More on Epistemic Injustice

 

I became aware of a paper on epistemic injustice (1) this morning and just finished reading the paper.  I wrote a blog on this topic with reference to one of the paper the authors discussed about 2 ½ years ago and I was interested in learning if the authors agreed or disagreed with my position. As suggested by the title – my position was that the concept of epistemic injustice was misapplied to psychiatry and further that it was misapplied in much the same way that other philosophical concepts have been. That misapplication typically begins with a false premise and the application of the concept is built upon that.

I took the original authors definitions of epistemic injustice in my original post.  The current paper defines epistemic injustice as occurring in two forms and once again I will quote the authors directly:

“Testimonial injustice arises when an individual’s factual report about some issue is ignored or taken to be unreliable because of individual characteristics that are not related to her epistemic (knowledge-having) ability.” (p. 1)

“Hermeneutic injustice… an individual’s knowledgeable reports fail to receive adequate attention because she, her listeners, or society as a whole lack the conceptual resources to interpret them.”

They give numerous examples both within and outside the field of psychiatry analyzing the arguments about why the epistemic injustice does or does not exist. I took the same steps in the previous blog post and my arguments were very similar to the authors of the current paper.  We basically agree that psychiatrists need to be focused on the subjective state of the patient.  That means we cannot arbitrarily discount what anybody says. We are also trained to not discount histories based on the demographic, social or interpersonal features of the patient.  In fact, we are the only physicians trained to recognize those tendencies and correct them.  The authors also agreed that all of the patient’s narrative need not be arbitrarily accepted and as an example they describe a patient who is at high risk for suicide and who is denying any risk in the emergency setting despite obvious evidence to the contrary.   They suggest just accepting the narrative for the sake of social justice may result in patients being placed at risk. I agree with that opinion.

I addressed this issue in my original post by describing what I consider to be the clinical method of psychiatry.  That involves listening carefully to the patient but at the same time deciding about the continuity and plausibility of the narrative.  This is a general process independent of any specific patient characteristic that recognizes all human informants make errors and that there are multiple reasons for these errors.  In other words, this general process needs to be applied to every patient professional encounter with a psychiatrist.  One of my mentors in residency also suggested that at some point it extends to everyone a psychiatrist talks with including informal contacts.  That means that psychiatrists may be analyzing many people that they encounter – but not in the psychoanalytic or mind reading sense.  

 The clinical process is important because it can refine the assessment and assist the patient in communicating the problems that brought them in to treatment. The goal of the interview is to establish a diagnosis and formulation and discuss them with the patient.  Agreement with the initial assessment forms the basis for treatment planning and the therapeutic alliance between the patient and the psychiatrist.  There are also therapeutic aspects to this communication.  Interventions like confrontation, clarification, and interpretation not only to improve the factual report but to assist the patient in recognizing active defenses that are limiting their insight into maladaptive behaviors and thought patterns.

The best way to counter any possibility of epistemic injustice is to keep teaching psychiatric methods exactly the way they are being taught right now.  Psychiatric trainees need to learn early on that analyzing the subjective communication is a rich source of information that cannot be denied, but may need to be clarified. There are never any clear reasons for rejecting this information – but like all psychiatric communication it all has to be seen through a critical lens and in some cases multiple hypotheses apply.

The authors have an interesting take as a footnote at the end of their paper on why some authors may be interested in applying a philosophical concept where it might not apply – especially if the critic is a psychiatrist.  There is after all an established pattern of some psychiatrists doing this.  From the paper:

“To the objection that psychiatrists are the ones writing some of these articles, we would suggest that being a psychiatrist does not protect one from misunderstandings – or more likely, misrepresentations – of one’s own field when in the grip of an idea. This should be no more surprising than the possibility of an anti-psychiatric psychiatrist, a familiar figure in the philosophy of psychiatry.”

The authors condense various motivations for misrepresentation as an intellectual idea.  That may be a possibility as a one off paper but what about a pattern over years and decades?  What about the associated self-promotion over those years? What about the inability to recognize the good work of hundreds of colleagues over that period or personal mistakes?  There are always many unasked and unanswered questions when it comes to an idea that criticizes an entire field of work.    

It is indisputable that no medical field has been mischaracterized more than psychiatry. Philosophy has been one of the vehicles used to do it. I hope that more papers are written to illustrate exactly how it happens. In the misapplication of epistemic injustice, it starts with a false premise and builds from there. Psychiatrists everywhere know that one of our best attributes is being able to talk to anyone and more specifically people that other physicians either do not want to talk with or are unable to. Most importantly – we are interested in talking with these people and can communicate with them in a productive manner. We do not get to that point by rejecting what people have to say or not paying attention to them.

The qualifier in my original post still applies:

“There is no doubt that people can be misdiagnosed. There is no doubt that things don’t always go well. There is a clear reason for that and that is everyone coming to see a psychiatrist has a unique conscious state. There is no catalog of every unique conscious state. The psychiatrist's job is to understand that unique conscious state and it happens through direct communication with that person.  That direct communication can happen only if the psychiatrist is an unbiased listener.”

There are plenty of external constraints that directly impact the time needed by a trained psychiatrist to interview and understand a person. That is probably a better focus for criticism than the continued misapplication of philosophical ideas.

George Dawson, MD, DFAPA

 

References:

1:  Kious BM, Lewis BR, Kim SY. Epistemic injustice and the psychiatrist. Psychological Medicine. 2023 Jan 5:1-5.

 

We Need A Model Terroristic Threat Statute

 

Over the past ten years of writing this blog, I hope that I have been clear about a few things. First, violence and aggression are complicated problems. Most of the political arguments out there today focus on peripheral issues like gun violence. In a country of gun extremists – there will always be excuses for why there is so much gun violence.  A common one is that there are mentally ill people with guns.  Some of the gun extremists have gone so far recently to suggest this is due to a crisis of untreated mental illness. Nothing is further from the truth.

Second, people with mental illness can be violent and aggressive. In political arguments where violence and aggression is being attributed to mental illness it is common to deny it. In a Community Psychiatry seminar 40 years ago – my position was “people with mental illness are no more violent than anyone else.”  My 40 years in the field has taught me that looking at violence across large groups is meaningless. In the acute care setting where I worked many if not most of the patients I treated were there for violence against others or self-directed violence.  Some were aggressive toward me and the staff I worked with – with some threats that persisted well after any hospitalization.

Third, violence and aggression can clearly be treated in many if not most cases, especially if it is a manifestation of acute psychiatric illness. Despite that being common knowledge in acute care settings – there is no effort to characterize it as a public health problem like suicide. There are no public service announcements about what to do if you have violent or aggressive thoughts. No hopeful messages that you do not have to act on any of those thoughts and that you can get help to restore your baseline thought patterns.

Fourth, violence and aggression are stigmatized in society. Most people at some point in their lives have been bullied or traumatized by other forms of aggression. In the US, incidents of extreme violence and aggression are commonplace in the daily news. There is a fascination with true crime television and documentaries about serial killers. The media seems preoccupied with discovering a “motive” for these crimes.  Apart from the usual sociopathic motives of intimidating and injuring people to get what one wants – motives are generally lacking. In fact, I would go so far to say that in the homicide cases broadcast on television the limiting factor was the availability of a firearm. In other words – no homicide would have occurred if a firearm was not present. The resulting stigma toward aggression, leads to biases toward patients with psychiatric illnesses who are violent because of those illnesses.

Fifth, there is a limited rational response to violence and aggression even if a public health response is ruled out. This occurs daily. There has been no clinic or hospital where I have worked where I have observed a well thought out plan to respond to these incidents even though aggression toward health care workers is a current epidemic. There are plenty of errors along the way whenever an incident occurs in the community. I have had patients who were in the cross hairs of a police sniper until somebody noticed they were pointing a toy gun at the police. Anyone in my field has had people who assaulted them, threatened them and their families, and in some cases that aggression has resulted in serious injury or death. The rate of intentional injury by another person is five times greater in the healthcare industry than all other industries and that rate is ten times greater in the psychiatric and substance use fields. With a healthcare system run by administrators rather than physicians – it is not clear why there are no functional approaches at the institutional level. In the case of the community and the hospital the usual approach is to send the person to the emergency department to see what they can do and if necessary, hospitalize them on a psychiatric unit.  By that time, it is common to see people who have been escalating for days or weeks and the necessary interventions are riskier than they would have been at an earlier point.

In thinking about a more functional response there are two problems – epidemiology and existing laws.  From an epidemiological standpoint there are many studies documenting specific forms of violence and how that individual may have been victimized in the past.  A joint Department of Justice (DOJ) and Centers for Disease Control (CDC) report from 2000 estimated that physical assault and stalking affected roughly 2.9 million women and 3.5 million men every year.  Intimate partner violence affected 1.3 million women and 835,000 men. Getting to the earliest point in that cycle of violence from an epidemiological standpoint seems to be missing.  At least I cannot locate any data.

From a legal standpoint, intervening before there is any physical danger is a highly problematic threshold. And if the necessary statutes exist, there is wide latitude in their interpretation by law enforcement and the judicial system. There has been some progress over the past 40 years but not much.  For example, in the past if a person was threatened – it was common for law enforcement to say they could not do anything because the threat has not been acted upon. That was clearly a suboptimal approach because threats involving lethal force often result in the precipitous application of lethal force. In many cases the lack of a firm limit on threatening behavior encouraged more of it. Contingency based systems also have the tendency to put the responsibility for action on people who have no relationship to the person making the threats.  Even though there has been substantial progress in domestic violence scenarios, it is common for the person being threatened to need to seek a court order for protection and convince a judge that threats or actual violence have occurred. In the case of threats by patients with known psychiatric illnesses, the Tarasoff decision has placed the treating professionals in the position of law enforcement with a duty to inform the person who is being threatened. A clear terroristic threat statute could address all of these issues and provide a path for early intervention.

Since most of my career was in the State of Minnesota, I will be referring to their statutes.  Preparing for this piece, I also read a paper from the University of Pennsylvania Law Review (2) highlighting some of the confusion in this area.  Minnesota, if a health care professional is threatened it is a good idea to inform the police about the threats and present them with any hard evidence (voice messages, emails, mailings, etc).  Laws enforcement who I have dealt with in these situations may refer to the threat as a “terroristic threat”. That is defined in Minnesota Statutes (3) as:

“Threaten violence; intent to terrorize. Whoever threatens, directly or indirectly, to commit any crime of violence with purpose to terrorize another or to cause evacuation of a building, place of assembly, vehicle or facility of public transportation or otherwise to cause serious public inconvenience, or in a reckless disregard of the risk of causing such terror or inconvenience may be sentenced to imprisonment for not more than five years or to payment of a fine of not more than $10,000, or both.”

I have highlighted the relevant section of the statute. Minnesota legislation appears to cover both the individual case as well as larger scale incidents that would typically be equated with terrorism.  This statute allows law enforcement to exercise some judgment in dealing with threatening individuals.  For example, they can go to that person and say that if they persist, they will be arrested and charged with making terroristic threats. No other action is required by the person being threatened. In many cases that is a definitive intervention and no further action is required.

The paper by Flanders, et al looks at various scenarios that have occurred in the context of the current COVID-19 pandemic.  Their basic argument is that much of the mayhem created during the pandemic would not reach the legal standard of terroristic threats and if charges were required – they could occur under other statutes such as disorderly conduct or harassment. They are using a standard suggested by the American Law Institute Model Penal Code that includes the following:

“A person is guilty of a terroristic threat if he threatens to commit any violent felony with the intent to cause evacuation of a building, place of assembly or facility of public transportation, or otherwise to cause serious public inconvenience, or in reckless disregard of the risk of causing such inconvenience.”  (2)

Note the difference with the Minnesota Statute – there is nothing about threatening with intent to terrorize another.  It is more about violent felonies that disrupt the public.  The authors in this case go on to specify the elements of terroristic threats in their “core case” model as consisting of a credible threat, use of a dangerous weapon, targeting the public or government, and the intention to create a panic or forced evacuation (p. 68).  They illustrate how this model statute has been modified and adapted in other states. I am not a legal scholar but to me – the model statute is missing one of the prime elements of terrorism – the intent to kill and injure people. The way it is written seems to make this implicit and secondary to disrupting the public. The public is disrupted because of their fear of being killed or injured. The Minnesota statute covers both cases by including the element of the individual being threatened.

Whether you are a health care professional or a member of the public, this is the level of protection from threats that is needed. Even then there is no guarantee that there will be a successful intervention by law enforcement. The person making the threats needs to be identified and the police need probable cause to intervene.  I have seen it work well even if no arrests or emergency holds are placed. Most importantly it creates clear boundaries between the police, the person being threatened, and the person who is threatening. The responsibility for action is no longer on the person being threatened.

There are also potential benefits in terms of earlier intervention in the case of psychiatric illnesses associated with threatening behavior.  There is a current awareness that crisis intervention services may be a better early option than the police and that may be a better early intervention.  The epidemiology of threats needs additional work.  My speculation is that there are tens of thousands of people who are trying to live every day with these kinds of threats.  They are a disenfranchised group whose needs have only partially been addressed by domestic violence and civil commitment laws.  A more functional terroristic threat statute like the one in Minnesota could result in early intervention and providing significant relief from that stress.

And finally early intervention can provide relief to many of the people I treated in inpatients settings for 22 years.  They were generally suffering from severe psychiatric disorders and substance use problems. I saw most of them recover to the point that they regretted the aggressive and violent behavior and were appreciative of the treatment they received to resolve that problem. It is easy in our society to view these folks as hopeless and as outcasts – but every acute care psychiatrist knows that is nonsense. The first step in making a societal change is to get the message out that violence and aggression can be treatable problems and earlier treatment generally leads to better outcomes.  More functional and comprehensive laws on aggressive behavior are a part of that.

 

George Dawson, MD, DFAPA

 

Supplementary 1:

A better terrorist threat standard also may also serve to improve the likelihood of early firearms interventions.  Just from news reports the main obstacles seem to be a combination of easy gun access, gun extremist rhetoric, the ability to avoid background checks, legal action to defeat any gun access legislation, and extraordinary efforts necessary by law enforcement to restrict gun access to individuals who are either at high risk or proven risk based on their recent behavior. If a person meets a statutory terroristic threat standard - that could trigger red flag laws or laws to block or remove gun access at the local level by statute.

References:

1:  Tjaden P, Thoennes N.  Prevalence, Incidence, and Consequences of Violence Against Women: Findings From the National Violence Against Women Survey, Research in Brief.  Washington, DC: U.S. Department of Justice, National Institute of Justice, 1998, NCJ 172837.

2:  Chad Flanders, Courtney Federico, Eric Harmon & Lucas

Klein, “Terroristic Threats” and COVID-19: A Guide for the Perplexed, 169 U. PA.

L. REV. ONLINE 63 (2020), http://www.pennlawreview.com/online/169-UPa-

L-Rev-Online-63.pdf

 

3:  Various MN Statutes:

 

609.713 THREATS OF VIOLENCE.

https://www.revisor.mn.gov/statutes/cite/609.713

 

609.79 OBSCENE OR HARASSING TELEPHONE CALLS

https://www.revisor.mn.gov/statutes/cite/609.79

 

609.795 LETTER, TELEGRAM, OR PACKAGE; OPENING; HARASSMENT

https://www.revisor.mn.gov/statutes/cite/609.795

 

609.749 HARASSMENT; STALKING; PENALTIES

https://www.revisor.mn.gov/statutes/2022/cite/609.749

 

Graphics Credit:  Tim McAteer, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons.  Page URL:  https://commons.wikimedia.org/wiki/File:SWAT_team.jpg

Another Note on Gun Extremism - An Appeal to Grandparents

 

I cannot let this latest incident slide by. A colleague posted this article yesterday about a 6-year-old boy who shot a teacher during an altercation inside of a Virginia school. At the time I am typing this the teacher was listed in critical condition. The way this incident is reported is bizarre for a guy whose K-12 years were 1956 to 1969. It has nothing to do with banning guns – but it has everything to do with gun extremism to the point that people get casual about guns. They either forget that children and young adults do not have the necessary judgment to responsibly handle guns or the adults themselves do not exercise adequate judgment and either allow their children to have access to guns or do not secure them at home. Using firearms to settle trivial or inappropriate disputes is a clear example of a lapse in judgement.

Let me paint the picture about what it was like in the 1950s and 1960s before we were deluged with gun demagogues. Many families in the remote area where I was raised hunted for food or sport. The hunting included deer, rabbits, ducks, geese, pheasants, and partridge.  I don’t have any statistics but if I had to speculate – the hunting families were in the minority.  Most families that did not hunt and had no firearms on the premises. The only exception might be World War II veterans with souvenir weapons – mostly not maintained and unloaded.  If you had friends from hunting families and there was a chance that you might go hunting or target shooting with them – you had to take an NRA (National Rifle Association) Hunter’s Safety course. Most people took that course when they were in middle school.  It was taught by a middle-aged guy I knew from church.  He presented the course in a very calm matter-of-fact manner and clearly outlined all of the dangers of firearms.  I recall anecdotes about people being accidentally shot at home and injuries from the wrong ammunition being used in the wrong gun.  Rule number 1 was "never point a gun at anybody - even if you think it is not loaded."  We all fired air rifles and .22 caliber rifles at indoor ranges in his basement and at a larger range in the basement of a retail store downtown.  All guns had to be pointed downrange at all times away from the shooters.  Nobody fired a handgun, because you had to be 21 years of age to do that and we were all 12 or 13.

There were no political or marketing movements focused on firearms at the time.  We had to be NRA members to take the course. As long as you were an NRA member you got a monthly copy of their publication the American Rifleman.  The centerfold for that magazine was a long list of “sporterized” military rifles that could be purchased at a low price. I recall many days pouring over that list and thinking about what kind of rifle I would buy when I was old enough.  I never did buy that rifle.

The other incentives to stay engaged with the gun community was getting ratings based on your marksmanship. If you could demonstrate certain scores on targets you would qualify for small military style medals saying that you were an Expert or Distinguished Marksman. Like most skills, it took a little practice (but not that much) to become proficient in shooting. Contrary to some stories that you read today about hunters and school – nobody ever brought a gun to school. There were no Second Amendment discussions and no suggestion that the training had to do with militias. The result was that there was a small group of middle school kids who had taken a safety course focused on handling firearms while hunting.

That did not mean there were no firearm related deaths in my small community. During those early school years there were 2 suicides and a hunting accident, all involving kids who I knew.  Firearms are never completely safe even with limited access and training.

Back to the article – let me examine two direct quotes starting with:

“Experts said a school shooting involving a 6-year-old is extremely rare, although not unheard of, while Virginia law limits the ways in which a child that age can be punished for such a crime.”

Extremely rare but not unheard of is quite an introduction.  Within the space of 2 generations, we have gone from unheard of to rare but not unheard of. Without being an expert on Virginia law my speculation is that any legal decision about culpability and punishment is based on the capacity of a child to formulate a plan and rationally decide to shoot someone.  The irony here is that you can watch true crime television and see the same problem in all of the 20+ year old men who impulsively commit gun homicide. There are no reasons for these homicides.  They all seem to occur during trivial arguments where somebody gets angry and starts shooting.  The problem, is depending on the judgement of children and immature adults and the solution is not providing them access to firearms.

“Today our students got a lesson in gun violence,” said George Parker III, Newport News schools superintendent, “and what guns can do to disrupt, not only an educational environment, but also a family, a community.”

Unfortunately – the students did not need this “lesson”. From the description they were all traumatized and school shootings are so common in the US, that they are continuously exposed to it. I would not be shocked to learn that many of the students and parents involved had been worrying about an event like this for a long time. The people who ignore this “lesson in gun violence” are all adults.  Many of them are in positions where they could make a difference but consistently fail to do so – or even make decisions that increase the likelihood of future incidents. In the case of politicians, you share responsibility by voting for gun extremists.

As a country are we so oblivious to gun extremism and gun violence that we continue to allow a political party and a politicized gun organization to compromise the safety of school children and teachers? My appeal today is to the grandparents out there – people of my generation. If you remember what the gun atmosphere was like when you were a kid – compare it to what is going on right now.  Were there kids in your first grade class getting into altercations with teachers?  Was there gunfire in primary school?  Do you recall routinely hearing about primary and high school students being shot and killed?  Were there military style high capacity firearms widely available?  Were there armed militias wearing body armor standing outside of your state capitol?  Did the musicians you listen to endorse a lifestyle that involved gun violence to settle minor disputes? Were there people suggesting that you needed to carry a gun around with you at all times for protection? Could you pick up a gun and carry it around with no training and/or no permit?  If you are a person of my generation - the answer to these questions is no.

That is the country we have become. And it is all due to one political party, their politicized allies in the community, and their judges in the Supreme Court drastically changing gun access and attitudes about firearms in the community.  Nobody is safe with these people in power. 

Be a single issue voter and vote the gun extremists out.

 

George Dawson, MD, DFAPA

Supplementary 1:  Update on the incident that initiated this post.  Reports in the press today (1/9/2023) say the teacher was intentionally shot with a 9 mm handgun that the 6 year old took from his mother. There are conflicting reports that the teacher was trying to disarm the student when the shooting occurred.  She was shot though the hand and into the chest. She assured the safety of the rest of the students before seeking help for herself. The status of the handgun while all of that happened is unclear. She was reported as being in stable condition in a hospital.  The school is closed to give "students and families time to heal."

Supplementary 2:

Based on an initial response to this post let me be clear about the way to reign in gun fanaticism in the US.  To my knowledge no responsible person has ever suggested "grabbing guns" or "coming for your guns".  There are too many firearms in the United States for that or for gun "buy backs" to ever be practical. The gun grab argument was basically invented to create gun extremism.  Nobody was worried about it in the 1970s.

We are stuck with widespread gun availability and we need to keep them out of the hands of people who are likely to do the most damage.  Unfortunately that means a majority of people who would not fail either background checks or red flag laws. They are also probably more susceptible to the impulsive use of firearms not just for gun homicides but also gun suicides.  A good starting point would be:

1.  Universal background check - no state to state loopholes or private sale loopholes.

2.  Red flag laws - already incorporated broadly in the FBI NICS (National Instant Criminal Background Check System) database.  That would include people adjudicated by a court as being at high risk of harming themselves or others if they had firearms.  Red flag laws should depend only on a direct or indirect threat to harm with a firearm. Since there is a very serious bomb hoax statute - an actual threat to an individual or a facility should be taken at least as seriously.  The standard should ne a threat to use a firearm and not having to provide the likelihood or using the firearm or potential dangerousness of the person making the threat.

3.  People with substance abuse disorders or mental illnesses at high risk for violence to self or others.  That should include a permanent ban on firearm acquisition where determined by a court.

4.  People with a history of actual violence to self or others. 

5.  Additional factors per the NICS system.

6.  Serious discussion is needed about the permit less system that is now in place in many states. A practical law would be to prohibit assault weapon sales, high capacity magazine sales, and increase the age for handgun purchases to 25+.  But now that there has been a lifting of the moratorium on gun violence research the research on gun violence in this age group and what kind of firearm is being used will make these conclusions obvious.  

7.  Stop encouraging legal gun violence. Stand your ground laws, permit less carry, and widespread access make guns available for dispute resolutions that do not require lethal violence. 

8:  Waiting periods for gun purchases. I have had too many people tell me that a waiting period saved them when they had transient thoughts of self harm.

Supplementary 3:  The easy access to firearms by everybody who want them is based on many false premises.  Here are a few:

1.  Do you really want everybody on the street to carry a firearm? Or do you only want a few special people to be carrying these firearms?   The assumptions here are obvious.  Only the good guys or maybe the masculine guys should be carrying guns. How do we determine who those people are?  Is it sex or gender based?  Or maybe it should depend on race?  Is there a box you can tick to just get a gun. Maybe this is why the gun extremists eliminated all of the boxes.  Thinking through that problem is just too hard.

2.  Maybe the gun extremists really mean that everyone should carry a gun. In that scenario it is fairly predictable that more and more minor disputes and arguments will be settled by gun violence. We have seen that happen in many national cases already and it obviously happens on true crime TV.  Even the Sheriffs in western towns in the 19th century saw this as a problem and had people coming into towns check their guns. (see Tombstone statute from 1851)

3.  There is an assumption that gun owners, especially concealed carry owners are supermen (or superwomen) who never make a fatal mistake with a gun, never get in an argument where they might threaten somebody with a gun, know where their gun is at all times, and never accidentally shoot themselves. We know from the data that none of that is true and we can see recordings of real time incidents on television that illustrate this fact including the news report that lead to this post.

References:

1:  Finley B, Barakat M. Police: 6-year-old shoots teacher in Virginia classroom.  Associated Press.  Fri, January 6, 2023 at 2:20 PM CST  Link

2:  American Progress.  Fact Sheet: Weakening Requirements to Carry a Concealed Firearm Increases Violent Crime.  October 4, 2022. Link

Graphics Credit:

Photo of the Polychrome Mountains that I shot in Alaska.

The Curious Sober Movement

 

I saw an interesting story on the news yesterday and found it was linked to an even earlier report in the Tokyo Times. There is a cultural movement in Japan among the younger generation to abstain from alcoholic beverages or drink only on special occasions. I saw a young woman interviewed and she described her motivation as wanting to spend her money on other things.  The report also said that alcohol use in Japan was a ritual for bonding in the workplace.  They showed images of work parties with many people drinking as well as a man in a suit passed out on at the edge of a train platform.  Survey data was quoted as saying that 90% of Japanese drink alcohol rarely or not at all. The most sobering statistic was that tax revenue from decreased alcohol use was down 30%. That drop caused the government to ask for suggestions about how to get people drinking again. That approach did not get any positive reviews in the man-on-the street interviews including a bartender serving non-alcoholic drinks. 

This story was immediately interesting to me for several reasons. First, I have always been puzzled by the American approach to intoxicants. On a cultural basis, they are considered a rite of passage and the best evidence is the data on substance use in college aged students and how it generally decreases over time. Second, there is always a great deal of ambivalence advocating sobriety as a reasonable lifestyle, even though most Americans either don’t drink or drink very little.  The American population has a lower level of lifetime abstainers and (expectedly) a higher number of former drinkers per the world average.  There is ample rhetoric in popular media and culture to ridicule people who don’t drink and in many cases drug users are idealized.  Third, the attitude extends to other drugs. Contrary to pro-cannabis hype, there are very few countries in the world where cannabis is legal much less sold in highly concentrated forms.  That same hype promoted the medical use of cannabis even though there is little evidence that it does much.  Similar arguments are being made about hallucinogens and in some cases, all scheduled drugs that are currently considered illegal. Fourth, intoxicants are generally heavily marketed to the public.  Vodka is a clear example.  The New York Times did a famous taste test of vodka comparing various vodkas to the least expensive brand (3). The least expensive brand won the competition.  At the time, many much more expensive designer vodkas had emerged from several countries.  One of the authors main points is that vodka is sold based on marketing rather than taste.  Many essays about vodka describe is as tasteless. Since 2005 there have been endless taste tests, rankings, and other promotions - basically more marketing.  More recently several prominent celebrities have promoted their own expensive brands of vodka and tequila. In some cases, the businesses have grown to very large values.  All of that based on marketing what is essentially a tasteless, intoxicant that comes with a long list of problems to people who want to drink it for how they see it advertised.  Fifth, the issues of tax revenue. Let’s face it – the only good reason to promote intoxicants is to make money. 

Most common intoxicants also reinforce their own use – at least for a significant segment of the population. That leaves politicians needing to counter that common knowledge. There are two arguments commonly used to do that.  The first is that we will tax the new intoxicant and that will create all kinds of revenues for services that taxpayers want. Alcohol, tobacco, and gambling taxes have been around for a long time and generate billions of dollars per year at the federal level.   Since, everyone knows that drugs and alcohol carry a heavy burden in terms of mortality and morbidity the second argument goes something like this: “We will create a special fund to help all of the people adversely affects by these intoxicants (and gambling).”  During my career as an addiction psychiatrist, I saw treatment services basically disappear.  They were few functional detox units, few functional substance use treatment units, and few addiction specialists.  There was a small remote gambling addiction residential treatment program – but it did not match the degree of gambling problem in the state.  If adequate finding for substance use treatment from sin taxes exists – please let me know about it because I have not seen it.  Like many products and services in the US, alcohol, intoxicants, and gambling all end up being promoted by governments at all levels as a revenue generating activity.  The damage done is rarely discussed.  

In the case of alcohol, the damage is unmistakable if you know friends or family members with the problem. Damaged relationships and marriages, legal problems and incarceration, and a list of significant medical complications.  The current government warning (7) on alcohol is:

GOVERNMENT WARNING: (1) According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects.

(2) Consumption of alcoholic beverages impairs your ability to drive a car or operate machinery, and may cause health problems.

 May cause health problems is an understatement. A more appropriate statement would say can cause health problems up to and including birth defects and intellectual disability, mental illness, severe cognitive problems, liver disease, pancreatic disease, cancer, hypertension, and death. Rather than being explicit about the health risks for many years alcoholic drinks were promoted as heart healthy and increasing HDL or "good" cholesterol. Any slight advantage disappears when subjects recovering from alcohol use disorders are eliminated from the control group.

What about consumption figures?  The usual way that consumption is compared is by taking the alcohol content of all of the beverages consumed in a country and converting it to the equivalent amount of 80 proof ethanol. The per capita annual consumption can be compared in total volumes or standard drinks. A standard drink is 1.5 fluid ounces of 80 proof (40%) alcohol or the equivalent in any one of those drinks is considered a standard drink.   In the US 14 grams or 0.6 ounces of pure alcohol is considered a standard drink. Apart from consumption there are estimates of what the standard drink threshold might be to cause cirrhosis or pancreatitis. 

Comparing levels of alcohol consumption between the US, Japan, and Russia those numbers are 10.5, 10.09, and 9.97 liters per year. These are population averages and there is typically great variability between various populations and historically – even within the same population over time.  There is also a graphic that I made a few years ago (see header of this post) that takes a look at comparisons across several types of drinking relative to the average consumption of the world.

What is curious sober movement?  There seems to be very little written about it and essentially nothing in the scientific literature. That may be why the headlines all involve decreased tax revenues from decreased drinking.  Historically there have been sobriety movements in the past. The most well known one in the United States was the Temperance Movement.  It seems that a basic mistake of these movements is proselytizing and trying to influence politicians. The resulting Prohibition Era in the US is widely cited by drug legalization advocates as a failure, even though it was a law that could never be enforced and there were clear cut benefits for those who had no choice but to abstain.  The current pandemic highlights how limits on established behaviors including measures designed to limit infection and loss of life are immediately politicized and the resulting chaos results in a loss of any benefit. Some people would rather threaten public health officials rather than simply wear a mask. In the area of intoxicants, I am sure any measure to prohibit the sale of alcohol would result in similar reactions today. The legalization of cannabis has been sold to the public and politicians and once that is out of the gate – there is no turning back even though there is early evidence that it will be another blight on the land.

Whatever curious sober is – I hope it has traction in the United States. The travelling medicine show here never seems to stop. We have a massive drug and alcohol problem here and everybody should know it and more importantly act like it. The single best way to stop it – is not by providing treatment for addiction. The single best way to stop it is to not pick up a drink or a cigarette or any other intoxicant in the first place. In the public health field that is called primary prevention.  All of the intoxicant promoters joke about the "Just say no to drugs" public service messages.  Of course they would. Nobody ever talks about the fact that the best life you can live is a sober life. 

The young people in Japan are discovering that.

 

George Dawson, MD, DFAPA

Supplementary 1:  Vodka Pricing, Cost, and Profit 

I decided to make a graphic to show the raw material cost and various taxes on a 750 ml bottle of 80 proof vodka to illustrate how much profit can be made from marketing intoxicants in various ways. The raw material cost in this case is very low since beverage alcohol is distilled and sold by agribusinesses in large volumes.  There is apparently only one manufacturer in the US that does their own distilling. For most the manufacturing process consists primarily of filtering and adding various flavors.  The tax references are at the bottom of the page using Minnesota Department of Revenue guidelines.  There is conflicting information on sales tax but the Dept of Revenue said that it is charged so I included it in the graphic.  In Minnesota there is also an excise tax and a separate 2.5% tax on gross liquor sales.  Minnesota has taxes like the the MinnesotaCare Provider Tax on health care services that is currently at 1.6%.  In theory it can be passed through to the customer/patient but it is selective since reimbursement rates are set without it.  I would see this 2.5% tax as being similar and it would be included in the pricing. (click to enlarge graphic)

 

For tax comparisons, here is a table from reference 3 about the tax revenues generated from the last year available.

Note the differences in excise tax collected on each group of beverages based on the fact that alcohol content is the basis of taxes and also that the 2.5% tax on gross sales generates substantial revenue.

The most recent budget for the state of Minnesota was $53.7B compared with alcohol excise taxes of $187M or about 0.35%.   For comparison Japan generated $8.1 in alcohol tax in 2021 – 1.7% of overall tax revenue.

References:

1:  Why Japanese government is encouraging drinking.  CBS Morning News. December 31, 2022  https://www.cbsnews.com/video/why-japanese-government-is-encouraging-drinking/

2:  A 'sober-curious' generation leaves Japan with a hangover.  Should an arm of the government be encouraging people to drink, even in moderation?  Japan Times. August 24, 2022  https://www.japantimes.co.jp/opinion/2022/08/24/commentary/world-commentary/liquor-taxes/

3:  Asimov A.  A Humble Old Label Ices Its Rivals.  New York Times.  January 26, 2005.

4:  Lachenmeier DW, Kanteres F, Rehm J. Is it possible to distinguish vodka by taste? Comment on structurability: a collective measure of the structural differences in vodkas. Journal of agricultural and food chemistry. 2011 Jan 12;59(1):464-5.

5:  Hu N, Wu D, Cross K, Burikov S, Dolenko T, Patsaeva S, Schaefer DW. Structurability: A collective measure of the structural differences in vodkas. Journal of agricultural and food chemistry. 2010 Jun 23;58(12):7394-401.

6:  World Health Organization (WHO).  The Global Health Observatory. Global Information System on Alcohol and Health.  Levels of Consumption. https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/levels-of-consumption  Accessed on 01/04/2023

7:  PART 16 - ALCOHOLIC BEVERAGE HEALTH WARNING STATEMENT.  § 16.21 Mandatory label information.  Link

8:   AMERICA'S INSATIABLE DEMAND FOR DRUGS.  COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS.  UNITED STATES SENATE.  ONE HUNDRED FOURTEENTH CONGRESS.  April 13, 2016  Link

The Rights Versus Treatment Debate

 

Just yesterday I coauthored a brief opinion piece on the issue of civil commitment and the issue of rights versus treatment (2). My co-author Mark L. Ruffalo had the great idea to initiate our commentary based on a letter from the late Darold A. Treffert, MD who was then the Superintendent of Winnebago State Hospital in Wisconsin. Dr. Treffert was also an expert on autism and savant syndrome.  I heard him speak on that topic about 15 years ago at the Door County Summer Institute.  His letter (2) was both a statement about the need for legal intervention and a call to action. In the final line, he attempted to solicit negative experiences from other physicians about a civil commitment process that erred on the side of rights rather than recognition of severe problems and treatment and the resulting problems.

Historically this letter came around the time that antipsychiatry forces were building and one of their main talking points was that there was no such thing as a mental illness.  People simply had “problems in living” and therefore no medical or legal intervention was necessary.  Certainly not a legal intervention that resulted in the deprivation of civil liberty.  The antipsychiatrists and liberty advocates failed to recognize the problem of severe mental illness and the associated lack of problem recognition and impaired decision making.  Those impairments greatly compromise any person’s ability to negotiate the world safely and take care of their self. The usual examples include suicidal or aggressive thoughts and behavior.  They can also extend to routine medical care and activities of daily living.  As an example – a person with severe mental illness may no longer see the need to take insulin for diabetes, or blood pressure medications, or anticonvulsants. That can precipitate a medical emergency in addition to any existing psychiatric emergency.

In Dr. Treffert’s letter, he mentions that the Wisconsin Supreme Court set a new commitment standard of “extreme likelihood that if the person is not confined he will do immediate harm to himself or others.”  Imminent likelihood became an impossible standard in many cases. Even if a patient had attempted suicide or assaulted someone, at any point during a one or two week court process – they could make the argument that the imminent danger had resolved – even if they were refusing treatment and continued to have severely impaired judgment. In that case what frequently happened was that courts experimented with rapid dismissals of commitment petitions – until there is a catastrophic outcome.  At that point they become as cautious as the physicians involved in assessing and treating the patient.

The dangerousness standard for commitment has additional unintended consequences. It functions as a de facto hospitalization standard. It is common that managed care companies deny payment for admissions or even continued stays in the hospital based on the imminent danger statute even in patients being treated on a voluntary basis. The applicable standard in this case should be an adequate treatment standard – also a quality standard.  It is highly likely that any patient admitted after a suicide attempt or episode of severe aggression will continue to have that problem if they are discharged without adequate treatment. Adequate psychiatric treatment generally takes much longer than typical 2-to-3-day crisis hospitalizations. As a de facto standard in the managed care era, it is also easy to discharge a patient who is uncooperative with care by documenting the resolution of the imminent crisis and discharging them rather than working on relationship building and a plan based on a therapeutic alliance. The adversarial legal standard becomes an adversarial medical process. 

Imminent danger standards also fail to recognize forensic populations, the subgroup of people with severe mental illness who have a pattern of violent crimes and have a chronic risk of violent and aggressive behavior. This group of patients often cannot be treated in the same setting as other patients with severe mental illness, and require treatment in forensic settings with adequate staffing and protections for both patients and staff. That segregation can also occur at the community hospital level, where just a few hospitals have psychiatric units and fewer have units that are designed to contain aggressive behavior. Aggression and violence in psychiatric settings is so stigmatized that its existence is commonly denied unless someone is trying to make a political argument that involves blaming societal violence on psychiatric patients.  Even then there are counterarguments that it does not exist. I have been advocating the position that violence and aggression secondary to mental illness are public health problems that should be addressed at that level for at least 20 years.  During that time, I have not seen a single public service announcement with that message.  Instead, the political and legal system continues to ignore that approach by flooding the country with firearms, closing many if not most community mental health centers, closing supported housing, and failing to provide affordable housing.

The response from journalists is not much better – ranging from overt misinformation about psychiatry and mental illness to the occasional human-interest story. The people who know the most about the problem – psychiatrists, social workers, and case managers are left out of the loop in favor of the most convenient critic. Journalists seem unaware of conflict of interest of many of their recruited experts and do not apply the same standard that they would for a psychiatrist.  Journalists and politicians also promote widespread cannabis use and in some cases legalization of many drugs that all pose serious health risks to psychiatric populations.  It is as if saying that out loud is bad for business and tax revenues.  

The humane aspects of involuntary treatment are often turned on their head in the rights versus treatment debate.  Is it more humane to keep persons with mental illness circulating between short term hospital with minimal to no treatment, jails, and homelessness because they do not recognize the problems they are having and fail to come up with solutions, or is it more humane to offer involuntary treatment?  Context is very important.  In my experience, during involuntary treatment – therapeutic alliances occur as it becomes evident that the treatment providers are helping the patient survive better. People with impaired insight and judgment require evidence that they are being helped and that is generally a turning point in the process. If a person is homeless, the evidence has to be provided right where they are – on the street.  That requires active outreach by treatment teams. Ideally that can happen before any crisis occurs that may lead to civil commitment and involuntary treatment. But even if the patient is committed active intervention to support them outside of institutional settings is possible.  This method of community psychiatry and community support has been around since it was invented by Len Stein, MD and Mary Ann Test, MSW in the 1970s. I was fortunate enough to have been supervised by Dr. Stein during residency and one of the key concepts was “the money has to follow the patient.”  In other words, the money used to finance extended state hospital stays had to be used to treat people in the community and provide them with their own housing.  This was a model to maintain people disabled by severe mental illnesses in their own housing.  The other elements included active outreach and 24/7 availability of staff to help them resolve any crises. That basic model has been around for 50 years and it is rarely implemented and only recently discussed in mainstream medical journals.

The primary reason we have a problem with both homelessness and untreated chronic mental illness in the United States is economic. The managed care model of health care administration showed how easy it was to deny and ration psychiatric care to make money.  That model was sold based on increased efficiency and cost containment – but at this point it is obvious that it does neither. It does reroute funds to pay for a massive increase in the number of administrators at both the private and public levels.  These administrators are largely focused on enforcing the rationing of care instead of providing quality care. In fact, the real onset of managed care heralded the total disappearance of quality metrics in medical care. Quality was no longer monitored by external agencies.  It was internalized in managed care organizations. The focus went from adequate treatment of a problem to how quickly a person could be discharged to maintain profitability under an unrealistic reimbursement system.  That approach is a disaster for acute care psychiatry, community psychiatry, and it makes involuntary treatment more likely from the resulting chronicity. It has also been a major frustration for outpatient psychiatrists trying to get hospital access for their patients in crisis. But the economics are generally swept under the rug or discussed at a superficial level by the critics.

At the community level, rather than active outreach by trained mental health staff most communities end up using law enforcement or other first responders with minimal to no mental health training. In most communities they are the only staff available on a 24/7 basis and that is also a funding issue. There are situations where the police do need to be involved in a mental health crisis, but that is far less common than the need for mental health intervention.

What are the solutions? I have written about many on this blog over the years. At the top of my lost today is just moving past the rights versus treatment debate. It has been a stalemate for 50 years while the entire system of care has collapsed due to rationing. The rights have been adequately safeguarded for decades and arguments about abuses before that time are irrelevant. What do I mean about adequate safeguards? In the state where I worked, there was a prepetition screener, a prepetition screening team (to discuss the merits of commitment and whether the patient met statutory requirements), 2 court appointed examiners, a defense attorney, a country attorney, a probate court judge, and if necessary, a substance use assessor.  That is about 7-10 people independent of the treating staff and any one of who could disagree with the commitment process.  I am not aware of any legal process that provides more safeguards.

On the treatment side, there is a legal concept called least restrictive treatment. That simply means a treatment setting where the person is free to come and go as they please rather than being in a facility where they either can’t leave or have to ask for permission.  The goal of the Stein and Test model was to maintain people in their own apartment – the least restrictive of all. That is a goal that any functional system should aspire to.  When we hear about the homeless problem only a fraction of those folks have severe mental illnesses.  Another fraction has substance abuse problems. The obvious solution is a housing first option that may include social support or in the case of mental illness case management services with active community psychiatry outreach.  The first step is not transport to emergency departments and admission to psychiatric units.   

Another unmentioned dimension on the treatment side is well trained and motivated staff.  Police officers do not choose a career in law enforcement because they are interested in communicating with and treating people with severe mental illnesses. Mental health staff do.  Communication and relationship building goes a long way toward defusing a crisis and preventing involuntary treatment.

Addressing the dilapidated psychiatric infrastructure is the final step. The issue of psychiatric beds is a chronic problem with the ongoing political rhetoric that no more are needed compared with needs analyses based on bringing the length of stay (LOS) of psychiatric patients in the emergency department to the same LOS as medical and surgical patients. On that basis – there are very few places in the US with adequate psychiatric beds.

By far – the single most detrimental factor has been the managed care model of rationing in health care systems and by the states. Denying care will always be more cost effective than providing care.  It is also a good model for generating profits. Much of that early profit was made by shifting the cost of effective care for serious mental illnesses away from subscriber-based health care systems to state funded systems – at least until the states adopted the model for themselves. Any serious discussion of the rights versus treatment debate needs to start at that point. Involuntary treatment and civil commitment will never be a solution to the problem of homelessness or the revolving door of people with severe mental illnesses getting inadequate treatment.

I wish that I could end the year on a more positive note but things seem very grim out there. We are still in the midst of a pandemic that has showcased how susceptible the public is to misinformation and political manipulation.  I can't help thinking that this has been the state of affairs in psychiatry for the past 50 years and this post is some of that evidence.  I am hoping that we can see the rise of some leaders in psychiatry to counter these trends - just as we have seen experts in virology and engineering counter the coronavirus misinformation.  But it seems like it will take a lot more than that.

Here is hoping for a better year in 2023 and beyond!

 

George Dawson, MD, DFAPA

 

References:

1:  Ruffalo ML, Dawson G.  Still Dying With Their Rights On, 50 Years Later.  Psychology Today December 30, 2022 Link

2:  Treffert DA. "Dying with their rights on". Am J Psychiatry. 1973 Sep;130(9):1041. doi: 10.1176/ajp.130.9.1041. PMID: 4727765.

Photo Credit:

Eduardo Colon, MD with thanks.

Additional Posts Relevant To This Topic:

 1:  The Problem With Inpatient Units:  Link

 2:   Are There Any Good Jobs Left for Psychiatrists?  Link

 3:  The Bureaucratic Takeover of American Psychiatry: Link

 4:  There Is No Identity Crisis In Psychiatry  Link

 5:  Holding Tank or Psychiatric Unit?  Link

 6:  Medical Care of the Seriously Mentally Ill - The Way It Should Be Provided Link

 7:  Governments and Psychiatric Beds  Link

 8:  The New York Times Steers The Mental Health Conversation in the Wrong Direction  Link

 9:  Bedless Psychiatry and  Recipe for Remaining Bedless  Link

10:  The New York Times Article on Why Mental Health Can't Stop Mass Shooters  Link

11:  My Opinion on Community Mental Health from 1989  Link

12:  Minnesota's Abandonment of the Severely Mentally Ill - Nearly Complete  Link

13:  Treatment setting Mismatches - The Implications  Link

14:  Why There Are No Bipartisan Solutions to Exorbitant Health Care Costs in the USA  Link

15:  A Circular Ethical Argument About Psychiatric Services  Link

16:  The EMTALA Paradox  Link  June 11, 2017

17:  Managed for Mediocrity - Corporate Medicine in the 21st Century  Link

18:  Remission Before Discharge?  An Un-American Concept  Link

19:  Do Businessmen Dream of Medicine Without Doctors?  Link

20:  Americans Can't Do Basic Health Care Arithmetic  Link

21:  The Largest Psychiatric Hospitals in the USA Link

22:  Hospitalists...  Link

23:  A Better Analysis of the Psychiatrist "Shortage"  Link

24:  Just When You Thought American Healthcare Could Not Get Any Worse  Link

25:  Newsflash from the StarTribune - Psychiatric Patients Have Nowhere to Go  Link

26:  Medicine to Psychiatry to Parking Lot:  The Evolution of Detox Over the Past 30 years  Link

27:  Admission, Discharge, and Readmission Policies: No Better Example of Business Driven Pseudoscience  Link

28:  How To Ruin You Life Without Being Dangerous  Link

29:  How the Ruling Class Impacts Your Health Care and Why They Need to be Stopped  Link

30:  Trauma In Psychiatric Hospitalizations  Link