Psychiatric Views on the 2014 News

Hoping that 2015 will be a healthy and happy New Year for society.

To know this whole region needs a shrink . . .

So says the well-known journalist Thomas L. Friedman, referring to the seemingly intractable conflict between Israel and Hamas, in his November New York Times article, “New Drumsticks.” The Psychiatric Views on the News series that began in September for Psychiatric Times attempted to bring together societal events and psychiatry to start a conversation.

In an early piece, titled “Beheading and Brains,” I recommended that the government involve a cultural psychiatrist to help understand the cultural values of ISIS. I don’t know whether that has taken place, but we do know that yet another defense minister, this time Chuck Hagel, has resigned. Certainly, the practice of cross-cultural psychiatry practice has improved. Could it not be successfully applied to societal groups?

So said Sigmund Freud, who more than treating mental disorders, wanted to understand “the riddles of the world.”¹ Many psychoanalytic studies of society followed during the heyday of psychoanalysis.

What would Freud say about ISIS? Though I was trained in psychodynamics, I am not a psychoanalyst, so I may be accused of the “wild analysis” that Freud deplored. Nevertheless, here goes. Freud might say that the culture of ISIS is an expression of internal family Oedipal conflicts with other expressions of Islam. Would he interpret the beheadings as a real and/or symbolic castration of the phallic West?

Since the decline of psychoanalysis, psychiatrists have not said much about culture, as psychiatry has become dominated by the biological perspective. One exception is Robert Jay Lifton, MD, who studied the nature of authoritarian societies, including how such societies challenged medical ethics.² Beyond his research, Dr Lifton became an activist against the Vietnam War, and more recently against global warming.

Observations
After this lull of psychiatrists’ commenting on society and involvement in activism, so say again many of my colleagues. Against the backdrop of the subjects covered in this series over the last few months, I asked those I knew from various sources, as well as some of the public, if they thought any societal issues had important psychiatric aspects which needed our attention. Gordon Peacock Harper, MD forwarded to me the column by Mr Friedman who I quoted at the beginning of this article.

Carl Hammerschlag, MD, well known for his work with Native Americans and the therapeutic use of clowning, thought that the topics could be endless, as he wrote:

There isn’t an important societal story that doesn’t have such relevance . . .from the escalation of fanaticism and terror, allowing people with terminal illness to choose to end their lives, racism and the Ferguson shooting (or the Washington Redskins), the growing economic divide, to global warming.

Dr Hammerschlag believes that mental health professionals are well situated to address the psychological sequelae of such issues, although he is not sure of how can be done successfully.

Fear of the other
My colleague and friend, Herb Bateman, tied together his top three stories from Psychiatric Views on the News by what they had in common. He concluded that ISIS, Ebola, and Ferguson were linked by fear. Along with fear came anger and a sense of being out of control.

The challenge is to contribute to reducing that fear in society. In “Ebola, Courage, Fear, and the Ethic of Reverence for Life,” I suggested voluntary or forced quarantine of health care workers returning from epidemic areas. One of the last of these workers to recover from Ebola is Rick Sacra, MD. In the article “Doing Good in Harm’s Way”³ he is quoted as affirming this kind of societal psychotherapeutic approach:

We recognize that sometimes you have to make adjustments above and beyond what is necessary legally, according to the rules, to relieve anxiety in the community.

In Pakistan, the population faces another growing epidemic, a resurgence of polio. Although many want to distribute the available vaccine, there is much resistance-and some assassinations-under the rubric that this is a plot by the West against Islam. Here, the challenge to reduce anxiety, if not paranoia and a quest for power, is even more complicated.

Suicide of Robin Williams
Some other respondents mentioned stories with a more obvious connection to psychiatry. These included gay marriage, domestic violence in the National Football League, the impending execution of Texas inmate Scott Panetti, and the suicide of Robin Williams. Indeed, Chuck Buck, Publisher of ICD10monitor, felt that the single most important societal story in 2014 was the suicide of Mr Willams:

For in one terribly tragic moment, Robin Williams’ death focused international attention-as no other story this year-on the insidious tentacles of depression . . . His suicide reveals the potential of psychiatric treatment . . .

A Rabbi I know well agreed that this was the top story, given the importance of Robin Williams to so many around the world.

Report on the Sandy Hook shootings
Some responders to my query went into depth about some societal issues that didn’t seem to get enough attention from me or anyone. Andres Pumariega, MD thought that the recent release of the investigative report by the State of Connecticut on the Sandy Hook school shootings was the most important news story. He felt that its significance was the adverse effects of stigma on addressing serious mental illness in youths, even though there were excellent resources and educated parents. His recommendations for psychiatrists:

Publicize the findings of this report even more widely with commentary by psychiatric leaders as well as by political leaders. More aggressive public education campaigns that drive the points and lessons home (may need sadly to be something like “stigma kills”).

I was struck that this was the first discussion of the report that I read or heard. How can we address such issues if we forget about them after the acute news dissipates? This occurs after intense storms, wildfires, and drought that may relate to climate instability. Will the same thing eventually happen with Ferguson, in which the racial divide is eerily reminiscent of the O.J. Simpson trial so many years ago?

Added to this specific focus on Newtown is that of John Rozel, MD. He wrote me:

As terrible as Newtown was and as significant of an issue as stigma is, the widespread and quotidian toll of gun violence is devastating and is measured out in smaller, isolated shootings, mostly unrelated to mental illness but with staggering damage to the mental health of surviving victims, their families, and their communities. This is not in any way intended to minimize the severity of active shooting/mass casualty events nor is it intended to suggest that stigma remains a terrible problem and a barrier, but merely to point out that at a public health level, gun violence needs a very different fix.

The Cold War heats up
An American History professor, after noting the unusual positive and fast change to gay marriage, also noted a more baleful change. That is the upsurge in military force, which included Russian aggression in the Ukraine. A colleague added to that, from the perspective a 100 years from now: “2014: The Destabilization of Europe, Westernization of the Ukraine, and Russian Hegemony.”

Following up two weeks after that prediction, this colleague noted that the Ukraine has put together a plan to build a wall between Ukraine and Russia. To me, that sounded reminiscent of the Berlin Wall, now gone, and the wall Israel built, still there. How such walls will prevent air aggression is uncertain, and besides being a physical barrier between people, such walls serve as psychological barriers.

Enhanced interrogations-and psychiatric interviews
My vote for the news story of the year from a psychiatric perspective is the recently released Senate Investigative Report of post 9-11/01 on enhanced interrogation techniques. Perhaps some of my colleagues and the public would agree, as they made their recommendations before the report was released.

Not surprisingly, given the contentious political divisions in US politics, there are differences of opinion over the necessity and usefulness of these techniques, which ranged literally and bodily from waterboarding to rectal feeding. One way they are connected to psychiatry was linked in my previous blog on the killing of the mentally ill. If one reads the Miami Herald report⁴ referenced in the blog, one wonders where mental health professionals were when the forensic psychiatric inpatients were reported to be abused, tortured, and killed.

Of course, we cannot really know whether the interrogation techniques were better than an alternative because a double-blind study of those techniques on separate, but equivalent, detainees was not feasible. Time seemed too short to respond. However, in the most unfortunate possibility of retaliation by terrorists for this report, how will any detainees then be interviewed? A psychiatrist has to wonder about the psychological wisdom of releasing the report now, because it seemed to be a political decision by the Democrats, who will lose power after the end of the year. It sure is hard to understand a 400-page summary of a better than 4000-page report.

Certainly, psychiatric interviewing is vastly different from enhanced interrogation. Gentle questioning and empathic responses contrast with aggressive demands and real threats to obtain information. In psychiatry, the closest we have ever had to interrogation is sodium amytal, sometimes called “truth serum” interviews, but they were questionable in their clinical usefulness. Yet, between the extremes of psychiatric interviewing and enhanced interrogation, there is a continuum that could be used to try to justify that psychologists personally participated in some of the interrogations.

Nevertheless, despite the differences in techniques, both psychiatrists and psychologists were involved in military torture.⁵ Major ethical concerns emerged, ranging from the dual allegiance of the professionals to the military to the needs of individual patients versus a larger population in terms of national security.

By 2006, the American Psychiatric Association approved a Position Statement declaring that psychiatrists should not participate in such interrogation, whether in the military or in civilian life, essentially because it would likely cause harm to the detainees. The American Psychological Association did not follow this lead. With what seems to be a tortuous (if you'll excuse the term) route, this association in 2005 endorsed that psychologists could be involved in such military interrogations.⁶ Finally, in 2009, organized psychology made a conclusion similar to organized psychiatry, when its Ethics Committee concluded that there is “no defense to torture.”

A New York Times editorial⁷ (see the online version of the editorial here) examined the role of psychologists, including the fact that the CIA outsourced the overview of the interrogations, from how to do them successfully to the effects on detainees, to a group of psychologists from 2005 to 2009. The end of this contract in 2009 marked the year of the new ethics policy.

I must admit that I still feel ambivalent. At times, my personal morals conflict with my professional ethics. I wonder, for instance, if those techniques helped to prevent any terrorist attacks within the US over the last 13 years. Osama bin Laden was caught and killed. More than that, I wonder how I would feel if I thought enhanced interrogation techniques could save a loved one’s life in a “ticking bomb” scenario? I might say: go for it. Would you?

An international perspective
Driss Moussanoui, MD has been a Professor and Chair of the Department of Psychiatry at the University of Casablanca and a President of the World Association of Social Psychiatry. He has a unique perspective on international news, both in the US and globally. He sees a lot of new as well as ongoing stories of concern, to wit:

One of the important things happening in the world is the reaction of people to lack of human approach to power: the politicians are abusing the privacy of 7 billion human beings because there are a few thousands bad guys trying to terrorize the world (Snowden is a hero and will be considered as such in the years or decades to come).” “Big Brother is watching you!!”

People are fed up with the bankers and the golden boys playing with money of the world like in a casino, and when they go bankrupt, they ask for money from taxpayers. People are fed up with police that kill young students (adolescents) by dozens in Mexico and burn their bodies. People are fed up with the policeman who killed in the USA a young boy of 12 just because he was black. People are fed up with enriching the rich people (50% of the world wealth in the hands of 1% of the world population) and impoverishing the poor.

There is loss of faith in politics: in the management of power in the city. Psychiatrists should say that real democracy and respect of human rights is an essential part of well-being and mental health. They are destroying the minds of people and should be aware of that. I know that his is not a story that started in 2014, but it has never been this visible.

Art, psychiatry, and society
Interestingly, the art world currently has challenges similar to psychiatry in responding to societal news, at least according to a front-page article in the Arts and Leisure Section of the New York Times. In the article. “Looking the Other Way,” A.O. Scott⁸ (see the online version here) asks “What are the responsibilities of culture to address a moment of economic inequality, racial tension and political impasse in American?”  Just substitute “psychiatry” for “culture” in his question. Is art only art for art’s sake (or is psychiatry for the patient’s sake)-or is it something more?

Mr Scott wonders where something like the play Death of a Salesman is today. So, he, like me, asked artists, why not?

Rapper J. Cole answered:

It’s hard to fight for other people when you’re trying to fight to survive yourself.

Psychiatrists have said that the obstacles to practice psychiatry today prevent paying attention to social issues. As Eitan Schwarz, MD wrote that he couldn’t think of anything significant socially, “since psychiatry as it actually is right now . . . has declined so far that it is practically irrelevant in most arenas . . .”

Debra Granik, a filmmaker, calls for more from artists:

When you take on themes that address existing social issues, you open up the possibility of being part of a larger conversation. I want my work to participate in some of those discussions.

Although none of my correspondents commented on the news item, “Should the Metropolitan Opera Cancel ‘The Death of Klinghoffer’?”, perhaps the protests about the opera were just the kind of provocation we need for artists to produce.

Society and psychiatry
What, then, does the news from 2014 tell us about society and psychiatry? Though I received many responses from those in our field, there were hardly any from the public. Does that mean that the public doesn’t see the relevance of psychiatry in the broader world? Few comment in the media, with the exception of Dr Drew, Sanjay Gupta, and many “talking heads” from fields outside of mental health that comment on the psychology of societal events.

Isn’t it curious that two of our most humanitarian fields, the arts and psychiatry, have been socially marginalized in recent years? Is there some underlying societal force causing this that needs unmasking?

Patrick Malone, extending the commentary by Dr Moussanoui, has an answer:

The unmasking of the deep racism and anti-female, anti-science, and anti-poor and ill that the scab was pulled off of in the past year by the politics and tactics of a huge segment of our society. We found out we were not who we pretend to be. And just like in therapy-until you truly see yourself, you cannot change yourself.

If Dr Malone is right, society needs insight, as does psychiatry. If psychiatry comes to understand that it should play a role in society beyond the most important one of taking care of patients, it can not only help to provide that insight to the public, but perhaps help to turn some of the anti’s into pro’s for the poor, minorities, ill, and science. One common thread that runs through many of the troubling news stories covered is the role of humiliation in disrupting relationships, from one-on-one domestic violence to large-scale racial and religious conflicts, along with the corresponding need to increase human dignity. We must not forget that the AMA Principles of Medical Ethics lists “society” as one of our secondary ethical priorities. Let’s see what might change in 2015.

What do you say? Is a psychiatric view on the news important? If so, what other news stories have caught your attention, and why?

References:

1. Chasseguet-Smirgel J. Reflections of a psychoanalyst upon the Nazi biocracy and genocide. Int Rev Psychoanal. 1990;17:167-176.
2. Lifton RJ. Witness to an Extreme Century: A Memoir. Free Press; New York: 2011.
3. Schwartz J. Doing good in harm’s way. New York Times. November 26, 2014. www.nytimes.com/2014/11/07/giving/relief-work-in-ebola-zone-is-fraught-with-risk.html. Accessed December 30, 2014.
4. Brown JK. Prisoner: I cleaned up skin of inmate scalded in shower; human-rights groups call for federal intervention. Miami Herald. June 25, 2014. http://www.miamiherald.com/news/local/community/miami-dade/article1972693.html. Accessed December 30, 2014.
5. Halpern AL, Halpern JH, Doherty SB. “Enhanced” interrogation of detainees: do psychologists and psychiatrists participate? Philoso Ethics Humanit Med. 2008;3:21.
6. Risen J. Pay Any Price: Greed, Power, and Endless War. New York: Houghton Miffin Harcourt; 2014.
7. New York Times Editorial Board. The Senate Report on the C.I.A.’s Torture and Lies. New York Times. Dec 9, 2014. Online version: http://www.nytimes.com/2014/12/10/opinion/the-senate-report-on-the-cias-torture-and-lies.html. Accessed December 30, 2014.
8. Scott AO. Is our art equal to the challenges of our times? New York Times. November 27, 2014. Online version: www.nytimes.com/2014/11/30/arts/is-our-art-equal-to-the-challenges-of-our-times.html. Accessed December 30, 2014.