Racism and gun violence both exist in an overtly gun extremist society: They cannot be explained away by mental illness.

I suppose I should have not been very shocked that a Wall Street Journal editorial this morning (1) chose to double down on both gun rights and the myth that racism is not a problem and had nothing to do with the recent mass shooting – while scapegoating both mental illness and the rationed system of mental health care that we have in this country.  For good measure he added another conservative agenda item - that there was also blame for the public health officials like Dr. Fauci for mismanaging the pandemic.  This post is to straighten all of that out.

Let me preface these remarks by saying that I have no information about the most recent mass shooting other than what is reported in the media.  The author of the editorial does not seem to either. What I do have is 22 years of experience in acute care psychiatry and involuntary care. That’s right – for 22 years I was one of the guys you would have to see if you were admitted to my hospital on a legal hold for behavior that involved threatening or harming other people or yourself.  That included all kinds of violence - homicide, suicide attempts and severe self injury, and violent confrontations/shoot outs with the police.  I had to evaluate the situation with the considerable assistance from my colleagues and decide if that person could be released or needed to be held for further assessment and treatment. People (including psychiatrists) like to summarize that situation by saying: “Nobody can predict future dangerousness” and that is certainly true. But we do pretty well in the short term (hours to days).  We also do well coming up with a plan to prevent future violence.

The details about the most recent mass shooting are still being reported at this time, but so far include interviews with the families of the victims, police reports, videos, and excerpts from a manifesto written by the perpetrator.  According to reports that manifesto discussed Replacement Theory as a potential motive for the mass shooting.  Replacement Theory is a white nationalist, far right ideology that claims non-whites are a threat to the white majority in several countries including the US. A corollary is that the Democrats are trying to get aligned with more non-white voters to develop more political power. This is the rationale currently given in the media for the actions of the mass shooter who scouted neighborhoods and said very explicitly in documents that his intent was to murder as many black people as possible. He had no difficulty obtaining firearms legally – even though he was detained and sent for an emergency evaluation a little less than a year earlier for stating “murder-suicide” in response to an online question about what he planned to do upon retirement.  Those details and his response talking about how he got out of it and continued to plan to kill people are at this link.  

As a psychiatrist and member of the American Psychiatric Association, I can’t speculate on the diagnosis of anyone who I have not personally assessed and if I did do an assessment – I would need a release from the person to discuss any details.  The editorialist is under no constraints speculating that “signals were missed” and that “psychotic young males whose outlet is killing” is not the object of his column.  Instead, he makes the claim that he is really concerned about the post pandemic mental illness and addiction trends in this country. He is apparently not consulting the correct sources about what has happened in this country in terms of mental health care before the pandemic.

I will start with his anchor point in the 1970s.  At about that time Len Stein, MD and coworkers invented Assertive Community Treatment and a number of additional innovative approaches that were focused on keeping people with severe mental illnesses in their own homes.  Dr. Stein was one of my mentors and in seminars he would show what Wisconsin state hospital wards used to look like. About a hundred patients in one large room with their cots edge-to-edge and all wearing hospital pajamas. By the time I was working with him in the 1980s, those folks were living independently supported by case management teams and psychiatrists. Dr. Stein and his colleagues also ran a community mental health center that included crisis intervention services and outreach. That model of community mental health and crisis intervention is still practiced and has been covered in the New England Journal of Medicine.  Psychiatric residents are still trained in community mental health settings and many prefer to practice there.  Counties are not as enthusiastic and have shut down many if not most community mental health centers.

Community psychiatry is an obvious 50-year-old solution but it has to be funded. The same is true of affordable housing.  In some cases that housing needs to be supervised and also a sober environment. Both community psychiatry and affordable housing are casualties of business rationing that can only occur with the full cooperation of both state and federal governments. The current system costs about a trillion dollars in overhead that is directed to Wall Street profits and unnecessary meddling by middle managers. The only people who “sweep mental health under the rug” are large healthcare organizations and state bureaucrats who disproportionately ration it.  The "science of mental health" is not difficult at all.  Being forced to do it for free is difficult.

The 1980s were a critical time in establishing the managed care industry and taking all healthcare out of the purview of physicians.  While rationing psychiatric resources was being ramped up, services to treat alcoholism and addiction were essentially demolished. Suddenly you could not longer get detoxification services at most hospitals.  People were sent to social detox units run by counties where there was no medical coverage.  The thinking was that if a person developed medical complications like seizures or delirium tremens they could always be sent back to the hospital. The biggest risk was continued substance use and immediate relapse. Residential and outpatient treatment facilities never materialized.  Inadequate funding was a significant problem.  The managed care industry played a role in that case as well with absurd expectations and limits on treatment.  It is no accident that treatment for substance use disorders basically became non-existent.  None of the disproportionate rationing of mental health or substance abuse treatment is new.  It has been like this for 30 years because it is the government endorsed model of care.  

Overall, this editorial is a smokescreen over the proximate issues of guns and racism.  The author trivializes this as political rhetoric when in fact the rhetoric has all been pro-guns and pro-white supremacy.  It is the only rational explanation for turning the United States into an armed camp that has progressively increased the likelihood of gun violence. We are not talking about a pandemic precipitated phenomenon.  The gun violence has been multi-year and the pro-gun party has “doubled down” on it to make it more likely.  As far as politics go – now that we know how a partisan Supreme Court works – the Heller decision and the resulting liberalization of gun ownership should not come as a surprise.  On the issue of hate crimes, I can’t really think of anything more relevant in a case based on the public disclosures.  This was a specific crime directed at black Americans intentionally perpetrated in a neighborhood that was scouted ahead of time for that ethnicity. Brushing that aside to claim that this is a response to an embarrassing record on mental illness, when there is no evidence that is a factor is disingenuous.

American history including other recent mass shootings tells us that racism can be a causative factor.  What is never addressed is the omnipresent gun culture in the USA.  People with an apparent need for military weapons and handguns and politicians willing to give them unlimited access to carrying them in public, carrying them without permits, and stand your ground laws - encouraging violent confrontations with firearms.  All fueled by one party and their affiliated special interests.

Disingenuous discourse and misinformation is what we typically see these days. If you want the facts about what needs to be there in terms of a functional mental health system (and I know there are absolutely no business people and very few politicians that do) – ask a psychiatrist. If you want to know about what gun control needs to be in effect rather than claiming that psychiatrists are not preventing gun violence from people with no mental illness – you can also ask me.

I could put all of those details on a 4” x 6” card and it would work. 

But there is certainly nobody on the right or at the WSJ who wants to know that either.

 

George Dawson, MD, DFAPA

 

References:

1:  Daniel Henninger. The Next Pandemic: Mental Illness.  Wall Street Journal. May 18, 2022.

Graphics Credit:  Eduardo Colon, MD

Drapetomania - The Lack of Relevance To Psychiatry

 

I will address this issue one final time. I have written about it in the pages of this blog in past. Drapetomania was a pseudo diagnosis coined by Southern physician named Samuel A. Cartwright. He wrote the following in 1851:

“DRAPETOMANIA, OR THE DISEASE CAUSING NEGROES TO RUN AWAY.
It is unknown to our medical authorities, although its diagnostic symptom, the absconding from service, is well known to our planters and overseers...
In noticing a disease not heretofore classed among the long list of maladies that man is subject to, it was necessary to have a new term to express it. The cause in the most of cases, that induces the negro to run away from service, is as much a disease of the mind as any other species of mental alienation, and much more curable, as a general rule. With the advantages of proper medical advice, strictly followed, this troublesome practice that many negroes have of running away, can be almost entirely prevented, although the slaves be located on the borders of a free state, within a stone's throw of the abolitionists.” 

Characterizing running away from slavery as a disease and physical punishment as a treatment was certainly a radical concept even in the Southern states before the American Civil War. In subsequent paragraphs Cartwright invokes divine providence to explain why white masters are destined to remain in a superior role to slaves.  He was concerned about “two classes of person who were apt to lose their negroes – the overly permissive defined as “treating them as equals” and the cruel owners who denied slaves the ordinary necessities of life.  His solution was to treat them well enough, but not allow many freedoms, and physically punish them into a submissive state “for their own good.”  Since Cartwright wrote these paragraphs the common interpretation is that his disease characterization of a rational act is a prototypical misapplication of the disease concept.

Not much has been written about criticism at the time. Writing in the Buffalo Medical Journal Samuel Hunt provided a satirical editorial on the original paper (2):

“Our purpose in this formal introduction, is to give due importance to an article recently published in its pages by Dr. Samuel Cartwright, of New Orleans. Characterized by the same cautious induction and logical accuracy whichever attended the literary efforts of that gentleman, it deserves careful consideration of the medical philosopher, the anatomical statesman, and the benighted Saratoga convention.

Those of our readers who are in the habit of referring to Cullen’s Nosology for the definition of diseases, will find no mention there of Drapetomania. The ignorance of the ancients was surprising, and we need but refer to Drapetomania as an evidence of this progressive spirit of the age in which we live.

Dr. Cartwright has conferred this name, Drapetomania, upon a disease peculiar to the south, and which is, we believe entirely confined to that section, and only manifested at the north in certain analogous if not identical forms, which we shall have occasion to mention when we have given our readers time for the perusal the following extract from Dr. Cartwright’s able article:”

After additional sarcasm following the extract, the author goes on to close his editorial by describing a disease he calls Effugium discipulorum or a tendency of school boys to leave school and spend time in the fields and orchards of rural districts. He suggests that the same solution – whipping “have been sanctioned by ages of experience in Effugium discipulorum; thus confirming the allied nature of the 2 diseases and the correctness of Dr. C’s hypothesis.” Hunt’s satirical editorial of 1855 and additional sources describing how the paper was mocked in the northern states is an indication of how serious this “diagnosis” was taken by some physicians at the time.

Historian Christopher D. E. Willoughby (3) described a much more nuanced environment and the multiple roles that Cartwright played. He was apparently widely published on a number of medical topics and there was widespread interest in the medical community about racial differences in medicine. Cartwright portrayed himself as an expert in this area, but due to his reputation he generally received deferential treatment – even when other physicians disagreed with him.  The medical emphasis at the time was on anatomy and in terms of disease theory there was a doctrine of specificity outlining the few factors relevant to how a disease could be treated. One of those factors was race. A physician could be regarded as a quack if one of these factors was disregarded – reinforcing the role of racial medicine. Despite Cartwright’s medical and political role, Willoughby describes his drapetomania as being so far outside of the medical norms at the time that drapetomania was not adopted as a diagnosis by many physicians and it was never a psychiatric diagnosis for the obvious reason that psychiatry and its diagnostic systems did not exist.

.The sampling of how often the term was used over the intervening decades both independently and relative to actual psychiatric diagnoses is indicated in the following Google NGRAMS.  To read about the graphing procedure consult this source (4). (Click to enlarge)

It seems fairly obvious that there was a flurry of references around the time of Cartwright’s article and then a very long flat period until Szasz resuscitated it in the 1970s (5) and it was picked up by the anti-psychiatry crowd subsequent to that.  Given the Google NGRAMS approach, relative to standard psychiatric diagnoses the interest in this pseudo diagnosis was practically nil.

A critical question is how a theory largely ignored at the time, now has more references than in the past?  A lot of that may have to do with a reinterpretation of his image. The description of him as a respected surgeon who trained with Benjamin Rush at Pennsylvania Hospital was apparently due to mistakes in an early biographical history (3) and persist today in Wikipedia and many other places.  Further reading suggests that he was in medical school as a teenager, dropped out to fight in the War of 1812 where he sustained injuries and then went back to complete his medical training. Looking at that timeline does it seem plausible? (click to enlarge)

Cartwright was born in 1793. In the years 1808-1813 he would have been 15-20 years old. Benjamin Rush died in April of 1813 and had been ill since the previous November. His biographer Stephen Fried (6) described Rush writing and active doing hospital rounds during this time period but for the first time starting to miss those rounds. It seems unlikely that even in the 19th century that anyone in their late teens would have been a military veteran and in medical school between the ages of 15-19. Willoughby (3) confirmed that there was no evidence that Cartwright matriculated at Penn or that he apprenticed with Rush. There are a multitude of sites on the Internet and in papers that state otherwise. Contrary to these many references there was no connection between Cartwright or Rush and the University of Pennsylvania Medical School. He did graduate from Transylvania Medical School (Lexington, KY) in 1823.

What about the purported connection between psychiatry and Cartwright and his invented diagnosis? Per the timeline above psychiatry had not yet been invented. There was an organization of asylum superintendents at the time but they had no formal diagnostic system.  The Association of Medical Superintendents of American Institutions for the Insane (AMSAII) was founded in 1844 and it had a total of 13 members - none of them were described as psychiatrists or alienists.  Despite the fact that racism and proslavery attitudes were widespread,  none of them used the term drapetomania or admitted asylum patients on that basis. In fact, only one asylum accepted slaves with mental illnesses at that time.  

The American Medico-Psychological Association was established in 1892 and at that time the number of alienists versus psychiatrists was not known.  In fact, it wasn’t until a meeting of the Alienists and Neurologists of America in 1917 (7) that anyone suggested specific training was necessary to treat asylum patients.  In those proceedings there are three times as many references to alienists than there are to psychiatrists, despite Reil’s first use of the term in 1816.  No mention at all of drapetomania but an interesting section on the importance of social diagnosis and social work.  The main diagnostic focus was on alcoholism, catatonia, epilepsy, syphilis, dementia praecox, various forms of chronic illness, and intellectual disability described as “feeble mindedness”.  None of the alienists or neurologists seem remotely concerned about drapetomania.  This is the only reference to race in that 228-page document:

“Preservation of self and of the race are directly dependent upon gratification of the appetites and this fact necessitates reaction of man to his environment and appropriation of those things which serve to fulfill his desires.”

It was included in a section on “Criteria of Defective Mental Development”.

On the timeline, the initial forms of psychiatric diagnostic manuals appeared in 1918 and 1952. Neither contained any reference to drapetomania and most of the diagnoses proposed are recognized as being similar or precursors to current diagnoses. One of the often-used tactics in criticizing psychiatry today has to do with the diagnostic manual and what it means.  Contrary to the rhetoric, alienists and psychiatrists involved in asylum care were often criticized for the lack of science in those settings most notably by the neurologist Weir-Mitchell (8):

“I shall frankly have to reproach many of those who still bear the absurd label of ‘medical superintendents'. Where are your annual reports of scientific study of the psychology and pathology of your patients? We commonly get as your contributions to science, odd little statements, reports of a case or two, a few useless pages of isolated post mortem records and these are sandwiched among incomprehensible and farm balance sheets”.  He went on to state that neurologists believed asylum care was care of “last resort”.

From the start psychiatric diagnostic manuals had the dual role of diagnostic description and data collection in asylums, specialty hospitals, specific populations, and for research purposes. Contrary to modern antipsychiatry philosophy there was no goal to increase diagnoses or the number of people with a diagnosis and no goal of social control through diagnosis.

I have established that Cartwright had no connection to Benjamin Rush of the University of Pennsylvania medical school. I have also established that drapetomania was certainly not accepted as a diagnosis and was probably widely derided in some areas.  It was essentially a product of the racist south, inadequate diagnostic theory and medical racism, had medical and political implications, and was written by a physician who owned 14 slaves and had a personal interest maintaining that practice.  I have also established that it has nothing to do with the field of psychiatry or its intellectual roots. It is only through massive misinformation that these false ideas persist. That misinformation landscape if so large at this point that it is not likely to ever be corrected. I certainly doubt that this blog will have much of an effect against what is now decades of drapetomania misinformation.  Many of the people spreading that misinformation are doing it in bad faith and by definition are not interested in correcting it.  There are also many (presumably) good faith errors such as recent statements from within organized psychiatry and in texts. A psychology colleague posted that every undergraduate Abnormal Psychology text uses drapetomania as an example of coercive psychiatry. Hopefully the good faith errors will correct themselves.  

The modest goal of this post is to hope that I can keep all of this misinformation out of the psychiatric literature.  That will be no small task. Szasz is already published despite the fact that he has been widely discredited. Even last month I was reading the American Journal of Psychiatry (9) and came across this statement:

“Over 60 years after the ratification of the US Constitution, physician Samuel Cartwright played a prominent role in the rise of racism in psychiatry.  His descriptions and characterizations of mental health conditions in enslaved Africans, particularly drapetomania which he described as the illness of enslaved people wanting to run away and escape captivity, and dysaethesia aethopica, a disease of ‘rascality’, were the beginning justifications of pathologizing normal behavioral responses to trauma and oppression.”

Based on everything I have established this is an inaccurate statement. Cartwright was not a psychiatrist or even an alienist. He was not trained in researching or diagnosis any mental health conditions and essentially made these up. His isolated racist ideology has nothing to do with the subsequent development of psychiatry or the way psychiatry is practiced today. Cartwright and drapetomania have become a convenient meme with the imitators using it as an indictment of psychiatry or the psychiatric diagnostic system – even though it is unrelated to both.  The latest application has been the use of this meme by psychiatrists to acknowledge systematic racism within the field as a basis for future correction. I have no problem with acknowledging that racism in psychiatry and society exists – but let’s make that acknowledgment on a realistic basis not an unconnected anecdote.

I expect a fair amount of opposition to this post. I base that on a reaction I got in a psychiatry listserv when I suggested that professional organizations should suggest the Rosenhan paper be retracted. Although I got several very supportive replies and replies from people who were shocked about the facts, there was also a very vocal contingent proclaiming they want social justice. Social justice cannot be predicated on a misinformation, even if that misinformation seems consistent with your overall message.  And there is a much better way.  That better way was in this weeks New England Journal of Medicine (10) in an article highlighting the work of W.E.B. Dubois and his colleagues who accomplished what can only be described as landmark work in the area of structural racism. In it DuBois and colleagues concluded that the excess mortality from tuberculosis in the black community was a product of racial disparities secondary to social forces. The report was published in 1899.  DuBois also successfully countered the theory of an insurance company actuary who suggested that black people were “ill adapted to freedom but also doomed to imminent extinction because of their biological differences from white people.” (note the parallels with drapetomania). Dubois successfully refuted these claims and showed that heredity could explain only a small part of differential mortality between groups and that social inequity accounted for most differences. The work of these social scientists and theorists is a solid place to start.

The solid scientific ground that we are on today is that we know race is a non-specific factor and that biologically all of mankind comes from the same place.  We are much more biologically similar than different. Discrimination and the resulting outcome disparities based on racism are the real problems to be addressed and there has been a scientific basis for that since 1899.    

 

George Dawson, MD, DFAPA

 

References:

1:  Cartwright SA.  Diseases and Peculiarities of the Negro Race.  De Bow's Review. Southern and Western States. Volume XI, New Orleans, 1851  Link

2:  S. B. Hunt (1855). "Dr. Cartwright on "Drapetomania"". Buffalo Medical Journal. 10: 438–442. (full text). https://books.google.com/books?id=coBYAAAAMAAJ&pg=PA438#v=onepage&q&f=false

3:  Willoughby CDE.  Running Away from Drapetomania: Samuel A. Cartwright, Medicine, and Race in the Antebellum South. Journal of Southern History
The Southern Historical Association Volume 84, Number 3, August 2018 pp. 579-614; 10.1353/soh.2018.0164

4:  Younes N, Reips UD. Guideline for improving the reliability of Google Ngram studies: Evidence from religious terms. PLoS One. 2019 Mar 22;14(3):e0213554. doi: 10.1371/journal.pone.0213554. PMID: 30901329; PMCID: PMC6430395.

5: Szasz TS. The sane slave. An historical note on the use of medical diagnosis as justificatory rhetoric. Am J Psychother. 1971 Apr;25(2):228-39. doi: 10.1176/appi.psychotherapy.1971.25.2.228. PMID: 5553257.

6:  Fried S. Rush: Revolution, madness & the visionary doctor who became a founding father. Crown Publishing Group, a division of Random House LLC; New York, 2018.

7:  Alienists and Neurologists of America: Proceedings of Sixth Annual Meeting.  Chicago, IL  July 10-12, 1917.

8:  Shorter E.  A History of Psychiatry: from the era of the asylum to the age of Prozac.  John Wiley & Sons, Inc. New York, 1997: p.68

Weir-Mitchell’s criticism was delivered in 1894.

9: Shim RS. Dismantling Structural Racism in Psychiatry: A Path to Mental Health Equity. Am J Psychiatry. 2021 Jul;178(7):592-598. doi: 10.1176/appi.ajp.2021.21060558. PMID: 34270343

10:  White A, Thornton RLJ, Greene JA.  Remembering Past Lessons about Structural Racism — Recentering Black Theorists of Health and Society.  New England Journal of Medicine August 26, 2021 385(9):850. doi: 10.1056/NEJMms2035550

11:  Callender JH.  History and Work of the Association of Medical Superintendents of American Institutions For The Insane - President's Address.  Am J Insanity. July 1883: p. 1-32.

In this reference, the Association President reviews the first 40 years of progress and points out that 13 members started in 1844 but by 1880 there were 115 members representing 130 public and private institutions in the US or Canada and a total of 41,000 patients.  In this same document the President refers to the distinguished members of the organization as alienists rather than psychiatrists. Gonaver (see below) refers to the physicians of the AMSII as "asylum doctors" or "psychopathists" but also points out that many had no specialized training at all in the treatment of the mentally ill.

Supplementary 1:

This reference was posted to me on Twitter.  In it the author points out that the term drapetomania was not a diagnosis in the only asylum that treated slaves during the time when there was peak interest in the term:

"Readers may be therefore surprised by the conspicuous absence of these so-called conditions in the only insane asylum in which  slaves were patients."

Gonaver W. The Peculiar Institution and the Making of Modern Psychiatry, 1840–1880. University of North Carolina Press, 2019.

Supplementary 2:

The nosology text by Cullen referenced in the satirical critique of Cartwright's work is available online through the National Library of Medicine.  The only references to mental disorders were mania, melancholia, and bulimia.  

Cullen W (1710-1790).  Synopsis and nosology: being an arrangement and definition of diseases. Hartford : Printed by Nathaniel Patten, MDCCXCII [1792]: 80 pages.  Link to NLM

Supplementary 3:

 

I got this book in the mail today and read it.  It is a 1918 edition "prepared for the Committee on Statistics by the American Medico-Psychological Association" - see timeline. The text is 40 pages long, contains 21 diagnoses in the classification system and was designed to facilitate data collection for statistical analysis. There was a detailed section on race and ethnicity that would not be included in any modern analysis.  Drapetomania was not listed anywhere in this volume.

Supplementary 4:

Precursor organizations to the American Psychiatric Association published a journal - The American Journal of Insanity that encompassed the period of time when drapetomania was proposed. In order to see if there was any recognition of drapetomania in the line of journals that the APA considers related to psychiatry I went back and looked at one 1850s decade of the American Journal of Insanity and then did a search on the APA web site validated against terms like sitomania discovered in that decade of material.

On the APA web site, the time span of journals is indicated below:

American Journal of Insanity vol. 1 no 1 (July 1844) to vol. 99 no. 6 (May 1943)

American Journal of Psychiatry vol. 100 no. 1 (July 1943) to current time.

There were no references to drapetomania in the interval 1851-1859.

The search engine was validated to discover relevant diagnoses in the American Journal of Insanity.

The search of APA journals yielded 19 references dating back to 1971.  The first two references from that year were both written by Thomas Szasz.  The references in general have to do with racism in medicine including a recent number of references, some book reports including one about ADHD that for some reason contains the word drapetomania. 

The exercise in this supplemental information confirms that drapetomania was never considered a diagnosis in what are considered the early journals of psychiatry.  In my reading of the American Journal of Insanity I also found much to support Weir-Mitchell's 1894 criticism of the field (see above and reference 8).

Supplementary 5:

I received the following book in the mail today after a Twitter colleague referenced it.  The author Wendy Gonaver is a historian who had access to a significant volume of records from the only asylum that treated and accepted slaves and free black persons as patients and employed slaves as caregivers.  So far I have read the 18 page introduction and the writing and rationale are excellent.  She introduces a level of insight and objectivity that is rarely seen in the content that she is covering. On page 6 and 7 she debunks the importance of drapetomania that occurred right in the middle of the years she is covering for this book (1840-1880). In commenting on the complete absence of Cartwright's invented diagnoses:

"For good reason, Cartwright's work has become synonymous with all that was horribly wrong with both slavery and spurious science.... but Cartwright's posthumous notoriety does not appear to match his reputation during his lifetime.  His fabrications were, at least for Southern doctors who considered themselves serious practitioners, more rhetorical proslavery provocation than legitimate diagnoses." (p. 6-7).

She points out that Cartwright was not a "mental health specialist", never attended a meeting of The Association of Medical Superintendents of American Institutions for the Insane the only professional organization at the time, his work was never discussed at those meetings, and there were no records to suggest that slaves were admitted for running a way or that they were whipped.  There is also no mention of a connection to Benjamin Rush - another frequent error when Cartwright is discussed.

At the same time Gonaver points out that previous historical documents ignored race as a dimension for analysis and illustrates some of her insights in that area in the introduction.  I look forward to completing the book. 

A brief synopsis of the book follows:

After some consideration, I elected to post a synopsis of the book rather than each chapter due to the length of that document. The book is based on archives of the Eastern Lunatic Asylum (ELA) as reviewed by the author historian Wendy Gonaver. The descriptions of the state of the asylum, administration, staff including the enslaved staff, and the patient population role based on detailed notes by the asylum superintendent during the time interval of interest (1840-1880). Most of the material consisted of records written by John Galt, the superintendent. He was appointed age 22 and 1841 after studying at the University of Pennsylvania. He remained the superintendent until his death by suicide on May 18, 1862. Although the author refers to her book as a study of the “broader ideological underpinnings of early psychiatry” - the asylum doctors were clearly not psychiatrists. They are typically referred to as “asylum doctor” or “psychopathist”.  He was a member of the Association of Medical Superintendents of American Institutions for the Insane (AMAAII). This association was founded in 1844 and at that time it had 13 members. The only real connection to psychiatry is that the American Psychiatric Association uses this date to claim that psychiatry was the first medical specialty. That is a questionable claim on multiple levels.

The ELA itself was housed in an inadequate physical plant even in the pre-Civil War era. Sanitation was clearly a problem with inadequate drainage and sewerage systems. Potable water was also problem. There were a large number of fires on the campus for heating purposes until central heat could be installed. Nutrition was also a problem. Although the patients got about a pound of meat 5 days a week and fish 2 days a week several patients were diagnosed with scurvy. That led to an emphasis on expanded gardening of fruits and vegetables. Children of staff living on campus were not served regular meals but had to subsist on scraps.

One obvious conclusion is that there is much material in this book that could be used to blame psychiatry in much the same way that drapetomania has been used. But there are many qualifiers. Racism both overt and covert were clearly present in both the northern and southern states. Even though much of the events described in this book occurred 30 – 70 years after Benjamin Rush’s death there were no true abolitionists, not even reformer Dorthea Dix.  John Galt supported his enslaved staff in many cases humanistically but from a pragmatic rather than a moral perspective. He clearly believed that blacks were socially and intellectually inferior, but he realized that his institution could not run without enslaved blacks.  That led him to defend the quality of care provided by the enslaved staff at his institution. Racial stereotypes cut across the dimensions of religion, gender, and culture with African Americans receiving the harshest treatment and the greater work load. When John Galt died and the Civil War ended, the integrated ELA also ended and black patients were transferred to a segregated institution where their care was noticeably worse.  During a transition period, multiple military physicians with no training in asylum care were appointed to run the ELA.

Politics factored prominently in the workings of the ELA and whether Galt received any recognition for his work of ideas.  Shortly after his arrival, a conflict developed with the asylum board when they removed his hiring ability and blamed him for the resulting problems. He was also resented by AMAII colleagues over his advocacy for integrated asylums and eventually an outpatient community-based model. Despite praise for innovation at their meetings he was never credited for his ideas or his death mentioned in one of their meetings.

The author is a critical presence in this book. In places, she is clearly suggesting that stressors, abuse, domestic violence, war, and other forms of trauma may be the most important factors in why someone, but particularly white, black, and enslaved black women ended up in the ELA. She acknowledges that there may be a role for severe post-partum states. As I read though these case reports, I had questions about the degree of detail available as well as the primitive to non-existent diagnostic system. If all of the details of stressful events were there – could they really not be considered given the primitive state of medicine that was being used?  The only treatment being supplied was basically moral therapy and environmental containment to reduce the risk of aggression, suicide, and starvation.  There were no trauma or stress based therapies available in the mid-19^th century. If there were it would take a much larger professional staff to administer them.

All things considered, the logical conclusion is that the ELA, like most institutions was not able to rise above the prejudices of the population where it was located. The practices described in the book are common overt and implicit racist themes – even today. Covert segregation still exists even though school segregation ended in 1954. In keeping with the timeline of this book, the Civil Rights Act of 1875 was supposed to have ended racial discrimination but the Supreme Court overturned it in 1883 saying that individuals and private business could discriminate on the basis of race.  

The Peculiar Institution is a very scholarly work. It is well written and I encourage anyone with an interest in the history of this time or discrimination based on race or gender to read it.  My only other concern is with the extended title – The Making of Modern Psychiatry.  I would submit that it really contains very little to do with modern psychiatry – and like Cartwright’s drapetomania diagnosis is more the product of racism, politics, and an inadequate system of care. 

Supplementary 6:

The state of Virginia lists Eastern State Hospital as the first mental hospital in the United States dating back to October 12, 1773 and states that at one point it was called the Eastern Lunatic Asylum.  There is some history available on this Virginia State web site including commentary on Dr. Galt.

Supplementary 7:

The journal Alienist and Neurologist: a quarterly journal of scientific, clinical and forensic psychiatry and neurology was published between 1880 and 1920 when publication ceased.

Full text of this journal is available via the HathiTrust web site. 

Supplementary 8:

Drapetomania errors on the Internet - needless to say there are many.  I thought I would catalogue them but do not have the time. Unless the use is restricted to Cartwright and not applied to psychiatry it is probably safe to say it is being used rhetorically. 

The Current Moral Crisis In The United States

 

It is fashionable these days to talk about moral crises that really aren’t moral crises. The level of rhetoric is at the point where disagreements can be spun as moral crises, while people are dying in the streets. The best examples I can think of are the long-standing epidemics of gun violence and racism. New examples are cropping up every day. There are current trends in violence against Asian Americans and Jews against the backdrop of long-standing trends. Discrimination and violence against black Americans is finally acknowledged as being widespread and is the basis of an activist civil movement and hopefully systematic reforms.

All of the statistics to back up my statements in the first paragraph are easily available and I am not going to post all those references here. Since I started writing this blog one of my concerns has been gun violence and how to stop it given the level of interference with common sense gun law reforms by one of the major parties and major lobbying concerns. I saw the attempt to counter that political interference as being futile and focused more on public health interventions and possible psychiatric intervention. The latest good review of that approach is available in a review by Knoll and Pies (3).  For many years I have advocated that homicidal ideation should be seen as a public health intervention point and that it should be part of the strong public health message. To this day nothing has happened. Public health organizations do have research-based suggestions such as locking up firearms and common-sense gun laws like banning large capacity magazines, banning assault rifles, and universal background checks, but the general lack of progress in that area is not reassuring. There has been some movement in allowing more research on gun violence, an area that was previously blocked by gun lobbyists.

What is the connection between gun violence, racism, and violence toward our fellow Americans?  I think there are all based on the same interpersonal dynamic. That dynamic is seeing another person as being significantly different from you, attributing negative characteristics to them, and using both of those premises for treating them different from you up to and including perpetrating violence toward them.  In psychiatric jargon, we use the term projection to capture this process or in the extreme projective identification. These are not psychiatric diagnoses, but defense mechanisms that are distributed across the population even though they may be more likely in people with specific psychiatric diagnoses.

In my readings over the years I have been looking for a likely origin or at least first sign of this kind of thought pattern. In other words, have people been thinking like this since the beginning of recorded time, or is this a new phenomenon?  In the course of that reading, I came across a book written by the anthropologist Lawrence Keeley called War Before Civilization. In this book, Keeley explores the idea of the noble savage from prehistoric times.  In other words, were pre-historic people inherently peaceful as some had suggested or were there early signs of violence and aggression. A review of the evidence suggests that the majority of human prehistoric civilizations engaged in frequent warfare and total warfare – in other words attacks not limited to combatants and decimating the opposition’s infrastructure and ability to make war.  Keeley reviews the motivations and consequences of primitive warfare in great detail including tactics (surprise attacks, slaughter of noncombatants, and general massacres) and specific practices like mutilating dead bodies. There is clear evidence the latter functioned in part to dehumanize and humiliate the enemy and send a message to the survivors. These dynamics were not limited to prehistoric man and have continued through modern times and modern warfare.

A recent report referencing Keeley’s book appeared on Scientific Reports (2) this week.  It was a reanalysis of a Nile Valley burial site of 61 people from about 13,400 years ago. It is thought to be some of the earliest evidence of Homo sapiens interpersonal violence.  In that analysis over 100 lesions were identified in the skeletal remains from what appeared to be projectile weapons.  Examining the mortality curve of the individuals in the cemetery showed that it was consistent with multiple burials rather than a single event.   The stone artifacts examined were consistent with spear or arrow heads. Some we designed to kill by lacerating and causing blood loss. Some were discovered embedded in bones, but others were discovered within the area where the body was discovered and that was viewed as being consistent with the ability to penetrate the body.  The authors conclude that the majority of people in the cemetery died of blunt or sharp force trauma and that there were multiple episodes of interpersonal violence.  Some of the combatants had been wounded multiple times prior to death.  They also concluded that these episodes were most likely the result of “skirmishes, raids or ambushes” likely related to territorial disputes that may have been affected by the weather. (p. 9).

What can be inferred from this long history of human violence and aggression? First, groups of humans have been perpetrating violence against one another since prehistoric times. Second, during these episodes total warfare was very common and the human cost of war is always high. The estimated percentages of deaths in ancient society were generally higher than in modern society for a number of reasons. That was not a deterrent to ancient humans.  Third, the psychological states during these episodes of violence show a potentially broad range of thinking leading to aggression.  Very limited incidents such as the theft of livestock or a rumor of a sexual affair between members of different tribes or villages may be all that was required to start a series of retaliations leading to all out war.  Once a violent conflict ensued – there were thought patterns and rituals in place to justify the killing, prevent bad outcomes for the killers, humiliate the dead, and embarrass their families.

The current moral crisis in America seems to have a direct link with prehistoric behaviors. It is enacted by aggressive behavior that is described as racism, antisemitism, and gun violence, but the dynamic is the same one described in ancient man.  In other words, once a person can be seen and characterized as an enemy (for whatever reason),  it is very easy to vilify them, attribute the worst possible motivations to them, and use that as a basis for rationalizing aggressive behavior. In the past weeks, I saw two elderly Asian American women attacked at a bus stop by a man wielding a knife. The attack as so violent that the large blade of the weapon broke off inside the body of one of these women. In a more recent event, a heavily armed long time employee shot 9 of his coworkers and then killed himself when he was surrounded by police.  In both cases, the “motivation” for the violent behavior is unknown.  There is a suggestion of mental illness, but the majority of people with diagnosed mental illnesses and even the same diagnoses are not violent or aggressive. The sheer volume of mass shootings in the United States suggests it is more of a cultural phenomenon here than anywhere else but that is confounded by the easy availability of firearms.  The main difference between modern and ancient times is that we have a societal structure that is designed to contain violence and aggression and prevent larger outbreaks.  It is clearly ineffective at this point in preventing violence.

I am suggesting a common thought process here that does not require any psychiatric diagnosis and one that can be intervened upon and self-monitored.  In order to perpetrate discrimination, hate crimes, and even homicidal violence toward others 3 conditions have to exist.  First, the potential victims of violence need to be seen as sufficiently different from the perpetrator so that he can attribute unrealistic negative attributes to them and rationalize his aggressive action.  Second, the attacker can see himself as sufficiently different from the potential victims that he feels threatened by them and can rationalize attacking them for that reason alone.  A common example is that the attacker feels victimized by his coworkers and feels the need to strike out at them.  And finally, the attacker must have a plan to either seriously injure or kill the victim(s). All of these thought patterns can be considered derivative of thoughts present in ancient man leading to the wide ranging aggression and warfare described in the references.

I think there is much to be said for intervention based on the observations in this post.  For the time I have written this blog, I have advocated for intervention based on homicidal or aggressive behavior. When I worked as an acute care psychiatrist – treating violence and aggression was easily half of my job.  If we can suggest that persons with suicidal ideation or self-injurious behavior contact a crisis intervention service or hotline – why don’t we have a similar suggestion for people with homicidal thinking?  And further what about general education about the primitive origins of these thought patterns.  Just the other day I posted the following:

“Ridiculing people who died of C-19 and were antivaxxers and anti-maskers is bad form - plain and simple.

Bring civility back and restart civilization.

It starts with recognizing the value of a single human life.”

There was much agreement with the post, but also several people who suggested that I was naïve for not being able to recognize enemies or that I was a “better person” for being able to overlook the behaviors of a group of people who were potentially dangerous to others.  My post was not about moral superiority or not recognizing enemies – it is all about the fact that disagreement should not lead to enmity and beyond that we are all members of the same tribe.  We all came from Africa. And seeing differences between us that do not exist is probably ancient thinking that obscures the fact that we are all a lot more similar than we are different.  As I explained to some of the critics of my post, they seemed to be focused on the exceptions rather than the rule.  They also seemed to be making arbitrary exceptions based on seeing more differences than similarities. 

We are currently at a crossroads in this country.  People are making money and generating political capital by emphasizing differences and exploiting the primitive thinking that I have outlined in this post.  Much of the aggression plays out at a symbolic level in social media, but the Insurrection at the Capitol building and the increasing levels of physical violence illustrates that it is far from always symbolic. Americans have traditionally left ethics and morality up to religious institutions where it may be presented at an abstract level.   

It is time to get back to the basic premise of why every person is unique and needs to be treated with respect by virtue of being a member of the human race. It seems like an obvious but untested approach to reducing interpersonal violence at all levels in a society that is not currently equipped to prevent it.

 

George Dawson, MD, DFAPA

 

References:

1:  Lawrence H. Keeley. War Before Civilization. Oxford University Press, 1997.

2:  Crevecoeur I, Dias-Meirinho MH, Zazzo A, Antoine D, Bon F. New insights on interpersonal violence in the Late Pleistocene based on the Nile valley cemetery of Jebel Sahaba. Sci Rep. 2021 May 27;11(1):9991. doi: 10.1038/s41598-021-89386-y. PMID: 34045477 (Open Access).

3:  Knoll JD, Pies RW.  Moving Beyond "Motives" in Mass Shootings.  Psychiatric Times 36(1) Jan 13, 2019. Link

Permissions:  Graphic above is from reference 2 per the following Creative Commons license. 

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to theCreative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creative commons. org/ licenses/ by/4. 0/.

Addiction Narratives Versus Reality.......

I recently posted my take on this issue of race in addiction treatment. The main argument that I was responding to was that the current opioid epidemic is whitewashed so to speak. In other words white opioid addicts are considered to be "victims" of the opioid epidemic and black addicts are considered just to be addicts at best and criminalized at worst.  Part of the way that white people are framed as victims is by calling addiction a disease.  The author who I was critiquing at the time suggested that the opioid epidemic was marketed to white people along with the medication (buprenorphine) that would "cure" them.  Further, that buprenorphine was more easily available to white people by the nature of the prescribing requirements.  The article went on to selectively highlight one segment of the population where "non-Hispanic blacks" had a higher rate of overdose deaths, despite the fact that the majority of people dying in most categories were white.  I consider my counterargument to be a solid one and that is - there is no known difference in the biological predisposition to addiction of any kind that is based on race and if that likelihood is equal - the only consideration is who is exposed to the drug.

The racialization of the opioid epidemic picked up more speed over the weekend.  One of the theories proposed was that there were no previous "epidemics" of opioid use and that this is another way to sanitize the problem and make it more acceptable to white people.  The article was written for a newspaper - the Guardian and the headline says it all:  "Amid the opioid epidemic, white means victim, black means addict."  That is the basic thesis that runs through the entire essay.  You are either a white, Christian, Republican racist, who considers himself to be a victim of prescription opioid tablets or drug dealers or the hypocritical structure of American society insults you for being black and an addict.  It is suggested directly in the article that common rationalizations of addicts - the ones that everybody uses irrespective of race or substance are the exclusively used by whites to deny responsibility for addiction.  Self-loathing of the addict is described as though that never happens with white people.  Guilt, shame, and self loathing happens to everyone with an alcohol or drug misuse problem.
          
A couple of the arguments can be debunked at the outset. The idea that the term epidemics is applied only to white people so that they can rationalize being victims ignores the medical literature of the 1970s.  In those days researchers were using the terms epidemics and microepidemics and applying the terms across racial groups (3-6).  Successful naturalistic studies were conducted in both white and black neighborhoods and the success in a Chicago study (6) was  correlated with use of the term medical management.  Those same authors used what they called an infectious disease model for intervening in heroin epidemics (5).  The Chicago study was so successful that it was suggested as an alternative to involuntary treatment (4):

 "This work suggests that heroin addiction can be prevented in many who are at risk; it further suggests that prevention may be possible by using psychological and social concepts based on humanist principles without the use of coercion. The authors' approach deserves close attention not only because it offers hope in the face of a mounting national tragedy but also because of its relevance in the current high-level and little-publicized debate over the use of compulsory urine testing and compulsory treatment of drug dependent persons."   - p.1156
     
It appears that at least in psychiatry - humanism was emphasized as the critical element in treating drug dependent persons (not addicts) as far back as 46 years ago.  The design of the naturalistic study in question was impressive and methadone maintenance treatment was used in a majority of the patients.

The issue of differences in the story about the self perception of a white versus black addict does not have the equivalent empirical basis.  I can say unequivocally that any attitude in treatment about being a "victim" of substance use of any type  would be vigorously confronted by treatment staff.  It is not possible to actively participate in treatment with that attitude.  The same is true of the self loathing patient.  Guilt, shame, and self loathing need to be actively explored and corrected to allow participation in the recovery process.  Both attitudes can lead to distress or increased cravings to use drugs and alcohol and relapse.

What about the contention that cultural differences and disparities are the primary problem with treatment differences.  I refer any interested reader to an in depth analysis of the issues by Coleman Hughes (2) and what he describes as the disparity fallacy - in other words that the difference in outcomes between blacks and whites (or any two groups) is due to discrimination being the causal factor.  He lists an impressive number of examples, but I see the underlying principle as being one of undeterminism (7) that is there are multiple theories to account for differences, and people tend to have a favorite and ignore all of the other possibilities.  There is probably no better example than the race rhetoric around addiction.  The promotion of these arguments ignores the primary causes of addiction - a biological predisposition and exposure to the addictive substance.  I am not suggesting disparities are irrelevant to exposure or treatment access but focusing on them as casual ignores the major factors.           

The continued stories about racial differences in treatment and self perception are not really conducive to reshaping America's addiction treatment landscape.  It misses the big picture that there are no differences in race when it comes to addiction.  Any reasonable treatment approach would disabuse anybody coming through the door who believed they were either a victim or a self-loathing addict.  Identical treatment modalities should be offered irrespective of race and that includes medication assisted treatment of all types, necessary psychiatric and psychological treatment, medical evaluation and treatment, and drug and alcohol counseling focused on recovery.  One of the reasons why addiction is viewed as a chronic illness is the high likelihood of relapse and need for ongoing recovery services and support.  One of the main tenets of any 12-step recovery program based on the AA model is that nobody is turned away. The only requirement for membership is a desire to get sober.   

The real problem with drug and alcohol treatment is not racial disparity. It would be fairly obvious if racial discrimination was occurring in any comprehensive treatment program.  The real problem with drug and alcohol treatment is the lack of standards and consistency in treatment.  The most clear cut example is the availability of detox services.  Some forms of withdrawal are life threatening and need to be immediately recognized and treated.  I doubt that the majority of treatment programs in any state have that capability.  Hospitals have been defunded from providing detox services from anyone who is not experiencing life threatening withdrawal for about 30 years now. That has led to a proliferation of subpar and non-medical county detox facilities where limited to no medical care is rendered.  These kinds of inconsistencies in care occur across the board and it is common to see patients who have not received even basic addiction care - completing a treatment program and being released back to their home setting.

Racism has no place in medicine.  I have discussed the advantages of therapeutic neutrality on these pages before and certainly any physician who is not able to do that should not be practicing medicine in the 21st century.  The psychiatric standard for neutrality is higher.  Psychiatrists in particular are trained to understand cultural differences, but it is not possible to be an expert on every culture.  It is possible to appreciate the person in the room and proceed cautiously enough to assure that culturally sensitive care is being provided.         

In the end, there are clearly ways to prevent and treat addiction. Suggesting that race and the narratives around race are the primary factors that account for addiction or recovery is unfounded.


George Dawson, MD, DFAPA


References:

1:  Brian Broome.  Amid the opioid epidemic, white means victim, black means addict.  April 28, 2018.

2:  Coleman Hughes.  The Racism Treadmill.  Quillette May 14, 2018.

3: DuPont RL, Greene MH. The dynamics of a heroin addiction epidemic. Science.1973 Aug 24;181(4101):716-22. PubMed PMID: 4724929.

4: Freedman DX, Senay EC. Heroin epidemics. JAMA. 1973 Mar 5;223(10):1155-6. PubMed PMID: 4739378. 

5: Hughes PH, Crawford GA. A contagious disease model for researching and intervening in heroin epidemics. Arch Gen Psychiatry. 1972 Aug;27(2):149-55. PubMed PMID: 5042822.

6: Hughes PH, Senay EC, Parker R. The medical management of a heroin epidemic. Arch Gen Psychiatry. 1972 Nov;27(5):585-91. PubMed PMID: 5080286.

7:  Stanford, Kyle, "Underdetermination of Scientific Theory", The Stanford Encyclopedia of Philosophy (Winter 2017 Edition), Edward N. Zalta (ed.), URL = https://plato.stanford.edu/archives/win2017/entries/scientific-underdetermination/.

What Is Missing From The Divisiveness Debate?

Migratory routes of Homo heidelbergensis from East African origins (numbers are approximate years in past) - see attribution for reference.  Homo heidelbergensis is thought to be the common ancestor for Neanderthals, Denisovans, and modern humans - Homo sapiens.

The recent high profile incidents involving the shooting deaths of young black men and police officers and the associated news coverage and involvement by high profile celebrities and politicians has sparked a social activism, debate, and dialogue.  Like any complex issue, there are people who have opinions that mirror their political party lines, people who have their own opinions and they are not interested in changing them and people who are more open to a dialogue.  Practically all of the dialogue seems focused on high risk incidents that happen in a matter of seconds that involve deadly force.  I have seen some neuroscientific ponderings about how unconscious or implicit biases can affect those split second decisions.  I thought that was possible until I went to the web site and took the tests involving implicit bias.  There was not a single case where I could not predict the outcome ahead of time based on what I already know about myself.  To me it appeared that unconscious bias was not operating in the decision.  Since I am a white psychiatrist and not a police officer, I am not going to suggest specific solutions for police officers or the black community.  I do see a number of scientific dimensions that nobody or very few people are talking about so it is time to add my two cents:

1.  We are all from Africa -

Practically all of the debate centers on race.  There are statistical studies that show black drivers are stopped at higher rates than white drivers.  There are more white people killed by the police but as a proportion of the population black people are overrepresented.  The numbers are real and require serious analysis, but the larger picture is ignored.  That larger picture is that race is a social and cultural convention and not a scientific one.  On a scientific basis, everyone in the world - all human beings originated in East Africa about 200,000 years ago.  At some point, different races were described but at the time this genetic evidence was unknown.  The genetic evidence for racial and ethnic differences is still an area of active investigation.  Those studies illustrate the difference in skin color for example may come down to mutations in two genes (1, 2).  At the proteomic level, a recent study (3) looked at an analysis of interindividual variation in the total number of proteins that could be identified in cerebrospinal fluid (CSF) and urine and found considerable variation between individuals.  There was a 26% difference across 968 urinary proteins and a 18% difference for 512 CSF proteins.  Those numbers are very large compared with the difference between 1 or 2 skin proteins.

Although the total number of proteins identified in the human proteins is 10,500, estimate of the true size has varied from 10,000 to several billion (4) making the number of proteins responsible for skin color differences even less significant.  More skin specific information is available from the Human Protein Atlas.  Their analysis shows that there are 95 skin enriched genes and 412 genes with enhanced expression in the skin.  Only three of these genes MLANA, DCT, and TYR involve melanin synthesis or skin pigmentation.  Person to person variation on an arbitrary racial classification based on skin color is obscured by the expected genetic variation among members of the same race.

Further evidence is available to anyone by sending their DNA for analysis by the National Geographic Genographic Project.  You will receive a map of how your ancestors migrated from East Africa and information about marker that you share with other ethnic groups across the world.  The analysis will also include information about DNA that you share with ancient humans specifically Neanderthals and Denisovans.  The current project also estimates regional ancestry based on markers that appeared over time if migration from Africa occurred.  All of these science considerations should point to the fact that what we have generally considered to be racial boundaries may have political and cultural meaning to people - but there is no scientific meaning.  Every human being on the planet is descended from a small group of ancestors in East Africa.  Time to put the cultural and political stereotypes about race behind us.        

2.  Every person in the world has a unique conscious state -

One of the concepts that I am careful to mention whenever I am discussing aspects of psychiatric diagnosis is human consciousness.  From a neurobiological perspective the human brain has evolved to be a very efficient information processor.   Plasticity leads to experience dependent changes in the brain.  Experience can have a biasing effect of the general form that "my experience is everyone's experience" or "my experience is more valuable than anyone else's experience" or in the extreme case "my experience is the only one that counts."  Fortunately the human brain also has top-down controls like empathy, the ability to recognize that other unique conscious states exist, and the ability to correct its own erroneous biases.  Just the fact that every person on earth has a unique conscious state has significant ethical and moral implications for how one person interacts with another.  Those individual ethical imperatives are seriously watered down by political and legal limits that often target the lowest common denominator.    

3.  Anger has a predictable biasing effect -

Let me start off by saying that this paragraph is not meant to discount anyone's anger.  Anger is a universal human emotion, but the analysis of anger usually stops at the point of whether it is justified or not.  The analysis seldom looks at how anger biases subsequent decisions or how it might affect the initial encounter between the police and suspects.  Any student of social media can observe the very predictable polarizing arguments that occur following these incidents.  Partisans will frequently post arguments and counterarguments followed by statistics and counter statistics.  In many cases the arguments are rhetorical at at some level fallacious.  The dynamic driving these arguments is never mentioned and that dynamic is anger.  Anger has been studied by cognitive scientists and it functions to squarely focus blame on a specific person whether that is accurate or not.  This is as important for the police officer on the scene as it is for the secondary clashes between protesters, the public and the police.  When police officers confront a suspect and start swearing angrily at him/her to comply with their demands - that may be part of their training, it may be something that happens spontaneously, but in either case any real anger on the part of the officer implies that the subject has done something wrong and that the officer's decision-making capacity may be affected by his/her emotional state.  Emotions are critical in human decisions, but not all emotions result in a focus on another person as a source of wrongdoing.  

4.  Human reaction time is a limiting factor - 

The human nervous system takes time to process information.  There is surprisingly little public data available on how much time there is to make a decision to shoot an armed suspect.  The only study I could find (6) involved a simulation where an untrained armed suspect was either holding a handgun to his own head because he was allegedly suicidal or holding a handgun at his side when confronted by a police officer.  In the case where the suspect decides to fire a shot at the officer instead - it took an average of 380 msec.  Highly trained officers shot in 390 msec.  That translated to inexperienced suspects shooting first or tying the officers in 60% of the scenarios.  An interesting article in the literature also suggests that shooting errors in high threat situations persist even after weeks of practicing these scenarios (7).  For comparison, this web site allows for a determination of reaction time in a scenario that is completely free from distractions and noise - like anxiety and trying to determine if what the suspect is holding is really a firearm or not.  It is obvious that these decisions to fire by both officers and armed suspects are not like they are portrayed in television programs and films.  In real life there are no prolonged standoffs with officers and suspects pointing firearms at one another while they talk.    


5.  Human beings have a long history of solving difficult problems through violence and aggression -

One of the major lessons of human history is that lives matter only up to a point and if nobody agrees at that point - people will die.  In human history there are very few exceptions to that concept.  The best analysis of the situation that I have seen comes from anthropology (8) and the detailed study of modern and ancient warfare.  Several authors have written about the attractiveness of war to some of the participants - most prominent Chris Hodges (9).  The powerful combination of war and winning a conflict by force and being reinforced by the secondary aspects of camaraderie, teamwork, meaningfulness, and the political illusions of what an armed conflict can accomplish are all powerful incentives to avoid peace and conflict resolution.  The last time there was as serious peace movement in the USA it was largely a reaction to a prolonged and unnecessary war in Vietnam.  Since then there have been three unnecessary wars and no corresponding peace movements.

The war metaphor doesn't stop at the level of nations fighting nations.  At the next level it is always local governments and police departments fighting drug dealers, gangs, terrorists and various criminals.  I don't think that the reinforcers that occur at a global level stop just because the conflict is at a local level.  Americans in general want to see the bad guys stopped in any way possible.  With that attitude there are invariably serious mistakes.    


6.  Widespread availability of firearms ups the ante -

I have written about firearm related issues in many places on this blog.  My primary focus have been to suggest that violence, especially firearm related deaths including suicide, homicide, and mass shootings can probably be stopped by public health measures.  Very few people agree on those points and there are various political reasons why they do not.  Stopping firearm related violence does not necessarily require addressing firearms availability, but make no mistake about it - firearms access rather than mental illness is the number one cause of these deaths.  The problem with high risk scenarios involving either firearms or the threat of firearms with the police is even more obvious.  Statistics are available for the number of people killed by the police in a number of countries and the numbers are skewed in the expected manner toward the US.  It is clear that widespread availability of firearms is dangerous for both the police and the people who are being policed.  A lot of that comes down to being able to assess the threat and react in less than a half second.  That is the time a police officer has in a high threat scenario.

The six dimensions I briefly described are critical but unmentioned in the current debate.  The current debate is framed in terms of race, immutable interracial relationships, and a lack of scientific consideration at several levels.  At the cultural level, the notion of race having some specific meaning needs to be put to rest forever.  There is no scientific basis for classifying people based on skin color or other so-called racial characteristics.  Racial diversity is nothing compared with genetic diversity and that needs to be the new standard.  The second scientific consideration is based on the unique conscious state of humans.  This important concept should form the basis for everyone being treated with respect and consideration.  That is not to say that will preclude criminal conduct or violent acts against bystanders, but it should be a standard for everyone else.  The expression of anger especially sustained anger has a particular biasing effect that is never mentioned.  We hear that anger is appropriate or justified, and therefore it should be expected.  Appropriate, justified and expected anger still affects human decision making in a predictable way.  The angry - no matter who they are need to realize that they may not be seeing things clearly due to the predictable and biasing effects of that emotion.  The technical aspects of human reaction time and the fact that decision making in high threat situations does not improve - even with training is a sobering fact that all police officers need to deal with.  Given the quoted statistics, in high threat situations when a subject is armed - the outcome of that confrontation will essentially be a coin toss.  The only logical approach to the situation is to design a new situation where it does not come down to reaction time and every officer knowing they have a 50:50 chance of being able to shoot first.  There is an innate human tendency for conflict resolution by aggression and choosing sides on how that plays out is not the best way to resolve the problem.  All that I have seen in social media and the press highlights a string of arguments designed to support one side or the other.

Considering the science behind this problem will lead to permanent, long term solutions.          



George Dawson, MD, DFAPA


References:

1: Murase D, Hachiya A, Fullenkamp R, Beck A, Moriwaki S, Hase T, Takema Y, Manga P. Variation in Hsp70-1A Expression Contributes to Skin Color Diversity. J Invest Dermatol. 2016 Apr 16. pii: S0022-202X(16)31047-8. doi: 10.1016/j.jid.2016.03.038. [Epub ahead of print] PubMed PMID: 27094592.

2: Yoshida-Amano Y, Hachiya A, Ohuchi A, Kobinger GP, Kitahara T, Takema Y,Fukuda M. Essential role of RAB27A in determining constitutive human skin color. PLoS One. 2012;7(7):e41160. doi: 10.1371/journal.pone.0041160. Epub 2012 Jul 23. PubMed PMID: 22844437; PubMed Central PMCID: PMC3402535.

3: Guo Z, Zhang Y, Zou L, et al. A Proteomic Analysis of Individual and Gender Variations in Normal Human Urine and Cerebrospinal Fluid Using iTRAQ Quantification. Pendyala G, ed. PLoS ONE. 2015;10(7):e0133270. doi:10.1371/journal.pone.0133270.

4:  Elena A. Ponomarenko, Ekaterina V. Poverennaya, Ekaterina V. Ilgisonis, et al., “The Size of the Human Proteome: The Width and Depth,” International Journal of Analytical Chemistry, vol. 2016, Article ID 7436849, 6 pages, 2016. doi:10.1155/2016/7436849.

5:  Skin specific proteome.  The Human Protein Atlas.  Accessed on 7/16/2016.

6:  Blair JP, Pollock J, Montague D, Nichols T, Curnutt J, Burns D.  Reasonableness and reaction time.  Police Quarterly Dec 2011; 14: 323-343 (especially pages 15-20).

7:  Nieuwenhuys A, Savelsbergh GJ, Oudejans RR. Persistence of threat-induced errors in police officers' shooting decisions. Appl Ergon. 2015 May;48:263-72. doi: 10.1016/j.apergo.2014.12.006. Epub 2015 Jan 16. PubMed PMID: 25683553.

8:  Lawrence H. Keeley. War Before Civilization. Oxford University Press, 1997.

9:  Chris Hodges.  War Is A Force That Gives Us Meaning. Public Affairs, New York, New York, 2002.

Attributions:

Attribution:  Graphic at the top is by Altaileopard SVG by Magasjukur2 [CC BY-SA 2.5 (http://creativecommons.org/licenses/by-sa/2.5)], via Wikimedia Commons at: https://upload.wikimedia.org/wikipedia/commons/4/41/Spreading_homo_sapiens.svg