Celebrating Abraham L. Halpern Humanitarian Award Winner H. Steven Moffic, MD

H. Steven Moffic, MD, and his wife, Rusti

CLINICAL CONVERSATIONS

At the 2024 American Psychiatric Association Annual Meeting, the American Association for Social Psychiatry (AASP) bestowed H. Steven Moffic, MD, with the Abraham L. Halpern Humanitarian Award for his achievement in advancing human rights. Following the presentation, Psychiatric Times sat down with Moffic to learn more.

PT: What does “humanitarian” mean to you? What does this award mean to you?

H. Steven Moffic, MD: When I heard that I was nominated for the AASP Humanitarian Award, I wondered what that meant and thereby, why was I chosen for it? Those questions went beyond the usual sense that when one receives an award, you know that many, many others were well-qualified, too.

“Humanitarian” was not a term I ever used much, nor heard about it much in psychiatry other than this AASP award. In recent societal times, however, it was used regularly to refer to some of the basic human needs of the individuals in Gaza that were going unfulfilled during the war of Israel and Hamas.

Like anyone whose career was in academics, I did some academic research! First, what did it mean to the AASP? The website states the award is bestowed “for extraordinary achievement in advancing human rights” and that nominees should “inspire our idealism and persistence and remind us to do some good is woven into the very soul of what it means to be a doctor.” How aspirational and inspirational!

But then, what are “human rights,” since they are a key aspect of the award? The United Nations (UN), following the most extreme inhumanity of World War II, in 1948 stated in its Universal Declaration of Human Rights, that:

“They range from the most fundamental—the right to life—to those that make life worth living, such as the rights to food, education, work, health, and liberty.”

That definition brought me right back to psychiatry and Abraham Maslow’s theory of the hierarchy of psychological needs, published first in 1943, during World War II, and titled “A Theory of Human Motivation.” Since they predated the UN declaration, did the UN know about them and adapted them, so that there was a psychiatric basis to this declaration of human rights?

Maslow ingenuously used the image of a triangle with a long base and pointed top to illustrate the original 5 levels. From bottom to top, they were:

• Physiological Needs
• Safety and Security
• Love and Belonging
• Self-Esteem
• Self-Actualization

For me, that meant asking myself, did my career have some useful emphasis on being sure that patients had those needs met in the outcome of their treatment? Being a medical director of a psychiatric hospital (for physiological needs, safety and security), President of the American Association of Social Psychiatry (for love and belonging), President of the Board of our local Clubhouse for those with mental illness (for self-esteem), and clinically asking patents what gave their life the most meaning (for self-actualization), were among the most influential opportunities I had to progress toward the pointed top of the triangle. The validation of those activities included: the Administrative Psychiatry Award from the APA (2016); designated as a Hero of Public Psychiatry from the Speaker of the APA (2002); and the Exemplary Psychiatrist Award from both the local and National Association for the Mentally Ill (1991).

PT: There are many in the field that look up to you as a role model. What was your role model when you started out, and who is your role model now?

Moffic: As I do not think about wanting others to consider me their role model, I am honored whenever others feel that I am one, and especially so if they also include my wife and family, given the importance of both our professional and personal aspects of life. One of the Jewish values is for us to be “a light among the nations,” and I assume that also applies to each individual, including me too.

My early role model was the psychiatrist Robert Jay Lifton, MD, who was on the faculty at Yale when I was a medical student there. He helped defuse student riots when Bobby Seale was on trial in New Haven. Dr Lifton was also willing to be jailed in protest of the Vietnam War. In the recognition of history repeating itself in some ways, here we are now with college student protests in regard to the war in Gaza. His groundbreaking research was on Nazi doctors and what made people vulnerable to be brainwashed into cultish thinking—such important social psychiatric problems and challenges. Dr Lifton also exemplifies the reform Jewish value of Tikkun Olam, trying to make the world a better place.

It was no surprise to me that Dr Lifton was the first awardee of the AASP’s Humanitarian Award, and I was honored to be asked to introduce him. I also did a review of his memoir for Psychiatric Times. In recent years, both of us have become climate instability activists.

Toward the middle of my career, the psychiatrist James Sabin, MD, was an essential role model. I was asked to develop a not-for-profit managed care system at the Medical College of Wisconsin in 1988, the first of its kind in the country. Managed care was a new system and full of ethical controversy for its control over what was paid for in providing care. I searched for someone who could guide me in the ethical way and found Jim at Harvard Pilgrim. He focused on the concept of rationing, which was already present in other systems of care and could ethically be applied to managed care. I followed his lead and advice. He eventually recommended I write my book, The Ethical Way: Challenges & Solutions for Managed Behavioral Healthcare (Jossey-Bass, 1997).

As to a recent role model, that is tough, because we usually consider role models who are older than us and I am getting pretty old! It would seem to need to be a psychiatrist who did a lot of writing and speaking, often on controversial topics, like mine on social psychopathologies. Perhaps the psychiatrist who models that best nowadays is John Peteet, MD, with whom I have coedited all the religion and psychiatry books. We have been described as the “odd couple,” he so gentlemanly and formal, me more or less the opposite.

But right now? To prove that it is never too late to get a role model, I just now got many, as in the book being released tomorrow, June 11, by Mo Rocca and Jonathan Greenberg: Roctogenarians: Late in Life Debuts, Comebacks, and Triumphs (Simon and Schuster, 2024). Yesterday, on Sunday morning, our favorite TV show, I heard about some of them and I aspire to be or become a roctogenarian. The plug for the book is:

“Celebrates role models who came into their own at a stage in life when society would have had them packing it in.”

In looking back on these 4 particular role models, they all seem to have had a humanitarian concern for certain mental health challenges: Dr Lifton with cultish thinking that supplants normal moral principles; Dr Sabin about how best to respond to scarcity in certain areas for certain populations; Dr Peteet for spiritual and religious beliefs that are important for one’s purpose in life; and Mo Rocca’s roctogenarians, who model how to age well in late life and counter the social psychopathology of ageism. They also all seemed to have grace under opposition, which was a model for me to follow, given my earlier tendency to become angry at what seemed like unnecessary obstacles to mental well-being.

But, really, if you take role model in its widest implications, there are countless ones in our lives—from the family (my wife Rusti, who I learned so much from, a master of socializing with sunshine), friends, colleagues, students, mentees, editors (especially!), Rabbis (especially my son), career counselors (especially my daughter), teachers (especially my high school English teacher who taught me how to write), artists, athletes, and more that you want to learn from and emulate in some—often small—but important way.

And patients, thousands of them over 40 years. Specializing in those with posttraumatic stress disorder, the most serious and chronic mental disorders, and the underserved like ethnic minorities and transgender individuals. How do I thank them for all they (and their families) taught me over the years? They taught me so much about the fragility of our identity, of courage, of maintaining hope for the future, and about the worse and best that human beings can do to each other.

For this particular award, it is also important to mention my colleagues who contributed to my selection and their live contributions to the award session, where so much of what they said about me startled me in the best way. They are:

• Aida Mihajlovic, President of the AASP and her unwavering support and teach of medical students
• Rama Rao Gogineni, who I understand pushed the nomination, brought my present back from a Synagogue shop in South India, and all around is a paragon of goodness
• Dilip Jeste, the kindest psychiatrist I have recently come to know, an expert on the wisdom we all hope to achieve, and a former President of the APA
• Vincenzo Di Nicola, MPhil, MD, PhD, FCAHS, DLFAPA, DFCPA, the current president of the World Association of Social Psychiatry, for the connection to our American organization and for his stimulating ideas about social psychiatry, many of which are appearing in his new weekly column for Psychiatric Times.

PT: Your career spans many positions: clinical, professor, administrator, and author. How has your approach to social issues changed in the various roles?

Moffic: I even was a bit of a researcher at times, at least in the sense of learning whatever was available for a new area of interest, as well as to measure outcomes in the large systems that I led. Now, I might say that is positive social psychiatry, a subcategory of positive psychiatry, as in my quest to list a potential classification of social psychoexemplaries.

All those different positions and roles to me were like spikes connected to the middle of a wheel. Social psychiatric issues or the social psychopathologies are at the center. Whatever I have done offers different ways to reduce these social problems, whether through the spokes of the social influences on patients (the social determinants of mental health), scholarly activities, leadership of various systems of care, or writings and presentations like we have done at Psychiatric Times over the past 15 years or so.

In general, these various roles allowed me to have a broad and deep social perspective on psychiatry, its strengths and weaknesses.

PT: Have there been occasions in your career where your professional role contradicted a humanitarian approach? How did you handle them?

Moffic: Yes, there have been inevitable ethical conflicts between my professional roles and a humanitarian approach. Sometimes that is called trying to satisfy 2 masters, or the challenges of 2 required allegiances. I have done much work in considering psychiatric ethics, including developing ethical guidelines for psychiatric administrators. I have come to feel that choosing between 2 ethical “goods” or 2 ethical “bads” is the hardest—not choosing between an apparent good or bad.

The first time it happened was in the Army back in 1975-1977, when I was asked to provide verification of homosexuality to justify a soldier’s dishonorable discharge. Homosexuality at the time was still in our DSM diagnostic classification. For the patients’ needs, and patient needs are the number one priority in our psychiatric ethical principles, I had to look for alternative explanations of their situation like, say, an adjustment disorder. At the same time, I had to follow Army regulations.

Or take when for-profit managed care became dominant in medicine and psychiatry, profit became a priority over quality of patient care needs, as I described in my book, The Ethical Way. The ethical resolution was to reduce unnecessary and ineffective treatment as well as unnecessary and ineffective administration. Our academic managed care system did have documented better outcomes than the public system it replaced.

There were other situations where I felt money outweighed medical ethics and I tried to stay away from them: being an expert witness unless I could be objective and speaking on behalf of pharmaceutical companies unless I could write my own text.

PT: What are some lessons you have learned from your humanitarian effort?

Moffic: One lesson learned is that our basic human nature makes humanitarian efforts difficult. We tend to initially be fearful of the other, selfish in times of scarcity, power hungry, put ourselves above nature and other living things, and even self-destructive as Freud maintained in his death wish theory. The key, I think, is to do whatever possible to treat patients and people equitably and lovingly, adding evidence that unity in the long run is better than divisiveness.

PT: At what point in your life did humanitarian issues become important to you?

Moffic: Humanitarian efforts most often come up in regard to physical and mental needs. My mother had rheumatic fever with mitral heart valve damage from strep throat (pre penicillin) when she was a teenager. During my youth, she had physical consequences, including the need for bed rest. One of my earliest memories was her fainting in a store when I was about 5. As her oldest child, I was often told how I needed to help her and not stress her. I introjected the humanitarian desire to help those in need. Many years later, my wife and I moved to Milwaukee from Houston to be by her in Chicago before she died 6 months later in 1990.

Then another humanitarian issue came to the fore in high school when I became so interested in jazz music. Soon, I had the cognitive dissonance of the magnificence of this innovative music developed by Black Americans at the same time that intense racism still existed. To resolve that seeming contradiction professionally, I later decided to focus my work on the underserved groups, in which Black Americans were prominent.

PT: What advice would you give to psychiatrists who are interested in taking a humanitarian approach to their work in the field?

Moffic: As simple as they may seem, you can hardly do better than to follow Maslow’s hierarchy of psychological needs, now expanded somewhat to include Transcendence at the top, in providing humanitarian care. Then take the step beyond individual patient care, the basis and backbone of our field, to also try to help fulfill humanitarian needs in society.

PT: Was humanitarianism taught or discussed in medical school or through your residency? What role should discussions around humanitarianism should occur during training?

Moffic: Strange as it seems with such basic human psychological needs, I do not recall humanitarianism taught or even mentioned at all in my medical and residency training. Maybe it was mentioned in passing and I have forgotten. That neglect has continued, and I was guilty myself in not doing so in my faculty positions. The word is almost absent in our lexicon—no American Association of Humanitarian Psychiatry, no Journal of Humanitarian Psychiatry. During training, it should be referenced in any subject being taught: the humanitarianism of psychotherapy, of psychopharmacology, of systems of care, and more.

PT: What role should humanitarianism play in psychiatry?

Moffic: At its basis, we must remind all—us, patients, and the public—over and over, with the headline that psychiatry is a humanitarian profession.

PT: You have done a lot of work on burnout. Do you think having a humanitarian approach is protective?

Moffic: If medicine and psychiatry took burnout as seriously as it should, it would seem that a humanitarian system approach would prevent or reduce burnout. Why? Because then the system would support the basic healing goals and capabilities of physicians and, thereby, in terms of Maslow’s triangle, provide psychological safety. Instead, currently there are too many obstacles and disengagement put into place by system administrations. Personal well-being activities—exercise, diet, family time—are all good in themselves but will have limited effect in reducing physician burnout. Moreover, burnout has spread to the rest of society, but remains highest among physicians, at epidemic rates overall.

PT: You have worked on so many social psychiatry issues: the environment, racism, burnout, etc. What project are you most proud of and why? What area do you wish you could do more?

Moffic: It is hard to pick out 1 project, sort of like picking out a favorite child. Early in my first academic position at Baylor College of Medicine, where I coled a community mental health system with a Black social worker woman, we were picked as the first center to be covered in a new publication: Mental Health Center Spotlight (Vol 1, #1, 1980). Among those that are also close to my heart are those projects that I started that have morphed into some larger movement: academic managed care, burnout in psychiatrists, climate change (now the Climate Psychiatry Alliance). Or, rescuing a valued organization, like when I was President of the American Association for Social Psychiatry around the turn of the new millennium.

However, perhaps because it is so recent and I think some of my interests have matured or expanded in a spiritual direction, I am probably most proud of this new series of books on religions and psychiatry: Islamophobia, Anti-Semitism, Christianity, and upcoming, the Eastern Religions and Spirituality. Proud particularly because the individual volumes and series is so unique and innovative (and let me make clear that it was not my vision, just my responsiveness to requests), but also because of conflict about who should edit and write got very intense at times. Does a Muslim psychiatrist need to be the lead editor and write all the chapters and why? Proudest of all that the conflicts and divisiveness did get worked out collegially and productively. In fact, the Springer editor recently requested a second edition of Islamophobia and Psychiatry, and we have enthusiastically and quickly come together this time around.

One unexpected learning experience I had as the series editor, is learning more about cults and cultish thinking from the chapter writers on the subject: Steve Hassan and Jon Atack, probably the experts on the subject in the world. That led to Jon interviewing me on Zoom for about an hour and a half every 2 months over the past year on various related topics.

In terms of humanitarianism, there is a bit of confusion in relationship to religion. The term humanism generally refers to a system of thought and values that is attributed to humans rather than the divine, although many of the values can be similar. It is based on reason and science. Humanists believe in a responsibility to care for one another.

The area I wish I did more for, and still want to address, is that on Native/Indigenous Americans (and elsewhere). If we could do a 5th volume on Native Spirituality, that would more than suffice. We have much to learn from them, not only about environmental sustainability and adaptation, but the spiritual use of psychedelics, and about being happier.

PT: You have studied a lot about culture and have traveled around the world. How is humanitarianism portrayed in psychiatry in other parts of the globe? What can we learn from other cultures and countries?

Moffic: Right away, in my first chosen job at Baylor College of Medicine, I had the benefit of an anthropologist, Charles Cheney, and sociologist, Howard Kaplan, being on our psychiatric faculty. As I was responsible for developing our teaching curricula on Social and Community Psychiatry, they were crucial for educating me about “psychiatry” around the world, and the local ethnic healers, like the curanderos of the Mexican-American community. Historically, shamans and medicine men in many cultures were our psychiatrist prototypes, using support, herbs, plants, and empathy as we still do in different ways. In many of these more indigenous communities, stigma about mental health is absent as the healer is just part of expected community processes.

Since values differ by cultures, so, say, humanitarianism is more common in democracies and not in dictatorships. Where it is most clear and prominent, unfortunately, is in wars because the humanitarian needs escalate on both sides.

Travel, as you indicated, was a gift to learn about mental health, illness, and relationships. As examples, there was Easter Island where environmental degradation was extreme; in Israel psychiatry has become expert in addressing trauma due to all their wars and military conflicts; Canada, where we go each summer, certainly has a better and more easily managed system for psychiatric practice, including psychotherapy.

However, although there may be activities around the world that would qualify as being humanitarian, it is not labeled as such generally in any sort of organized fashion. One psychiatrist, though, Lynne Jones, based in the United Kingdom, calls her work with disasters and violence around the world humanitarian psychiatry and has written a memoir about it titled: Outside the Asylum: A Memoir of War, Disaster and Humanitarian Psychiatry (Weidenfeld & Nicolson, 2018). Her definition of humanitarianism, which I like very much because it implies that humanitarianism should be ubiquitous, is:

“Humanitarianism is the small, continuing everyday acts of mutual aid, carried out wherever we live and in whatever situations we find ourselves” (Afterword, p. 319)

PT: You always have projects on the burner and you stay involved despite your “retirement.” What is your secret?

Moffic: My secret, though it is obvious to anyone who knows us, is my wife. Not only has she been my ongoing muse, but exposed me to all the arts and the so-called humanities, which are connected to some basic humanitarian needs of expression and enlightenment.

As I aged, it became clearer how most everything in life is connected, and therefore interesting and intersectional projects are almost ubiquitous. In addition, I try to never say no to a reasonable request, for it could turn out to be unexpectedly gratifying. Finally, pay attention to what seem to be serendipitous occurrences, which I seem to be experiencing daily for several years now, 2 things happening at the same time that have extra meaning, perhaps divinely inspired, when considered together.

I have gone from”retirement” to “refirement.”

PT: What are some of your current projects?

Moffic: Overlapping is the finishing production processes for the publication (due in September 2024) to the book I have been lead editor on, The Eastern Traditions, Spirituality, and Psychiatry, as well beginning submission of plans for a requested second edition of Islamophobia and Psychiatry. I would love to do more community Q&A sessions like I described in the June 5th, 2024, video.

One of the keys to this “refirement” is the control I have over what I do, hence my “affiliation” as a private bro bono community psychiatrist. The only things involving financial interest is expert witnessing and special invited lectures for a financially stable organization. Personal control is the antidote to organization control leading to burnout.

PT: If you could go back in time and change anything about your career, what would it be?

Moffic: This is such an important closing question because it connects to the tendency to look back on one’s life for its themes and meaning, especially at my age as I near the inevitable close of my life. I have no major career regrets. I tried to get the best out of any situation or change. I have found that often one learns more from failures and betrayals than successes. That can include colleagues who betray you. As one colleague warned me: enemies will stab you in the back; friends will stab you in the stomach. I was slightly wounded by both, but being a “wounded healer” as Jung discussed, is almost a necessary, and hopefully I came out stronger and more resilient. I went through 2 bosses, one who suddenly left town and ended up being convicted for criminal buying and selling of clinics, and the other who retired with a hidden deal for his own well-being at the expense of my own. The latter led to my unexpected early “retirement” due to new academic pressures that reduced adequate time with patients for financial reasons. Ironically, the most wonderful years of my life ensued—with increased writing, presentations, awards, travel, and much more time with my wife and family. It even made the COVID-19 shutdown a partial blessing, and some unexpected awards and collegial feedback topped by this recent one:

“Yes, you are the messenger, but, so often I seem to sense a huge humanity in your voice and presence - a cosmic connection for which I am most grateful.” - Chuck buck, Publisher of RACmonitor and ICD10 monitor, email 5/29/24

That mention of “cosmic connection” hits upon something I wish I had focused on earlier, not only in my career, but personally. One of my early special interests was in cultural psychiatry, which at least in that time focused on value systems of various ethnic cultures. Religion and spirituality was relatively ignored, as it was in general psychiatry due to Freud’s critical views on religion, until more recently. Around the time of pivoting toward religion in psychiatry came the same in my personal life. Our son decided to become a Rabbi around the turn of the new millennium and that stimulated me to learn more about Judaism and religion that my wife had always recommended. And one of the things I discovered was how much our Torah (the Old Testament) displayed modern psychological insights in the stories about individuals and families. However, as far as that might relate to humanitarianism, that would still take until the last decade or so when I started to participate as the first-call Jewish psychiatrist representative in interfaith projects and the religion and psychiatry book series.

If this makes sense, I could have earlier and more overtly pushed for a recognition of humanitarian psychiatry. The humanitarian approach is essential to the goals of positive social psychiatry in climbing to the top of Maslow’s triangle, starting with the primary relationship with parent(s) to later ones, and then spiraling out to colleagues, patients, communities, and countries. This model might be deemed a humanitarian social psychiatry, or perhaps better yet, social psychiatric humanitarianism, thereby suggesting that humanitarianism is the more comprehensive value and that social psychiatrists should do our best to emphasize and enhance that value. Although this humanitarian approach can be criticized for focusing on us humans and not the rest of living things and the earth, the fact that our fate is intertwined with our ecology requires our concern for our entire earth.

But, perhaps, it is not too late for me to pay more attention to the humanitarian approach, and this honor kickstarts the process. Possibly, as a roctogenarian would say, now is even the best or most important time. As artificial intelligence takes over mathematical and collating skills, the humanities will likely be needed even more. Although I do not recall discussing humanitarianism in residency training, we did discuss the humanities because we had an English professor from the University of Chicago discuss novels with important psychological insights. The humanities explore what it means to be human, including the arts, philosophy, religion, and more. Humanism puts those foci into a value system but does leave out the divine. Humanitarianism can include the divine religious beliefs and tries to address the obstacles, including mental challenges, to our human potential. Though often causing some terminology confusion, the humanities, humanism, and humanitarianism all together are connected to humans and our quest to find meaning in our lives.

Perhaps I am embarking on being a humanitarian futurist. Perhaps the greatest gift of this humanitarian award and your focus on it for me, and more generally, is that it emphasizes and reminds us of the importance of the humanitarian in psychiatry. In retrospect, humanitarianism was always there for me and psychiatry, but we did not seem to know it. Now I do. May psychiatry know it, too.

Dr Moffic is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry and is now in retirement and retirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has done a weekday column titled “Psychiatric Views on the Daily News” and a weekly video, “Psychiatry & Society,” since the COVID-19 pandemic emerged. He was chosen to receive the 2024 Abraham Halpern Humanitarian Award from the American Association for Social Psychiatry. Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now The Eastern Religions, and Spirituality. He serves on the Editorial Board of Psychiatric Times.