed it with them – their competition is most likely against high internal standards – some of which may be unrealistically high.

The psychology of enthusiasm has several dimensions. There are behavioral approaches to improve it – not the least of which is establishing predictable routines.  Athletes routinely push past nonspecific feelings of unwellness and notice that those feelings resolve and they feel much better with their workout routine.  This helps establish a long-term pattern of enthusiasm for high levels of exercise.  There is a social component that is used in sports for both the athletes and spectators involved.  Like all psychological phenomena there are rating scales that seek to describe the enthusiasm of teachers and work engagement in general (1).  In the age of burnout several studies have suggested that enthusiasm may minimize that problem.  It would be difficult to maintain enthusiasm in the face of moral injury.

From a psychodynamic perspective, identification with teachers, professors, and attendings is a largely unspoken but in my experience powerful process. In clinical medicine there is probably no better field to observe personal attributes of teachers and consciously or unconsciously incorporate them into your personality.  I was fortunate enough to work with so many enthusiastic and high energy physicians and teams and they had a direct impact on me.  The message was be compulsive, check and recheck everything, and do the research on the fly.  I have written about the last team I worked on in medical school.  Every person on that team from the intern to the 70-year-old nephrologist was interested in kidney disease 24/7 and we covered the largest inpatient unit I have ever seen (including transplant patients) and two outpatient clinics.  We worked at it from sun up to sun down and everybody was energetic and ready to work.  That team also showed me the importance of a sense of humor.  Everybody had it but one of the Internal medicine residents was practically a stand-up comedian.  On my last day of medical school, I worked until 10 PM with that team.  They were swamped with consults and asked me to do three after the clinic.  I was happy to do it and then skipped across the golf course like county grounds to my apartment a half mile away.  Even as an old man – I feel happy every time I think about that experience. 

As I am winding down this post, there is a moral dimension to enthusiasm at least as far as medicine goes.  People have been described as doing harmful things enthusiastically.  Enthusiasm has to be a positive force.  One of the derivations from the Greek is “possessed by God or divinely inspired”.  At times in history, it has been equated with madness.  Philosophers have written about it as both a positive (promoting desirable values and politics) and a negative (zeal overtaking rationality).  In the context I am discussing – it takes the form of improved focus on difficult to solve patient problems and espirit de corps.    

Identification only gets you so far – I don’t think anybody has ever mistaken me for a comedian.       

What about in the case I started this post with?  It was my brother responding to a compulsive table about what medical problems psychiatrists should be able to recognize, diagnose, and either treat or triage. Enthusiasm may be a part of that and I will admit to being very enthusiastic about medicine and neurology in general, but there is more going on.  I made most of the diagnoses in the table not just based on enthusiasm but at least three other factors.  First, I practiced across multiple settings and was often the only psychiatrist around.  When you are asked to see people in general hospitals, nursing homes, and outpatient clinics in the same week there is a good chance that you will encounter serious but vaguely characterized problems in all these settings.   That could range from agitation due to any number of underlying neurological conditions to a mother who wants her 3-year-old son put on stimulants because of uncontrollable behavior.  Second, neurologists are in shorter supply than psychiatrists.  That doesn’t mean that psychiatrists should practice neurology but it does mean that specialists who are trained in and expected to know neurology might do a better job with certain problems than primary care physicians. At the top of that list are recognizing aphasia syndromes, presentations of acute encephalitis and meningitis, movement disorders, and functional neurological disorders.  Third, there is always a group of psychiatric patients who see their psychiatrist as the primary care physician they prefer to follow up with.  I have been able to diagnose unrecognized illnesses just based on that difference in preference and communication.  Psychiatric liaison with primary care is a useful function.     

Heading into 2026, I hope that all the professionals reading this have been exposed to the levels of enthusiasm that I have during their career.  And I hope that the doctors I end up seeing in the future all have it.

 

George Dawson, MD, DFAPA

 

Some additional thoughts/anecdotes:

1:  One of the advantages of enthusiasm is embracing just how much you need to know in order to do a good job.  A long time friend of mine who ended up being an ophthalmologist showed me his standard 3 volume ophthalmology text and put it this way:  "Every specialty is covered in 2-3,000 pages.  It is what you need to know."  That always made sense to me but as a specialist - enthusiasm changes that task from last minute cramming to knowledge that is part of your personal identity.  It is knowledge that has to stay with you and you have to keep it current.  It can mean the difference between life and death.    

2:  When I was a PGY-2, I was staffing patients in a clinic with my attending who was a brilliant psychiatrist and researcher.   He was very enthusiastic about teaching.  He asked me this question that also turned out to be a thought experiment:  "Suppose you are done with all of the training and you are out at a cocktail party somewhere.  People come up to you and start talking. Do you think you will be talking with them like a psychiatrist or like somebody who has had no training?  That question seems very easy to answer at this point in time, but back in 1984 I was drawing a blank.  This blog is probably a good example of what that answer is.

3:  Obsessional behavior can be mistaken for enthusiasm.  At various points in my career I have seen physicians paralyzed by it and stuck in a loop of unproductive activity.  It has happened to me a few times.  If that behavior is related to patient care - there is aways someone in your field who can tell you if you are missing something or not.   If it is a case of administrative scapegoating - you can always move on though it may not be easy.

4:  The anecdote about how my nephrology team convinced me to work late the night before my graduation is humorous, but probably not in a way that I can convey in writing.  At about 5PM that night the senior medicine residents approached me with the idea of staffing 3 more consults. It went something like this: "Look George - we know you graduate tomorrow and probably want to get out of here but we are getting killed with consults.  Do you think you could help us out by doing three?  One last thing?"

To clarify - in teaching hospitals, medical students are not physicians.  As part of the learning process on a consult service, they see the patient, get the necessary historical, physical exam, and laboratory data and record everything in the chart.   Then they present it to the attending physician.  The attending shows up, interviews the patient, does the indicated physical examination, adds the additional insights of an expert for both the consult team and the patient, and adds to the note and countersigns it.  The medical student and residents need to come up with their own diagnoses and treatment plan for discussion purposes - but that is the ultimate responsibility of the attending. There is a progression in medical training that the initial work by the medical student or resident becomes either a much closer approximation or identical to what the attending would say as people progress from med student -> resident -> fellow -> attending.

The residents were trying to cajole me into doing the work but they did not need to.  When I said I would they increased the flattery to absurd levels and we all had a good laugh about it.    

5:  On the issue of competitiveness - I had no idea how bad it could be until I had graduated from college.  I attended a very small college and we did not have a specific pre-med track.  I was a chemistry and biology double major.  Long before I decided to go to medical school - I heard anecdotes about sabotage in the organic chemistry lab to either contaminate the products or reduce the yield of synthetic reactions.  As a former lab assistant that is probably not the best way to evaluate lab performance.  Organic chemistry was one of the feared med school pre-requisites.  There is even palpable bitterness about the course in some people who are practicing physicians. Sabotaging somebody else's lab results seems counterproductive in so many ways and it is difficult for me to see how that would work very well.  As a lab assistant I viewed my job as making sure everyone was safe (I did prevent 2 explosions) and knew what they were doing.     

6:  “Are you aggressive enough to be a physician?”  I was seated across the desk from the Head of Cardiology.  He was a stocky middle-aged man with a flushed appearance.  He looked younger than he probably was and had a full head of hair that was cut short, parted, and neatly oiled like he just left a barber shop.  The year was 1981 and it was my first interview to get into medical school.

“I am not sure what you mean…”  I stammered.

“Well tell me what you have been doing with your life since you graduated from college.”

I decided my joke about cramming 4 years of living into 8 would not go over well so I recited the details.  Peace Corps, teaching chemistry, and botanical research cloning Douglas Fir and Loblolly Pine.  Those were the high points and all the details took about 20 minutes.

When I was done his response surprised me: “Anybody who can go into the African bush and teach chemistry is aggressive enough for me!”  I did not say anything about the bush – I lived on a high plateau next to Mt. Kenya.  The only bushes around were coffee.  But he delivered the line like a football coach and it seemed like an endorsement when you played well.

All these years later – I think he was getting at enthusiasm.  And over the course of my career – I have seen this substitution (aggression for enthusiasm) by many physicians.    

References:

1:  Schaufeli WB, Bakker AB. Utrecht work engagement scale: Preliminary manual. Occupational Health Psychology Unit, Utrecht University, Utrecht. 2003 Nov;26(1):64-100.

 

Graphic Credit: 

Teaching hospitals of the Medical College of Wisconsin taken from the path walking from my apartment on 89th street.  The black and white photo is Milwaukee County Hospital shot in 1982.  The color photo is from the same spot in December 2025.  The two most visible buildings are the Froedert and MCW Center for Advanced Care (left) and the Froedert & MCW Clinical Cancer Center.  The Froedert legacy spread from the original Froedert Hospital that was there is 1982 - where I did 2 neurosurgery, a nephrology, and a neurology rotation.  B&W is shot with a Konica 35 mm and Ektachrome.  Color is an iPhone 15.