Coercion versus something else?

 

My motivation for writing this post comes from recent activity on Twitter about “coercive care” in psychiatry and an opinion posted there by a psychiatrist suggesting that psychiatrists need to be aware of their role as an agent of the state when they are engaged in involuntary treatment. After seeing this I checked the literature and there were papers published on the subject – so I thought I would write a post about the issue – specifically whether coercion is an appropriate word to use and how it compares to involuntary treatment as a description and a concept.

I don’t consider the issue lightly.  For most of my career I have been in acute care settings that required knowledge and skill in negotiating involuntary care scenarios – specifically emergency holds, probate court holds, civil commitments, conservatorships, and guardianships. That involved hundreds of court appearances in 7 counties and 2 different states.  I also testified as an expert on the issue of prolonged state hospital stays for a patient advocacy organization and testified in both malpractice cases and a criminal responsibility case.  I have personally seen how local politics can affect the civil commitment and conservatorship laws to the point that they are actively ignored for various reasons. In that unstable landscape, the staff responsible for treating the patient needs to be very flexible and innovative to provide the necessary care.  The following graphics show what that care generally looks like.  It is a diagram of how involuntary treatment gets initiated and carried out.

The commonest path is that there is an incident in the community, emergency medical services are activated, and the patient is placed on a hold and transported to the emergency department (ED).  While there an ED physician and mental health clinician (typically a social worker) makes and assessment of the patient and determines if they can be discharged, admitted on a voluntary basis, or admitted on an emergency hold. 

Following the admission, the inpatient staff makes their respective assessments and typically discuss their findings and the plan in team meetings. If the patient was admitted on a timed hold (72 or 96 hours) and a determination is made that the patient cannot be treated on a voluntary basis prepetition screeners are contacted.  They come in and see the patient and collect more collateral information than the inpatient team has access to.  They compile this in a prepetition screening document and in a team meeting separate from the hospital staff (they are typically county employees) make a determination that the hold will be cancelled or they will refer the patient for further court intervention.  If they determine to not support the emergency hold, the patient is typically discharged and it is illegal for a physician to immediately place them on another emergency hold. If they are referred to the court a probable cause hearing is held.  At that point the judge can release the patient or refer for a final hearing.  Before any final hearing, 2 court appointed examiners (typically a psychiatrists or psychologists employed by the county) will see and assess the patient. They will testify in court and give specific treatment recommendations to the court – independent of the hospital staff charged with treating the patient. At the final hearing the patient can again be released with no court intervention based on a judge’s decision. They can also be court ordered to follow treatment recommendations including further hospitalization and medications.  Courts can also accept a stay of commitment – meaning that the patient is not formally ordered to accept treatment for a duration of time but they can accept treatment and follow up and if everything is going well at 6 months any involvement with the court self dismisses.  There is a similar intervention for persons who have been formally committed called a provisional discharge. In that case, the person is discharged with a plan to report back on outpatient progress. The structure of this process highlights the fact that no single person or discipline makes a decision about involuntary treatment. In addition, the statutory requirements for mental illness or substance abuse do not specify any particular diagnosis but depend on whether there is behavior that is self-endangering, harmful to others, or significantly affects the person’s ability to function in their own interest at the most basic level (adequate self-care in terms of food, housing, and addressing significant medical problems).

The question critical to this post is how is this process coercive rather than involuntary?  And is there a difference between those terms?   Just looking at standard definitions coercion is clearly more insidious and it implies malignant intent. The Webster’s definition is “to compel by force or intimidation; to bring about by force; to dominate or control esp. by exploiting fear, anxiety, etc.”  Using the same source, the definition of involuntary is “not voluntary, independent of one’s will.”  At this level, coercion is nothing medical staff are ever trained to do and in fact would constitute a violation of professional ethics.  In psychiatry, the training is focused on helping psychiatrists overcome standard biases that people experience when interacting with others who have clear problems with severe psychiatric disorders.  The entire focus of psychiatric training is developing a cooperative and helpful relationship.

What about legal definitions and statutes pertaining to coercion?  The legal definition of coercion is essentially the same as the dictionary definition:  Verbal and/or physical threats and other forms of intimidation in order to force someone to do something/not do something that they are otherwise legally allowed/not allowed to do.  Laws against coercion in federal statues range from the obvious forms like sex trafficking to threats of retaliation for political activity or exercising rights at work. In all of these cases, the victims of coercion are generally going to be capable of making decisions in their best interest but are unable to make willful decisions due to coercion.

It turns out that an entirely different level of analysis has been applied to the issue of coercion and psychiatric patients. That level of analysis is done by philosophers using thoughts about coercion from previous works on ethics.  For example, Schramme (2) expands arguments from Frankfurt’s work to discuss specific examples of coercion. He begins with the informed consent model.  I consider Gutheil and Appelbaum to be authoritative in this area and they discuss three elements of informed consent: information, voluntariness, and competence (3).  The adequate information is discussed from the perspective of a professional level of disclosure and also a “reasonable person” or the level of information that most people would expect. The expected information varies from state-to-state and in some cases for psychiatry there is a written information standard. For example, in the State of Minnesota, antipsychotic medication consent requires a signed consent form about those potential side effects.  Voluntariness means consent is freely given. It is often assumed that since psychiatric patients are generally considered to be vulnerable adults who may be dependent on institutions that this is a form of situational coercion. Gutheil and Appelbaum point out that this would in effect not recognize the decisions made by large numbers of people in institutions just because of the place they reside. They describe more clearcut and explicit forms of coercion such as threatening the loss of food or clothing if the patient does not follow recommended treatment. Competence means that the patient has mental capacity to understand the information presented and may a make a reasonable decision in order to give informed consent.  Psychiatric disorders can affect all three elements of informed consent.

The philosophical look at coercion is a bit more complex and it is selectively applied to the case of psychiatric care. Just looking at the demographics raises some questions.  There are 1.3 million people in the US under guardianship or conservatorship. At the same time there are 6.96 million people with dementia, 500,000 people with moderate to severe intellectual impairment, 36.25 million with subjective cognitive impairment, and an undetermined number of people with cognitive impairment and impaired capacity secondary to severe psychiatric disorders. Those numbers suggest that there are not nearly enough guardianships in place to provide substituted consent for people during medical emergencies.  In many jurisdictions guardianships and conservatorships have to be pursued by family and that often creates an undue financial burden. In the jurisdictions that actively ignore conservatorships and guardianships – persons needing them often incur unnecessary medical risk because treating physicians realize that they cannot accept their consent to procedures involving risk – like surgeries.

Schramme has analyzed the issue of coercion in the following ways. He breaks coercion down to threats and offers.  For the purpose of his discussion, he states that he is exclusively focused on autonomous choices that are contrary to the will of the patient.  These choices cannot be made under the influence of threats but he outlines 3 scenarios where informed consent is lacking:

1.  A patient is not able to give informed consent – I think he makes a critical mistake here by stating that most psychiatric patients are able to give consent and their capacity is not globally impaired.  It clearly depends on illness severity and the stage of treatment. Most forensic hospitals are charged with the task of restoring competency to mentally ill offenders so that they can proceed to trial.

2.  A patient disagrees with treatment and makes that known but he is forced to accept treatment anyway. The example given is a patient who if forced to take medication because he is potentially dangerous to others. Schramme depicts this as “a conflict between the patient’s will and the opinion of the doctor”.  But where does the dangerousness come in? Why is the patient unable to see that he is at risk from an extremely adverse outcome (aggression and long-term incarceration or injury and possible death due to a confrontation with the police) and not incorporate that into his refusal?

3. A patient passively complies with a treatment recommendation and does not make an overt decision. Schramme states that although this would not typically be considered as coercive treatment – it all depends on whether the consent is given freely or not. The implication is that passive consent is not necessarily informed consent.  Schramme invents the term “interactive coercion” to suggest that psychiatric patients can be coerced by the interpersonal relationship beyond what is typical of medical paternalism. That presupposes that either nonpsychiatric physicians do not have relationships with their patients, psychiatrists are masters at manipulating people, or some combination.

From that point he goes on to provide 3 examples of interactive coercion  

Case 1:  The psychiatrist predicts that “damage or harm” will occur if the patient does not follow certain course of action. This may or may not be coercion. Schramme gives the example of taking away the patient’s cigarettes or writing them a suboptimal report (the damage or harm) unless they comply with the prescribed course of action.  He acknowledges that harm can be predicted due to non-compliance and it may not be a threat but a natural consequence of untreated illness. Prediction of future causal events is a warning and not a threat hence no coercion (p. 360).  On the other hand, he suggests an “unusual” prediction such as electroconvulsive therapy (ECT) if the patient had no previous experience either it would constitute a threat.  The two necessary features for predicted harm to be a threat/coercion would be that it needs to be intentional and unusual.

Case 2: The psychiatrist proposes a “detrimental unusual consequence if the patient does not comply an example of effective threats as coercion. In this case, if the threats are ineffective, they are inconsequential, lead to no coerced decision. Schramme points out that “there is no rigid line between a threat and a warning”. He gives an example of a patient interpreting an action as a threat that may have had more to do with the social roles of patients and nurses on the ward.

Case 3: The psychiatrist offers a beneficial unusual consequence if the patient complies with a specific task. In this case there may be intermediate conditionals. For example, the patient may not be motivated or feel like socializing but forces themselves to do it anyway to get the offer.

Schramme introduces the idea of irresistible threats and offers at this point. An offer becomes irresistible when there is no other real alternative.  In this case even if the choice is voluntary, it can still be against one’s will.  The best example is substance use disorders where the person may not want to take the drug but acts on the drug as an irresistible offer rather than a preferred motivation to remain abstinent. This is an example of an offer that is irresistible and therefore coercive in that it they are against the will of the person.  This is not a hard rule and Schramme emphasizes that all offers are not bad and they depend on the subjective preferences of the patient.  He goes on to develop the idea that “manipulation and coercion – at least in psychiatric hospitals – do not only stem from predicted consequences which bring people to do A, namely that they to prevent bad things from happening.” (p. 367). Instead, he defines it as “an influence on the autonomous will of the patient and not on the welfare of a person”.  He closes by pointing out that institutional and interpersonal dependencies can also result in irresistible offers to psychiatric patients.  He cites some examples that today are irrelevant or exaggerated. For example – giving a patient cigarettes if they take a medication or the offer of a “good report” for group attendance.  I have not observed either of these happening on inpatient units over the course of my career even when smoking was allowed on inpatient units.  Even so, Schramme concludes that these coercive offers are not necessarily morally wrong because “it might be good to sacrifice the freedom of the patient for the sake of his well-being.” (p. 368).  That is more than a trivial distinction and I would argue is the basis of both civil commitment and guardianship or conservatorship.

Szmukler and Appelbaum (4) reviewed the coercion literature to date and described their own approach to the issue of coercion. Their first step was noting that coercion was a loaded term and describing a graduated systems of treatment pressures including:

(1) persuasion

(2) interpersonal leverage

(3) inducements

(4) threats

(5) compulsory treatment (in the community or as an inpatient).

They provide an example of a community psychiatric nurse following a patient in the community and how each of these pressures may work. They develop models based on paternalism and capacity/best interests.  Their definition of paternalism based on previous research is given as:

“…a person is acting paternalistically towards another if his action benefits the other; his action involves violating a moral rule with regard to the other; his action does not have the other's past, present, or immediately forthcoming consent, and the person believes he or she can make his or her own decision on the matter. A paternalistic act requires justification because it involves the violation of a moral rule but with the intention of preventing a harm to the person.” (p. 240)

A series of questions is provided to answer whether or not a paternalistic intervention is indicted.  Answering those questions for a typical emergency admission to an inpatient setting is typically balancing the deprivation of personal liberty against death and disability.  More subtle tradeoffs don’t end up as admissions to inpatient units.

A capacity/best interest analysis is just the way it sounds.  The patient has impaired decision making and is not able to make decisions in their best interest. Best interest has a degree of subjectivity but the authors describe some general guidelines based on previous work. The authors suggest that clinicians need a consistent ethical framework for approaching these problems that is as rigorous as the typical technical frameworks they use in practice.  

“Protection of others” is described as a more difficult problem for Szmukler and Appelbaum largely because of the subjectivity involved. They discuss for example the low percentages of patients with mental illness who are aggressive and the impossibility of prediction. They do not mention that a number of features (acute care settings, acute threats, history of violence/aggression, psychosis, pooling of cases, access to weapons) may greatly increase risk but they are writing from the perspective of community rather than inpatient care. They make an interesting comment: “Mental health professionals may accept an obligation to notify appropriate authorities if there is a serious risk of harm to others, but what is serious and who should instigate or implement coercive responses is a matter for debate.”  (p. 242). My understanding is that there is a duty to warn in every state and the clinician not only needs to make a good faith effort to contact the potential victim and take what other steps may be necessary (eg. calling the police) to protect that person.

With that review, what assures that the term coercion is not just another term used to inappropriately criticize monolithic psychiatry?  The standard dictionary definitions implying malignant intent is certainly consistent with inappropriate criticism.  Schramme acknowledges that there are situations where informed consent cannot occur due to a lack of capacity but goes on to elaborate on treatment refusal where there is probably lack of capacity and consent where the patient interactively coerced by institutional or interpersonal scenarios.  There is a high degree of subjectivity involved in the interactive coercion scenarios.  Schramme seems to approach the problem hypothetically rather than interactively. For example, as a clinical psychiatrist why would I ask if the patient was perceiving a warning or a threat – I would just ask them. In many cases agitated and paranoid patients are spontaneously accusing staff of threats and malignant intent before any assessment or conversation has occurred.

The best way I can think of how to proceed is to post a vignette – in the standard way that they are posted these days – a composite of features noted over the course of 25 years and not any specific patient:

 

Case Vignette

 28-year-old man with schizophrenia and Diabetes Mellitus Type 1 since age 8. He stopped treatment for schizophrenia a year ago. Since then, he has been hospitalized for recurrent diabetic ketoacidosis (DKA) four times and the consult-liaison (C-L) team has noticed progressive cognitive problems. He is discovered by the police in a park at night. The air temp is -5°F/-20°C and he was not wearing adequate clothing (no jacket, caps or gloves). In the ED he is noted to have a frostbite injury of his feet and hands. He requests immediate discharge and states that he will follow up with medical and surgical care on an outpatient basis. He refuses to consider psychiatric care. He denies any hallucinations or delusions.  He is admitted to the burn unit on a 72 hour hold by the ED physician.  Is this coercion?

He is seen the next day by the C-L team. He has some mild cognitive impairment and memory problems.  He is detached and not saying much about why he was hospitalized. His affect is restricted but he does not appear to be depressed. He is requesting discharge but has no clear plan of what he will do when he leaves.  When asked about the diabetes mellitus diagnosis he replies: “I can’t have it because I don’t have a pancreas.”  The C-L team recommends referral to inpatient psychiatry and proceeding with a probate court referral.  The team speaks to a family member there who talks at length about the family’s concern for the patient’s safety and their relief that he is hospitalized. Is this coercion?

This is a realistic description of how patients are admitted to acute care hospitals. The police officers in this case call EMS and the patient is assessed by paramedics. The patient is taken to a local emergency department where he is seen by a physician and a social worker and admitted. In this case an involuntary hold is initiated by the police or by the ED physician. A psychiatric diagnosis per se is not required since the statutory definitions of mental illness are based on impaired judgement that endanger the person or their health.  Independently 6 people (none of whom were psychiatrists) agreed those conditions existed.

He is seen and treated by surgery staff. He passively goes along with treatment but there are obvious concerns about his capacity. Is this a case of “interactive coercion” by surgical staff per Schramme’s formulation? He is non-disclosing with psychiatry staff but the key observation is that he no longer believes he has diabetes because he no longer has a pancreas.  This is not a basis for adequate medical decision making or self-care and that is further documented by his 4 episodes of diabetic ketoacidosis, continued inability to manage this condition and the question of cognitive impairment after episodes of coma. This patient is referred for civil commitment and will be seen by pre-petition screeners (typically one screener but a team of 4-5 people make the decision), a defense attorney, 2 court appointed examiners, and a probate court judge.  A total of about 9 people are involved in a process to determine if the patient meets statutory requirements for civil commitment and whether treatment should be court ordered.

Looking at the formulations of both Schramme and Szmukler and Appelbaum is instructive.  The probate court proceeding that I describe is clearly a safeguarded capacity/best interest scenario. The patient clearly lacks the capacity to make an informed decision and consent on the basis that he no longer recognizes that he has diabetes or that it needs to be treated despite life threatening consequences. It is very clear that he would not get adequate treatment of diabetes or the frostbite injuries if he was not hospitalized, observed, and actively treated. By their formulation they would say that maximum treatment pressure is exerted by compulsory treatment. In the final analysis, the ethical issue is that the patient is being deprived of his right to continue to wander the streets without adequate clothing or medical treatment for the compulsory treatment.  Apart from a magical immediate restoration of capacity is there a better short-term solution that is better designed to protect his rights? I don’t see any.

An additional consideration is the issue of agency on the part of the inpatient psychiatrist.  That psychiatrist has a fiduciary responsibility to the patient. That involves discussing all relevant aspects of diagnosis and treatment with the patient, including the concerns about his ability to care for himself. Is that psychiatrist and agent of the state or as some philosophers like to put it – the will of the state is being enacted though that psychiatrist? Definitely not and here is why – the will of the state is transacted through the commitment court and all of those personnel.  The treating psychiatrist is unnecessary for the commitment proceeding and the court is focused on what their examiners conclude.  Psychiatrists have no personal stake in whether somebody is detained in a hospital by a court order. In fact, without a court order it is an unlawful detention subject to both criminal and civil penalties.  Over the years I have had to discharge many people because the court did not produce a timely court order or decided to release the patient.  Further, in the actual hearing the opinions of the court examiners are the ones the judges depend on. The only interest of the inpatient psychiatrist is making an accurate assessment, making sure all of the patient’s medical problems are treated, and making the optimal recommendations for medical and psychiatric care. The inpatient psychiatrist is also talking with the patient on a daily basis assessing progress and attempting to establish a good working relationship with the patient whether or not a court hold is in place or not. That working relationship is possible when the patient recognizes that there is no adversarial relationship with the inpatient psychiatrist. In fact, the treatment of patients on court holds should be indistinguishable from voluntary patients.

By Schramme’s formulation that patient is not a competent consenter. As noted about his passive cooperation with the burn surgeons, endocrinology, and the inpatient psychiatrist might be construed as interactive coercion. There is also a chance that it might not be according to these definitions because the psychiatrist is discussing adverse outcome with the patient but the discussion is based on what has happened many times already.  Even with compromised cognitive capacity the patient is able to acknowledge this and the fact that he does not want to end up in a coma in the ICU gain. Another important aspect of these discussions is the psychiatrist is very neutral and not reactive or blaming. They are a sincere expression of concern given everything that is going on an what has happened to the patient.

A final consideration here is that both philosophical and legal approaches to involuntary treatment probably do not capture what is really happening. For example the will  or the autonomous will is the focus of both the coercion and the involuntary treatment discussion.  Reading though any paper on the will, illustrates that it is a vague, changeable, and completely subjective concept.  It is also not constant over time. When philosophers like Schramme write about it – the are typically referring to an individual and not a class of people. It makes more sense to talk about a person’s conscious state rather than an isolated will.  Conscious states are complex and multidimensional (6).  Even though they cannot be accurately measured at this point – on a clinical basis it can easily be observed that conscious states can change from being adept at self-care and day to day living to states where inadequate self-care becomes self-endangering. It makes very little sense to think that the will or autonomous will of a person experiencing a major psychiatric illness is constant over time. The goal of treatment ideally is to restore the autonomous will and assist the patient with getting back to their baseline.  I have had that confirmed many times by people who benefitted from that process.

 

George Dawson, MD, DFAPA  

 

References:

1:  Bureau of Labor Statistics. Occupational Employment and Wages, May 2020 29-1223 Psychiatrists https://www.bls.gov/oes/current/oes291223.htm

2:  Schramme T.  Coercive threats and offers in psychiatry. In. Schramme T, Thome J (eds). Philosophy and Psychiatry. Walter de Gruyter; New York; 2004: 357-369.

3:  Gutheil TG, Appelbaum PS.  Clinical Handbook of Psychiatry and the Law, 3^rd edition. Lippincott, Williams, and Wilkins, New York; 2000; p. 153-162.

4:  Szmukler G, Appelbaum PS. Treatment pressures, leverage, coercion, and compulsion in mental health care, Journal of Mental Health. 2000 17:3, 233-244, DOI: 10.1080/09638230802052203

5:  Walter J. Consciousness as a multidimensional phenomenon: implications for the assessment of disorders of consciousness. Neurosci Conscious. 2021 Dec 30;2021(2):niab047. doi: 10.1093/nc/niab047. PMID: 34992792; PMCID: PMC8716840.

 

Supplementary 1:  Workforce exposed to involuntary treatment scenarios:

There are an estimate 30,451 working psychiatrists in the United States. According to the Bureau of Labor Statistics 25,540 are employed and the rest are self-employed.  Since it is very likely that acute care psychiatrists are employed by hospitals 4,160 are in General Medical and Surgical Hospitals and 3,550 are in Psychiatric and Substance Use Hospitals. There are currently 37,400 members in the American Psychiatric Association and that number may reflect researchers and the retired.  The total pool of psychiatrists who might be involved at some level in involuntary treatment is about 7,710 from the acute care setting but that is likely a gross overestimate for several reasons. First, not all acute care settings treat people on an involuntary basis. In any metro area emergency medical services (EMS) generally brings the patients to only those hospitals who can provide the full array of emergency services. Second, even among psychiatrists employed in hospitals only a small percentage of them will provide direct care to patients who are there on an involuntary basis. Third, there are very few free-standing psychiatric hospitals or substance use facilities that accept anyone on an involuntary basis. It is very likely that less than 10% of the psychiatric workforce ever provides treatment to people on an involuntary basis.   

Supplementary 2: Graphic modification to show the emergency hold and probate court hold

Supplementary 3:  Historical note

Although the patient is clearly safeguarded in the above process - some people might ask themselves: "Why don't we just abolish involuntary treatment and let things revert back to the way it was?"  It would certainly make things a lot easier for psychiatrists. The short answer is that it is inhumane to people with severe mental illness and their families.  The families are typically omitted from any discussion of involuntary treatment but historically they were charged with trying to contain a family member with severe problems.  Patients in those situations often had catastrophic outcomes and even if they did not entire generations of family members were adversely affected by single family members with severe mental illness.  That history is out there but it is difficult to find probably because of the stigma associated with those disclosures.

   

This Is How Civilization Ends...

I had that thought immediately after seeing the above graph on the CDC web site. Over a million new cases.  An all-time high by far.  At that point, the news had been heavy with discussions about the Omicron virus for about 3 weeks. The trail though Africa and Europe was described.  In the United States we had plenty of warning and plenty of time to adjust.  It wasn’t like that first peak in the fall and winter of 2020-2021.  Back then there were no vaccinations.  My wife an I finally got vaccinated in March of 2021 and then only by an extraordinary stroke of luck.  Before Omicron we were flush with vaccinations.  Two different retail pharmacy chains were scheduling appointments and they were free. When the booster came out that was also free and much easier to get. The overwhelming scientific evidence was that the immunizations were safe and effective.

The public health measures seemed less effective. That could be confirmed by a walk around Target or Walmart. At the absolute peak of mask wearing in Minnesota, my estimates were up to 30% of shoppers were masked. Half of those masks were loose fitting cloth masks and probably not very effective. Today, at the height of the Omicron spike 10% of the people in my coffee shop were masked and I was the only guy wearing an N95.  Despite an increasingly vocal group of aerosol scientists most people remain shockingly ignorant or willfully ignoring the airborne route of transmission. The most easily observed scenario is restaurant dining where the customers wear a mask to the table and then take it off to eat and talk for the next two hours. There is no magical protection from airborne virus in that scenario. Forget about the 6 feet safe distance rule at the start of the pandemic. Looking for restaurants that have improved their HVAC systems to improve airflow and air exchanges over time was also disappointing. So far in the Twin Cities Metro area I have found 1 restaurant. No restaurant or business as far as I know is posting their air exchanges per hour or carbon dioxide measurements to describe the potential risk of their environment. They are posting that they adhere to social distancing and all of the surfaces are wiped clean between diners.

Despite all of that inertia, the restaurants are packed.  Typically, shutdown occurs when a significant number of staff are ill with coronavirus and they cannot stay open. I dodged a bullet at Christmas just as infections were increasing. My wife and I were supposed to meet another couple at a restaurant. My suggestion to get take out and eat it at either of our homes was met with resistance. I was saved by a call from that restaurant that significant numbers of their staff were ill and they would be closing until things improved.   

The general cultural landscape has been even more grim. I follow all of the experts in the media on a regular basis – Drs. Fauci, Hotez, Jha, and Walensky.  On an average day they are awash in a sea of misinformation.  That sea contains the entrepreneurs who see the pandemic as a money-making scheme as well as the purely irrational who find that conspiracy theories about the virus, vaccine, and public health measures are easier to understand and believe than the science. Political opportunists are in the mix and as recently as today were suggesting that “white people” were being discriminated against and were less likely to get the vaccine as a result. The Florida Governor made this statement:

“We reject the biomedical security state that curtails liberty, ruins livelihoods and divides society.”

Biomedical security state? The politicization of this pandemic knows no bounds. It obscures both the science and goodwill toward the scientific and medical communities.  But it doesn’t stop there.  In some large health care organizations 10% of the workforce has been fired for not complying with workplace mandates on COVID-19 immunizations.  Some of these workers are physicians who should have been taught basic epidemiological concepts – the most basic being that vaccinations are a rare medical miracle that have saved the lives of tens of millions of people.  Disease have been eradicated, prevented, and the course of infectious diseases has been altered.  And even if you are not a physician, everyone has the experience of taking all of the mandatory vaccinations required to attend school.  Most of these vaccinations had a significantly worse side effect profile than the currently available COVID-19 vaccinations.

Apart from reducing rates of infection, hospitalization, and death these modern vaccinations also reduce the risk of chronicity. Chronic or “long COVID” symptoms might occur in as many as 70% of patients after the infection. Remission rates and rates of disability are still being determined at this time.  Given the risk/benefit considerations of the vaccinations it is difficult to see how any rational person would refuse it.  It is even more difficult to understand how a rational person would not take basic measures to protect themselves and their families from airborne virus or justify ignoring the pandemic on the basis of a completely implausible conspiracy theory. In some cases, the motivations are very clear.  Politicians would rather use various forms of rhetoric to attack the idea of a pandemic and what it takes to resolve it for political gain rather than taking positive steps recommended by experts. It is a standard political tactic.  That rhetoric has been advanced to extreme levels and to the point where scientists and their families are being threatened.  Today the suggestion that “white people” were being discriminated against struck me as white nationalist rhetoric.  It was viewed just as another “falsehood” in the media.  Certainly, blind partisan acceptance of these statements is not very likely to exhibit flexibility in thinking about the pandemic, the virus, or possible solutions.

The press has stepped in and commented on the process as a “mass delusion” or “mass psychosis” as if the use of psychiatric jargon by a journalist would add credibility to the criticism of many people thinking and acting irrationally. Many of them are agitated, visibly angry, and can become aggressive typically when confronted about pandemic precautions in schools and businesses.  Hardly a day goes by without seeing an airline passenger or town hall meeting participant screaming until they are red in the face and carted away by security. None of these people has a psychiatric disorder.  They can cool off somewhere, suppress their irrational thoughts and the associated anger, and get up and go to work the next morning.  During the run up to the 2020 Presidential election there was heated commentary about President Trump’s mental health and fitness for office. There was some debate in the psychiatric community if it was appropriate to discuss that issue based on Trump’s observed behavior rather than a psychiatric assessment. This essay looks at the other side of that debate. Why do so many people follow leaders who make repeatedly false statements that in some cases are viewed as potentially inciting people to do the wrong thing? And conversely – how do so many people accept the more obvious rational path and reject all of the paranoia and conspiracy theories?

There are of course numerous theories about how this comes about.  The theories generally depend on the same theories that have been used to describe normal development, psychopathology, and normal learning processes.  In some cases the theories have a philosophical basis – that seem to be fashionable these days. And despite many of these theorists incorporating a neurobiological model – very little explanation about how that is relevant.

The relevance is obvious to me starting with the relationship between emotion and cognition specifically decision making. In order for it to be obvious, the relationship between emotions and normal decision making needs a brief exploration. Human decision making typically occurs as an integrated process in the frontal cortex. I won’t digress into any subdivisions or tracks in this post. The key word here is integrated. That means the frontal cortex takes a large number of inputs and uses them to varying degrees in the ultimate decision. That includes a lot of memory input, specific types or learning, emotional input, and real time sensory and perceptual data.  The amount of input is large and much of it occurs at an unconscious level. How it occurs is largely unknown at this point but with our limiting inputs have been determined.  One of those inputs is emotion. We know for example from lesion studies that emotional input is absolutely critical for normal day to day decision making. Of the vast number of potential decisions we all have a subset that are associated with emotional valences that can affect our preferences. Without access to those valences decision making slows and grinds to a halt.

Restricting our consideration of the decision space to all of the possible decisions about the pandemic and how to proceed – all of the medical, scientific, personal, political, manipulative, and conspiracy theories the possibilities are very large. If we have 300 million decision makers and they all have unique conscious states and personal capacities for decision making the potential outcomes are large. It is also a more complex scenario than all of the typical explanations for pandemic denial.  Each one of our 300 million decision makers has unique experience affecting the emotional valences of their decisions. The overt decisions may seem to coalesce at some points but for many different reasons. For example, believing what a politician says despite the clear documentation that they are lying can occur as the result of identification with similar people in the past, identification with a general class attitude or ethos that it represents, or it simply could be activated by the angry emotion that politician effects. Those are just a few possibilities.

The pandemic vaccination vs. anti-pandemic antivaxx is by definition a binary polarized debate – the reality based on what we know about how the brain works it is far from that simple.  Even on what appears to be the rational side there is no Spock-like analysis.  The public health experts are all accessing emotion when making their decisions. Rational thought is reward-based learning and associated to one degree or another with a “Eureka” moment.    

The key question going forward is what can be done to address the degrees of freedom associated with the possible decisions of this brain process.  What can be done to improve the process and by improve, I mean assure that civilization survives the current and potentially more lethal pandemics. To that end, there are numerous cinematic depictions of apocalyptic pandemics. Based on the depictions prior to this pandemic they are probably fairly accurate. Once a lethal pandemic takes hold, the decision space for survival collapses as fewer and fewer decisions are possible. An intuitive writer or film maker knows that at some level.  Time to make it general knowledge.

 

George Dawson, MD, DFAPA

Yes - I am Retired and here is why....

 

Yes – I am Retired

Last January I posed the question  ”Are there any good jobs left for psychiatrists?”  Eleven months later – I have the answer and the answer is NO.  For the past 11 months I have been looking and have seen at least a hundred jobs descriptions forwarded to me by various people. I have also interviewed and negotiated a couple of times only to get a contract that was completely unworkable.  I am not an attorney but I don’t think you have to be when you see a contract suggesting that you are going to indemnify and hold harmless a large corporation for any problems that might arise during the course of your employment. I did incorporate that experience into a CME lecture I gave in November about telepsychiatry and encouraged legal consultation with contracts.

The job postings that I considered were remarkable for the obvious amount of leverage they would create for employers and some of those employers had clearly never worked with psychiatrists in the past.   What do I mean by leverage?  Leverage is bullet points in the job description. When I started out back in 1986 – job descriptions were straightforward.  I can still recall the first interview I had at a community mental health center where I was eventually hired as medical director. They asked me about my treatment philosophy in psychiatry and my exposure to community mental health.  They asked me if I would be comfortable supervising the community support staff and psychotherapists. I asked them about the medical resources in the area, where I could do physical examinations if necessary and where I could get laboratory testing done.  All of the stuff psychiatrists are trained to do.

Current job postings list a number of bullet points that seem irrelevant to the job of a psychiatrist. Things like customer and stakeholder focus, change management, systems thinking, courage, commitment, emotional resilience, training (prescribing appropriate medications, documentation, collaborating with therapists, considerable annual HR rules), and so on.  The term “stakeholder” is cringeworthy. For 36 years I have treated people who had the toughest psychiatric and medical problems. All of that treatment was based on establishing a relationship with the person.  In many cases that involved foreign language interpreters, deaf/hearing-impaired/ASL interpreters, and various attorneys, advocates, ombudsmen, case-managers, and social workers. Family involvement is often critical.  If there are any stakeholders besides me and the patient – those would be the stakeholders. But in the business world – the stakeholders are other businesses and bureaucrats. They also include middle managers in any business that hires me. I may go in to work one day and find a team of bureaucrats angry with the way I am doing things – not from a quality-of-care perspective but from a business perspective.  They may decide to make my life a living hell until I do what they want me to do. All of the irrelevant bullet points also come in handy at the annual review. A supervisor may solicit anonymous opinions about whether or not I am fulfilling the requirements of corporate citizenship irrespective of my work as a psychiatrist.  That is all corporate leverage.  It has happened too many times and I am done with it. As far as I can tell that eliminates me from the pool of psychiatrists eligible for employed positions.

I have considered private practice options and gotten a lot of advice about it. The problems at this stage are considerable due to the up-front investment and the issue of tail coverage or malpractice insurance coverage necessary when I eventually stop working. Establishing a reliable documentation and medical records system as well as the necessary network security and insuring that is also a wild card. Private practice seems like an option if I hit the lottery but not before.  It does lead me to give out the advice that starting all of these essentials for private practice earlier in a medical career is probably a good idea.  As an example, I have talked with psychiatrists younger than me who have carried their own malpractice policies independent of their employer's policy. That is something I never considered, but today see it as a great idea.   

I did a CME presentation in November and I think that went relatively well. I could do more – but doubt that will ever develop into anything sustainable. This blog will keep me going in the foreseeable future. I like reading about psychiatry, medicine, neuroscience, and basic science.  I have an interest in staying current as well as knowing where the research is headed. One of the reasons I started this blog was because I had a significant number of psychiatrists approach me and ask what I was reading and how I kept up on recent research.  This blog has enabled me to reach psychiatrists around the world and correspond with many on relevant issues. I have never capitalized this blog in order to avoid any appearance of financial conflict of interest. So, like most retirees I will be living on Social Security income and retirement savings.

I don’t anticipate many existential issues in retirement apart from the typical death anxiety from time to time.  One of my goals has been to live as long as possible, and based on my family history I have lived this long just by avoiding cigarette smoking, exercising, and getting timely medical care.  My diet has gradually transformed to a relatively healthy one.  Being married to an extrovert means that I am never socially isolated.  Retirement has resulted in a massive amount of freedom to finally do what I want.  For decades I was constantly working or worried about work – initially the patients but eventually the bureaucrats and patients. I also worked too long and found that I was living somewhat of an alternate existence. I did not know what it was like to go to a shopping mall in the afternoon – I was working. All of those daytime everyday activities were available to me during vacations where most of my time was spent recovering.  The freedom to go to a mall or Target or even to a local coffee shop for a mocha anytime I want to is something I really have not experienced since the first two years of medical school.  I plan on using it to the max as the pandemic clears.

Freedom also means much more time.  I have about 4,000 books in my library and a steady stream of incoming subscriptions of medicine and science journals. Not all of those books were meant to be read cover-to-cover, but I want to make sure that I read those that were meant to be read that way.  At some point I will probably reread Zen and the Art of Motorcycle Maintenance for a final time. That book is a mysterious connection to my past as well as one of my all-time favorites.

More time for exercise will be a challenge. I decided to adopt a treadmill strategy for workouts so that when a cardiologist orders another stress test I will be ready. So far that strategy has worked well.  My only limitation is joint pain and back pain.  I think a lot about the day that pain might not go away and necessitate surgical intervention. This is my hopeful exercise routine going into retirement (I have actually bumped the 6 MET treadmill routine to 8 METS).  The cycling section is currently on hold after doing about 71 sessions due to a medical problem.

I plan to push this as far as possible, but the writing is on the wall based on 4 decades of high levels of activity. The decision about surgery will depend on how things are going at the time as well as the quality of consultation. The insight I have developed here is that maintaining high levels of activity as you age is more than determination. It is a matter of back and joint preservation and what can be done to restore it, as well as what other medical problems exist.

The final existential issue in retirement is the one that many people seem to fear and that is meaningfulness.  I can recall running early retirement groups as part of residency training that were based on that theory, but it was never evident to me that was really the issue. I certainly have not found any physicians who found retirement to be a problem.  I have a number of goals in place that involve writing.  A senior psychopharmacologist sent me an email and suggested that I cover mechanisms of action of biological treatments in psychiatry. I will certainly try to maintain the position of being an advocate and defender of the profession for the basic reason that nobody else seems to be willing to do it.  I explain how this has evolved and happened in the past few decades and the previous post on this blog captures some of my thinking on this topic. Several papers are in the works on the diagnostic method in psychiatry, rhetoric used against psychiatry, and sleep transitions.  I am also in the process of outlining a book on diagnostic and treatment methods in psychiatry.  My goal with the book is too keep it as short as possible and not to get into all of the trivia seen in typical textbooks. The target audience will be trained, early career psychiatrists, and like most old people – I hope to pass on some wisdom that will prevent common mistakes.

Along with the meaningfulness, a few words about ageism are required here.  I have encountered it in blatant forms in the past 5-10 years from psychiatrists. It bothers me only in that these psychiatrists seemed to be unaware of their attitude and I have the position that psychiatrists need to be aware of their biases. To some degree it is expected of physicians in their 30 and 40s.  Medical training encourages competitiveness and it takes a while to develop a collegial attitude. Is that transition is the same in psychiatry as in other specialties? There are several reasons why it might be lagging. First and foremost is the constant barrage of negative and inappropriate criticism the field is under compounded by the lack of response by any leaders in the field or professional organizations. That atmosphere encourages people to come forward and say: “I am not like the rest of the psychiatrists who you are criticizing. Your criticism does not apply to me and here is why?”  That is an attitude I was explicitly critical of when I started to write this blog but probably did not articulate that well. I did say that my experience with psychiatrist-colleagues is that they are thoughtful, professional, and very competent with few exceptions. I don’t accept the unique psychiatrist defense against inappropriate criticism even though many authors of these articles come off that way. If the competitiveness and the unique psychiatrist defense is in the background, does it make ageist biases more likely?  I think that it does.  I have experienced the comments and the smirks from people who should have known better – even not counting the obvious gaslighting comments here on my blog. Psychiatrists should know better.  

Another factor are special interest groups like the managed care industry and recertification boards. The managed care industry has emphasized at times that younger physicians are more "managed care savvy" (as if that is a good thing) and the need to train residents with that same goal in mind. The implicit suggestion is that older physicians who generally do not like managed care are less "savvy".  Medical boards, after rolling out years of questionable recertification processes and data to suggest that older physicians may know less than younger recertified physicians have apparently come around to the position that a lifelong continuing medical education approach is now acceptable for board recertification.  That was where all of this started. In the meantime there has been about 20 years of rhetoric suggesting that older physicians, especially those who were grandfathered in to lifelong certification were self-serving and had less knowledge than the people being run through the recertification mill. In reality, there was not a single older physician who did not believe that lifelong education rather than an arbitrary recertification examination was a superior process. Managed care and the recertification boards were essentially splitting physicians based on age and facilitating ageist biases. 

The meaningfulness dimension also includes collaborating with others. I am currently working with a friend of mind on postmodernism.  He happens to be an expert in all things postmodern and I am running my theory about postmodern rhetoric by him.  I hope to collaborate with other researchers on theory and even experimental design and analysis for a number of problems in psychiatry. I also like making basic graphics and would consider collaborating on that. I don’t need any reimbursement for the right projects – authorship credit will do.

The most significant aspect of meaningfulness for many physicians is realizing how your profession has impacted your family. For too many years, physicians are emotionally involved with strangers often to the point of exhaustion. That process takes its toll on the people who you are supposed to be the most emotionally involved with and that is your spouse and your family. The increased freedom of retirement allows for a fuller realization of that emotional involvement and reflecting on what has happened over the decades of work.

That is my current retirement process. I will post any changes here on the blog.  I hope there will be a noticeable improvement in the quality of writing here on the blog.  I know there is information contained here that can’t be found anywhere else and I am satisfied with that accomplishment as well adhering to the general goals that I started out with.  If anyone reading this has any suggestions for topics that I should be covering feel free to post it in the comments section below or send me an email.

George Dawson, MD, DFAPA

Supplementary 1:

With no good jobs being available for psychiatrists what are the options?  Unless you can identify a funding source and open up a free clinic there really aren't many.  People in my situation can simply retire and I think that many are.  In fact, one of my medical school colleagues told me that all it took was the pandemic on top of the current administrative headaches to make that decision. I am sure that somewhere somebody can find a niche and avoid some of the administrative headaches.  Learning what it takes for private practice at an early age seems like a possibility but the administrative costs are shockingly high.  I recall an internist telling me that for his 2 physician practice they required 3 full time office staff just to handle the billing and coding requirements for hundreds of insurance companies. In my 3 psychiatrist outpatient clinic we needed 1 fulltime staff person to handle phone calls and prescription refills and could have used  nurse just to handle the prior authorization calls. The business world has conveniently set things up so that the barrier to private practice is high and it is easier to settle for one of their problematic jobs.  I am not sure there is much that can be done to reverse this.

Supplementary 2:

To paraphrase an old automotive commercial: "Quality is no longer job one!"  I was a quality and utilization reviewer for psychiatric hospitalizations in both Minnesota and Wisconsin in the 1980s and 1990s.  We had stringent criteria for reviewing records and making these decisions. As the federal government invented the managed care industry and turned control over to them including all of the reviewing - quality dropped off the radar. Now what consumers see are media polls of "Top 100" hospitals and curiously most of the hospitals that you drive by seem to have made that list.   The same administrative processes that have removed physicians from the decisions about program design and how patients are seen in a clinic have also removed them from monitoring quality and designing quality improvement programs.  I know because I have been in the meetings where administrators presented their ideas about quality.  They were clearly less knowledgeable about healthcare than Toyota is about producing cars.  At least Toyota listens to the people making the cars. 

Supplementary 3:

I have always dreamed about working. It is always inside a massive hospital that is staffed like you would expect a university hospital to be staffed – teams of specialists and their residents and medical students. None of the buildings look familiar – they are all brain fabricated and in technicolor. The people in those dreams all look, sound, and move realistically. The predominate mood in the dream is anxiety.  Some of it is the real anxiety of everyday medical practice – did I miss anything and have I remembered everything? It is the anxiety that you experience when you are under pressure and on the edge of being overwhelmed. It is the kind of anxiety that leads to physical symptoms like accelerated heart rate, palpitations, muscle tension, and restlessness. Last night (01/08/2022) I dreamed I was in another large medical center.  In this case I was on both a Renal Medicine team and an Internal Medicine team.  I could sense that I was a resident and paying attention to multiple deadlines and schedules.  In real life no resident would do rotations on both of those services at once.  There is just too much work and it would never happen. I was looking at labs and notes on Renal patients and figuring out what I needed to do – but then realized I needed to be on Medicine rounds and started to get increasingly panicked.  I recall thinking that this was an impossible position and asking myself how that came about.  I woke up with a fast heart rate and feeling anxious but immediately realizing it was just another working dream. Various interpretations of that dream are possible ranging from the affective tone of the dream (work anxiety) to possibly wishing I was still at work.  I have definitely experienced elements of both. In medical school Renal Medicine was one of my favorite rotations and I was one of a few people who rotated through Renal, Infectious Disease, Cardiology, and Endocrinology in addition to the required Medicine and Surgery rotations. There was very little that I did not like about medical school or training. On the other hand it was extremely stressful and I was never able to lose that stress and anxiety in 35 years of practice. If anything, the way I practiced tended to increase the stress and anxiety. So here it is almost a year since seeing my last patient and medicine is still very much on my mind.  With any luck it will get to the point that I can stop working in my dreams.

Photo Credit:  Eduardo Colon, MD

 

Waffling - A Rare Window Into Psychiatric Advocacy

 

Consider the following thought experiment:

[Ask yourself if you can think of a well-known proponent of psychiatry.  And if you can is there is a list of proponents as available to your thought process as the easily recalled list of detractors.]

First of all – Congratulations to the author for coming up with that thought experiment and wish I had thought of it myself.  Most psychiatrists are hard pressed to think of a single name.  The proponent  that came to my mind was Harold Eist, MD the only American Psychiatric Association (APA) President I recall who was a staunch advocate for front line psychiatrists, patient privacy, quality psychiatric care and the only outspoken critic of managed care.  But beyond that – nobody comes to mind. I have certainly worked with and become aware of first-rate clinicians, teachers, and researchers – but all of that seems to end when it comes to facing the withering attacks of many against the profession. At that level – the thought experiment is an immediate success.

This thought experiment was proposed by Daniel Morehead, MD in his article It’s Time for Us to Stop Waffling About Psychiatry in the December 2 edition of the Psychiatric Times.  He proposes the experiment after presenting a small sampling of the inappropriate and repetitive criticism against the field.  I started writing this blog with a similar intent and noted from the outset that responding to antipsychiatry rhetoric often resulted in attacks not from the originators of the diatribes – but often psychiatrists themselves. I was contacted by an expert in antipsychiatry philosophies who advised me that it was apparent that many psychiatrists seemed to have self-hatred and associated hatred of the specialty that they were practicing.  I viewed that as somewhat harsh – but did acknowledge a tendency towards self-flagellation as typically evidenced by acknowledging responsibility for criticisms that had no merit.

In Dr. Morehead’s paper – he reviews examples of attacks that nobody in the field seems to respond to and the resulting potential damage.  In his bullet points he lists the political arguments about biological versus psychosocial models of illness and treatment, the familiar identity crisis that only psychiatry seems to have, the accusations of corruption and conflicts of interest, books that describe psychiatry as either a completely failed medical specialty or one struggling for legitimacy as a medical specialty, psychiatric diagnosis is routinely attacked, and medications that have led to deinstitutionalization and have literally saved the lives of hundreds of thousands of people are vilified.  And that is a short list.

His conclusion that these criticisms “generate an image of psychiatry that is both wildly distorted and profoundly destructive” is as undeniable as his observation that there are rarely any responses to these diatribes from psychiatrists or other physicians. I would actually take it a step further and suggest that in many of these cases psychiatrists or other physicians are in the habit of piling on even in cases of the most extreme unfounded criticisms.  In fact, you can find many examples of this in the comments sections of my blog.  In the body of his paper Morehead takes on three common criticisms that are often viewed as definitive by people outside the field including the memes that psychiatric illnesses are somehow less real than physical illnesses, psychiatric medications make conditions worse, and psychiatrists are biological reductionists who are only interested in prescribing pills and some pharmaceutical company conflict of interest makes that bias even worse. I have addressed all of these fallacious arguments and many more on this blog. Morehead certainly provides adequate scientific refutations to these memes and concludes that:

“We live in an intellectual culture that has habituated the public to think of psychiatry as flawed, failed, corrupted, and lost.”

If only that were true. I think what most psychiatrists (and physicians in general) fail to grasp is that these endless arguments have nothing at all to do with science or an intellectual culture. In fact, the best characterization of these arguments is that they are anti-science, anti-intellectual, and rhetorical. Because this is a political and rhetorical process these fallacies give the appearance that they can’t be refuted. Those advancing these arguments seem to “win” – simply by repeating the same refuted positions over and over again.  In some cases the repetition goes on for decades - as long as 50 years! This tactic is a time honored propaganda technique and I would not expect it to go away by confronting it with science or the facts.

We have seen this clearly play out in other medical fields during the current pandemic. Government scientists who have been long term public servants are attacked and attempts made to discredit them – not on the basis of science, but on the basis of rhetoric.  The attacks are not made by scientists but most frequently by people with no qualifications, attempting to rationalize their attacks by whatever information they can glean from the internet or just make up. In some cases – the conspiracy theories being advanced are the same ones that psychiatrists observed in the late 20^th century as applied to some clinical conditions.  Many of these attacks have gone from anti-science attacks to attacks on a personal level including threats against the scientist or his family. Financial conflict of interest can be significant as anti-science stars take on celebrity status floating for profit social media and mainstream media companies. Sponsors and believers in the anti-science message flock to these sites and generate significant revenues to maintain the message and the celebrities.  This discourse is the farthest possible from an intellectual endeavor.

This same anti-science and anti-intellectual posture is working against psychiatry and it has similar roots in the postmodernist movement.  Postmodernism was basically a movement against realism and in the case of science - facts.  Postmodernist discourse emphasizes relativism and an inability to construct reality.  One of the best examples is history. A postmodernist approach concludes that due to the limitations of language – actual history is not knowable.  The historian is merely telling one of many possible stories about what really may have happened. That has popular appeal as it is commonly acknowledged that history as taught in American schools clearly omitted a lot of what actually happened to and the contributions made by large populations who were marginalized by racist ideology.  That is as true in medicine as in any other field. But does that mean that the limitation of language and the application of current social constructs make the study and recording of history unknowable? Probably not and the problem with postmodernism is how radical the interpretation – can it be seen to encourage skepticism rather than outright rejection for example.

In the case of science as opposed to history, philosophy, and the arts – postmodernism does not have similar traction. The main features of science including an agreed upon set of facts irrespective of demographic or cultural features and science as a process does not lend itself to political or rhetorical criticism.  In the case of psychiatry, that is not for a lack of effort. The continuous denial that mental illness exists for example stands in contrast with the cross cultural and historical observations that severe mental illness clearly exists, that it cuts across all cultures, and that there is significant associated morbidity and mortality. It is however a classic example of postmodern criticism that it often suggests mental illness is really a social construct to maintain the power structure in society. The associated postmodern meme is psychiatry as an agency for social control over the eccentric defined as anyone who does not accept the predominate bourgeois narrative.

I first encountered this idea when I critiqued a New York Times article about the DSM-5 that suggested it was a blueprint for living (2).  That is an idea that is so foreign to any trained psychiatrist aware of the limitations of the DSM that it borders on bizarre.  And yet – here was a philosopher in the NYTimes making this claim along with several defenders in the comment section. At the time I was not really aware of this postmodernist distinction and responded just from the perspective that it was a statement that was not based in reality. Nonetheless, there were several defenders of the statement.  In retrospect all of this makes sense. Postmodernist critiques can amount to mere rhetorical statements. If you believe that reality is merely a battle of competing narratives – blueprint for living becomes as tenable as the reality of the DSM – a restricted publication with obvious limitations to be used only by trained individuals in a restricted portion of the population for clinical work and communication with other professionals. The large scientific and consensus effort is ignored – as well as the fact that societal control over anyone with a mental illness is the purview of law enforcement and the court system.

Similar repetitive postmodernist arguments are made about all of the examples given by Morehead in his paper.  For psychiatrists interested in responding to this repetitive and inappropriate criticism – it is important to respond at both the content level as Dr. Morehead has done but also the process level because the process level is pure post modernism and at that level realism or the facts on the ground may be irrelevant.

That brings me to what I would refer to as a second order criticism. Suppose you do respond to the criticism as suggested and suddenly find yourself being criticized by the same peers that you hoped to support?  Let me cite a recent example. Drapetomania is another criticism leveled at both psychiatry and the relationship that modern psychiatry has frequently claimed with Benjamin Rush, MD – a Revolutionary War era physician who has been described as the Father of American Psychiatry.  Of course, Rush was never trained as a psychiatrist because psychiatry was really not a medical specialty until the early 20^th century.  He was really an asylum physician with an interest in mental illness and alcohol use problems.  He also advised Gen. Washington on smallpox vaccinations for his troops and treated people during Yellow Fever outbreaks. In other words he functioned as a primary care physician at the time.  Drapetomania and Dr. Rush are connected though a meme that suggests that the southern physician who coined the term also “apprenticed” with Rush.  Drapetomania was proposed as a diagnosis by Samuel Cartwright to explain why slaves running away was a sign of psychopathology rather than rational thinking. Cartwright himself was a slave owner and there was widespread interest among his peers in racial medicine. Despite this peer interest and the Civil War being fought around the issue of slavery – nobody ever used the diagnosis. It was openly ridiculed in some northern periodicals and largely ignored in the racial medicine publications. Rush was affiliated with the University of Pennsylvania Medical School over the course of his career and Cartwright graduated from a Kentucky medical school.  There is no evidence he ever matriculated at Penn or met Rush.  Despite that history drapetomania has been consistently marched out as a psychiatric “problem” and evidence of a failed psychiatric diagnosis for the last 40 years.  The implicit connection with Rush is also made – suggesting that as a mentor he may have had something to do with the racist pseudodiagnosis.

I did a considerable amount of research on drapetomania and connecting of Cartwright to Rush.  I was very fortunate to have definitive work available to me from Rush biographer Stephen Fried (4) and historian Christopher D. E. Willoughby (5).  The details of all of that research are available in this post that illustrates the lack of connections of drapetomania to Rush and psychiatry but also a very long period of time where it was not actively discussed.  Szasz (6) resuscitated the word when he published an article in 1971 that essentially concluded: 

“I have tried to call attention, by means of an article published in the New Orleans Medical and Surgical Journal for 1851, to some of the historical origins of the modern psychiatric rhetoric. In the article cited, conduct on the part of the Negro slave displeasing or offensive to his white master is defined as the manifestation of mental disease, and subjection and punishment are prescribed as treatments. By substituting involuntary mental patients for Negro slaves, institutional psychiatrists for white slave owners, and the rhetoric of mental health for that of white supremacy, we may learn a fresh lesson about the changing verbal patterns man uses to justify exploiting and oppressing his fellow man, in the name of helping him.” (4)

If you feel somewhat disoriented after reading that paragraph it is understandable. Szasz not only uses an example with no connection at all to psychiatry, but he creates a completely false narrative by using Cartwright’s racist work as a metaphor for psychiatry and then accuses psychiatrists of being rhetorical. This unbelievable screed was published in a psychiatric journal and the Szasz meme has continued in all forms of media since that time. It also happens to be a classic postmodernist technique of essentially making up a competing narrative and then writing about it like it is true.

Post-modernist memes like this invention by Szasz essentially cut across all of the inappropriate criticisms covered by Dr. Morehead and more. They are basically a vehicle for anyone with no knowledge of psychiatry to bash the field repeatedly over time and recruit like-minded postmodernists to do the same. The best examples of this process include the historical memes dating back to a time before there were any psychiatrists and the familiar themes of identity crisis, chemical imbalance, antidepressant withdrawal, epistemic injustice, psychiatric disorders as disease states, biological reductionism, the Rosenhan pseudo experiment, and more.

These memes are complicated by the fact that psychiatrists themselves are probably the only predominately liberal medical specialty and post modernism has an uneasy relationship with liberal or left-wing politics and overtly Marxism. This may leave many psychiatrists on the one hand feeling that their specialty is being inappropriately criticized, but on the other feeling like the criticism is justified on political grounds – even if it is grossly inaccurate or just made up. As long as it seems to be a liberal criticism, they support it. This may be the reason why the drapetomania meme was included as a legitimate topic in a recent American Journal of Psychiatry article on systemic racism (7).  It may also be why when I attempted to present my drapetomania idea another psychiatrist objected on the grounds of “social justice”.  How is a groundless accusation leveled against the profession a measure of social justice?  

In order to stop waffling, these complex relationships and the rhetoric of post modernism needs to be recognized. As I hope I pointed out – it is as unlikely that these memes will respond to factual refutation any more than I would expect antivaxxers or COVID conspiracy theorists to respond. A basic tenet of postmodernism is that the facts or actual history can never really be known with any degree of accuracy and it is always a matter of competing narratives. That may work to some degree in the case of disciplines where relativism exists, but it does not work well in medicine or science.

There needs to be a far more comprehensive strategy to counter postmodern rhetoric and its use against psychiatry. It needs to be limited in scope at first. It should be recognized in psychiatric publications so the memes are stopped at that level. Drapetomania is a prime example, but as noted above there are many others.   Trainees and residents in psychiatry need to be aware of this rhetoric in order to avoid confusion and demoralization. During an era when we are all more aware of our biases than at any other recent time, political biases that lead to acceptance of inaccurate rhetoric at the cost of the profession also needs to be recognized.

If that can be done – the waffling will be over.

 

George Dawson, MD, DFAPA

 

References:

1: Daniel Morehead. It’s Time for Us to Stop Waffling About Psychiatry. Psychiatric Times December 2, 2021. Vol. 38, Issue 12.

2: Gary Gutting.  Depression and the Limits of Psychiatry.  New YorkTimes February 6, 2012.

3: Gutting, Gary and Johanna Oksala, "Michel Foucault", The Stanford Encyclopedia of Philosophy (Summer 2021 Edition), Edward N. Zalta (ed.),  https://plato.stanford.edu/archives/sum2021/entries/foucault/

4:  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

5:  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

6: 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.

7: 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

Graphic Credit:

Wikimedia: CC BY-SA 4.0 https://creativecommons.org/licenses/by-sa/, via Wikimedia Commons" https://commons.wikimedia.org/wiki/File:Waffles.png https://upload.wikimedia.org/wikipedia/commons/thumb/e/e8/Waffles.png/512px-Waffles.png

The Kenosha Trial

 

I watched the Rittenhouse trial closing arguments on 11/15/2021.  Let me preface these remarks by saying that this post is not a commentary on the guilt or innocence of the defendant.  It is not a commentary on his behavior, speech, or mental status.  It has absolutely nothing to do with psychiatric evaluation or treatment. This post is all about common sense and how that has been suspended in the United States - especially over the past 10-20 years.

This post is about open carry laws in the United States. Open carry laws make it possible for people to carry firearms publicly without risk of arrest or search for merely having possession of those firearms. The original intent of these laws was to reduce the risk to hunters and target shooters when they were transporting their firearms home.  There are still regulations in many states about how those firearms need to be transported but the original open carry laws were to make sure that there was not a problem carrying the firearms to the home where they would be stored.

Over the past 10 years, we have seen a striking change in how firearms are carried in public and it is the direct result of these open carry laws. The most striking change has been the appearance of heavily armed men open carrying military style semi-automatic rifles and handguns. They were also often wearing bullet proof vests, body armor, and helmets. In some cases, they were also disguised so that their facial appearance was obscured.  Some of these groups were self-identified as militias or paramilitary groups.  Militias always have a sacred role in firearm debates in the United States because when the Second Amendment was written and approved 230 years ago – this was the wording:

“A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.”

The Second Amendment is interpreted unambiguously by gun advocates as a Constitutional right to own firearms and the most open interpretation is firearms of any kind and as many firearms as a person wants.  The sheer number of firearms possessed by Americans is a matter of public record available in many places so I do not plan to repeat it here. Record gun violence in the United States is also a matter of public record due to suicides, homicides, and accidental deaths.  The United States also has record number of mass shootings each year that can also be found in the public record and I will not repeat it here.   

For now, I want to briefly focus on the concept of militia and the idea that it is well regulated.  Militias are defined as able bodied residents between the ages of 17 and 45 years old who can be called to defend a specific state or the United States.  Private militias acting outside of the federal code definition are illegal.  That includes all groups who are not called to duty by a state governor or the federal authorities.  Even if these groups appear to be uniformed and operating under some command structure, they are illegal organizations.  All 50 states prohibit private militias from doing what state authorized militias do.  They are also prohibited from engaging in paramilitary training and in some states brandishing firearms in a way that it could be construed as threatening. Apart from these laws about militias, states also have terroristic threat statutes, and statutes that restrict firearm access to anyone with a history of domestic violence. There is a patchwork of additional law regarding background checks, safe storage of firearms, and collecting statistic data on firearm violence.  There is a currently a loophole in background checks because unlicensed private gun sellers are exempt from conducting background checks on potential purchasers.    

For at least 20 years, gun advocates and lobbyists have pushed open carry and concealed carry laws to the point that they are both unnecessary and a threat to public safety. There is no better example than when groups of private militias or heavily armed private citizens show up at public events or protests. History illustrates that these events can lead to confrontations, injuries, and even deaths when they are managed by law enforcement or the state militia – the National Guard. Is it realistic to think that untrained private citizens or illegal militias will do a better job?  Is it reasonable to have open carry laws on the books so that these individuals or groups can potentially function in a number of ways that contradict other laws about assuming police functions or threatening other citizens?

The only logical conclusion you can come to is that both heavily armed private citizens or unregulated militias with a stated purpose of assuming the function of well regulated militias or law enforcement have no standing at all and are much more likely to add more heat than light to the situation.  They knew that in Tombstone, Arizona back in 1881, when they passed the ordinance at the top of this post. This ordinance (in one way or another) precipitated the Gunfight at the OK Corral. We need to recognize that heavily armed citizens roaming around in our communities is unnecessary and a recipe for disaster.  Open carry laws need to be rolled back to 1881 or about 130 years after the Second Amendment was passed.

I anticipate plenty of blowback about that opinion. My only goals are public health/public safety and preventing both unnecessary deaths and the kinds of confrontations that led to this trial in Kenosha. I also wanted to get this opinion out there before there was a verdict by the jury, because at that point those opinions on what happened will fall along partisan lines. Few people seem to recognize the seriousness of this issue – both in terms of the high personal and financial cost of gun violence – but also the destabilizing effect it has on the country.      

I also realize that there is a sense of hopelessness in the United States that we will ever have sensible firearm rules resulting in safer communities.  For a generation there has been a massive misinformation campaign about gun rights. It is possible to have a Second Amendment the way it is written and have safer communities.  Rolling back open carry laws is the place to start. 

 George Dawson, MD, DFAPA

 

References:

Transcript Prosecuting Attorney Closing Remarks

https://www.rev.com/blog/transcripts/kyle-rittenhouse-trial-prosecution-closing-statement-transcript

 

Transcript Defense Attorney Closing remarks

https://www.rev.com/blog/transcripts/kyle-rittenhouse-trial-defense-closing-statement-transcript

 

Supplementary 1: (posted on 11/19/2021 @ 12:49 PM):

I just saw the news that the defendant in this case was found not guilty on all charges.  Staying with the theme of this post that verdict is all the more reason why open carry laws need to be rolled back. I expect the usual posturing about the need for firearms to be used for self protection, but the public health issue remains - people bringing firearms to public gatherings or even to the local supermarket is a setup for violent confrontations and their outcomes. I encountered a statistic today that armed demonstrations are six times likely to turn violent than unarmed demonstrations.  If physicians and their professional organizations don't feel they can change the law - they can advocate for common sense measures and provide the supporting data.  Primary prevention of gun violence needs to start long before there are any court proceedings. 

Supplementary 2: 

I recalled today that I took an NRA Hunter's Safety Course when I was ten years old in a remote northern part of a state.  That course was taught by a military veteran who vetted us before we could even get in to the course.  He made us promise that we would no longer play with toy guns.  The main rule of the course was "Never point a gun at another person whether you think it is loaded or not."  Somewhere along the line that rule seems to have been lost by modern gun advocates.