The Humanist Who Writes About Religion: A Relational Dialogue With H. Steven Moffic, MD

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SECOND THOUGHTS

H. Steven Moffic, MD: American Psychiatry’s Social Conscience

H. Steven Moffic, MD, a fellow Psychiatric Times columnist, is a social psychiatrist who has edited a remarkable series of multi-authored volumes on religion, spirituality and psychiatry, the most recent one being on Eastern Religions, Spirituality, and Psychiatry.¹ He was interviewed by Leah Kuntz for Psychiatric Times after winning the Abraham L. Halpern Humanitarian Award of the American Association of Social Psychiatry in 2024. In this relational dialogue, we cover his views on religion and Islamophobia as well as topics in social psychiatry, politics, his retirement, and his legacy. The notion of a relational dialogue was inspired by relational psychology and relational therapy, which are at the heart of social psychiatry.^2,3 A relational dialogue is “an exchange between two or more interlocutors who alternate fluidly in the roles of listening actively, attentively, and speaking quietly, respectfully to each other.”² It flattens hierarchies and creates intimacy through the experience of self-disclosure. It differs from a conversation or an interview in that the relationship between the interlocutors is the subject of the dialogue.^4,5 Hence, a relational dialogue is anchored in the relationship. “The relational dialogue is to relational therapy what free association is to psychoanalysis.”²

Vincenzo Di Nicola, MPhil, MD, PhD, FCAHS, DLFAPA, DFCPA, FACPsych: Dr Moffic, you coedited a ground-breaking series of books on religion and spirituality in psychiatry. Can evidence-based psychiatry coexist with a psychiatry of meaning and faith?

H. Steven Moffic, MD: Once upon a time, maybe until my son became a Rabbi, I thought that where clinical psychiatry ended, religious and spiritual faith began. That is, a patient’s mind was clearer and freer to consider what meaning any religious faith might have in their life.

However, now, after learning more about Judaism, being the father of a Rabbi, and then being asked to edit these volumes on the various religions and psychiatry, I think evidence-based psychiatry and faith are intertwined. First, there are varying degrees of faith in science—that is, evidence-based psychiatry. But of course, that evidence changes over time, so that it is time-based evidence psychiatry. On top of that, every individual patient is different, so whatever scientific evidence exists for understanding and treatment must be responsive to individual variation. In other words, it seems to me that we must have both faith in our science and faith in ourselves to use that science as applied to individuals.

On the other side of the coin, various faiths seem to be on a spectrum of wanting to know about whether psychology is relevant to faith. The more fundamental the faith, the less the interest in psychology and psychiatry, it seems.

There have been rare models of being a combined clergy and psychiatrist. For me, that was one of my mentors, E. Mansell Pattison, MD. I have often used his “Prayer for Psychiatrists” that he gave to open the 1985 meeting of the American Psychiatric Association.⁶ Unfortunately, he died rather young in an accident.

After grappling with your question for the last couple of decades, I settled on the need to ask and incorporate what each patient viewed as the meaning and purpose of their lives, and then to gear the treatment to some degree to fit that. The exception was the desire to continue to take harmful street drugs! Often, the meaning was their religious beliefs if they had them. Of course, atheists and agnostics also can sense a purpose in life, which can also have similarity at times to religious purposes. Strangely enough, my question of meaning to patients developed as the administrative time to see each patient diminished and seemed to intensify the importance of each and every minute of treatment.

Di Nicola: You are preparing a second edition of your volume on Islamophobia and psychiatry, to which I am contributing a chapter called, “Who’s Afraid of Islam?”^7,8 It is Ramadan, during which the followers of Islam, who number some 2 billion individuals, fast and pray to celebrate the month when the Quran was revealed to their prophet, Muhammad. How do we maintain respect for the many peaceful practitioners of this pillar of world religions in the light of radical movements using it as a banner for revolution?

Moffic: It seems to me from what I know and have learned about the history of the various major religions that most have had periods of radical violence, even if they desire to “love thy neighbor as thyself,” as the Golden Rule goes. Here we are dealing with human nature, the fear of the other, and the desire for the power of safety and security of one’s “tribe.” For those who believe in it, there is also Freud’s concept of a death wish that needs to be controlled. Then there can be competition between religions to get followers.

Islam is a relatively new major religion, the third of what is viewed as the Western monotheistic religions. Almost like Oedipal conflicts, the new ones try to make a case, faith-wise or conflict-wise, that they are the best. Christianity had the crusades. Judaism, the first, has an admonition to watch for and address enemies in every generation.

After a long period of a more fundamentalist Islam, it seems to me that it is struggling to modernize, but certain fundamentalism is fighting that and wanting to maintain power. Our first edition of Islamophobia and Psychiatry in 2019⁷ was a historical revelation to me in the sense that the first psychiatric hospital was developed by Muslims in the early Middle Ages, well before those in Europe, and what became Freudian ideas much later were being used, only to disappear in history until current times.

However, I think your question of “respect” has mainly to do with whether mainstream Islam accepts the more radical movements. When there is not opposition to the radical extremists, it often seems harder to respect. I do think we are seeing more pockets of trying to incorporate a mainstream Islam into clinical psychiatry and perhaps even wider influence.

As you note and started this question, Vincenzo, as we talk, we are still in the month of Ramadan. Extremism is not a quest of Ramadan as far as I know. Rather, Ramadan is devoted to spiritual growth and character development. In the first edition of Islamophobia and Psychiatry, as an editor, I was struck by an unexpected observation of the chapter writing by Muslim psychiatrists during Ramadan. The quality and depth of the writing often increased during Ramadan. I asked some writers why, and they said that they felt in a bit of an altered state of mind and consciousness, deeper and more spiritual. I guess I should not have been surprised, though. In the Jewish Holy Day of Yom Kippur, our day of atonement, we usually fast. For many years now, on that day, I have been asked to participate in a study session on various topics that connect Judaism and psychiatry, such as Interfaith relationships, the increase of anti-Semitism, and suicide. I, too, feel that even though I get a mild headache during my fasting, that I am tapping into deeper spiritual territory.

In this second edition, the same shift has occurred this time around, as multiple superb chapter drafts have recently come in as we come close to finishing this stage of the book’s development. Moreover, whether this has anything to do with Ramadan or not, for the first time in the current Mideast war, the Palestinian citizens in Gaza are peacefully and publicly protesting the current governance and radical movement of Hamas.

Di Nicola: We have both dedicated our careers to social aspects of psychiatry. What is your definition of social psychiatry?

Moffic: You and I in this interview fit my definition of social psychiatry. Social psychiatry is relational psychiatry. Except for rare examples, one never exists alone. So we start with a 1-on-1 relationship between parent and child and expand upon that in other relationships. Here, besides my beloved wife, who saved my life, I am thankful for my parents, sister, children Stacia and Evan, grandchildren, friends, acquaintances, colleagues, clergy, and even enemies. For some, that gets repeated in clinical psychiatry where we have the clinician and patient trying to establish a positive therapeutic alliance, sort of like Winnicott’s “good-enough” mothering.

From these basic dyads, we move out to larger groups, nations, and all humans in our crucial relationships, for better and/or for worse. These relationships produce what we in psychiatry now call the social determinants of mental health.

Di Nicola: You have written about social psychopathologies. Can you describe them and give us a few examples?

Moffic: Our social relationships, because of human nature, can turn out to be helpful and healing or harmful and humiliating. Psychiatry has been based on that essential dyad I just discussed, with some eventual branching out into family and group treatments. Our DSM diagnostic categories are all individually based.

However, there are other social sources of mental suffering and conflicts. These are our “isms,” “antis,” and social phobias, with such corresponding examples as racism, sexism, ageism, Islamophobia, and homophobia. Anti-Semitism gets both an “anti” and an “ism,” fitting for the world’s oldest hatred, as one of my son’s books is titled.⁹ There are also other forms of socially based suffering. Some of them are loneliness, burnout, and cults.

Historically, it has taken political measures to reduce some of the harm of what I have called these social psychopathologies. In the United States, we had the 1960s where new civil rights laws were developed to reduce some of these, and although there has been some pushback and falling back over the decades, some progress has been made. Psychiatry, at times, has tried to help; for example, the desire to incorporate racism into our diagnostic classifications, but that has been rejected.

So, as I have written for Psychiatric Times, I suggest we in psychiatry and related fields work on a classification of these social psychopathologies, which then might spur research into better interventions before we have major disasters, like nuclear war.

Di Nicola: You have written about the Goldwater Rule and advocacy. You even have a tie that says, “Goldwater Rules.” What is your stance on psychiatry and politics now? What is your view of advocacy in a polarized society?

Moffic: That tie was distributed by a colleague at an American Psychiatric Association (APA) meeting some years back as a protest against the so-called Goldwater Rule, which falls under our APA ethical principles. The Goldwater Rule was designed in the early 1970s to prevent embarrassing comments about politicians, like that which occurred when Barry Goldwater was running for President.

However, the question is whether this principle is now causing more harm than good. In an age where the behavior and comments about politicians are quite out in the open, to muzzle psychiatrists from publicly commenting on politicians leaves out our expertise, although we still can comment on governmental policies.

I was dubbed as a “gadfly” by my Chair of Psychiatry during residency training some years later. That referred to my activism to try to address political processes that I thought were harmful within society and psychiatry. I asked him if that was good or bad. He told me to keep it up and I have, now most obviously in the hundreds of columns and videos I have done for Psychiatric Times over the last few years.

Now, with the escalating political divisiveness in our country and policies that are beginning to decimate psychiatric resources, it is essential we reconsider the Goldwater Rule. Right now, I think it is more like the Goldwater Rule is the emperor with no clothes on.

Di Nicola: You have been in retirement for some time now, and yet you seem to be busier and more productive than colleagues half your age! Tell us about your notion of “refirement” and the secret of a happy old age in retirement?

Moffic: Yes, as you say, this has been an unexpected psychiatric retirement. As for-profit managed care was decimating the healing potential of psychiatry in the United States (see my 1997 book on The Ethical Way: Challenges & Solutions for Managed Behavioral Healthcare¹⁰), I desired to retire early, at the age of 66 when I could then get Medicare medical coverage. I thought I would ride off into the sunset with my beloved muse of a wife, Rusti. We would travel and enjoy our family, and we did. We even shared and still share a computer, though others thought it would end our marriage!

However, something unexpected happened which, going back to your early questions, came to feel spiritual, if not divine. I began to be asked to write more, not academic really, but more briefly and personally. I found that such blogs, beginning with Psychiatric Times, but spreading to other publications, fit my writing style so well. Then I found out that I could be a good book editor too, and get a very culturally and religiously varied team of editors and chapter writers to work together, hopefully as a model for what can be done for general cooperation. That even included what on the surface seemed absurd and inappropriate—that is, to be asked as a Jewish psychiatrist to be the lead editor for a book on Islamophobia at a time of great international conflict between Jews and Muslims. But that worked well enough that we were asked to do a second edition, which is about halfway finished right now, and has developed with little conflict, probably because of the essential trust that has built up over the years. Fortunately, I have also had the same complementary coeditors over all the volumes: John R. Peteet, MD, a Christian psychiatrist, and Ahmed Hankir, MD, a young Muslim psychiatrist.

So that is what I meant by “refirement.” I went from finding out from my friend and colleague Randy Levin, that I was burned out, to an ever-expanding collection of writings, presentations, and editing. For that, the greatest thanks goes to Psychiatric Times for supporting that development. I also had a life-long best friend and colleague of 70 hears who optimistically supported these new endeavors, including artistically illustrating some of them. Unfortunately, Barry Marcus died suddenly about 2 and a half years ago, though fortunately I followed my intuition that we needed to visit him a month or so before he died.

About 5 years ago, this “refirement” seemed to reach another stage of meaning for me. During the 2020 COVID-19 pandemic Jewish New Year holiday of Rosh Hashanah, I started to receive what seemed to me to be some sort of divine inspiration for what I wrote and said, sort of like some writers say is being a vessel of transmission. Although I discussed this with Rabbis and colleagues, I concluded these were likely divinely inspired serendipity not coincidences, and I suddenly had better access to my unconscious, and decided to follow what they told me to do. For a simple recent example, I was working on the column “Whither Psychiatry.” It was getting much longer than usual. One draft ended with 1776 words. Well, that was the serendipitous message to stop, I concluded, for my column had ended with discussing our revolutionary times of our country’s founding in 1776, so 1776 words must be just right! I think I will know when to stop these columns on my end when such serendipitous messages stop (although the publisher could end the columns for other reasons, of course).

Di Nicola: When I trained in London, England in the 1970s, I met Michael Simpson, MD, in a course on counseling before and after bereavement at the Tavistock Institute. He described a task he gave to medical students at McMaster Medical School where he had taught and where I later studied medicine. The task he gave them was to write their own obituary. You have honored and eulogized many of our colleagues in the world of psychiatry who have passed on. How do you want to be remembered?

Moffic: Well, before I began these eulogies, I did my own many years back for the Hastings Center “Over 65” blog, put together by a colleague, and now defunct. I have now done 3 versions of my own eulogy, the last being on July 24, 2023 for Psychiatric Times, titled “Have You Written Your Own Eulogy? I Have, Here is its Update, and Why I would Recommend Doing Your Own.” That meaningful personal experience led me to wanting to do the same for colleagues over this last decade or so, a real labor of love for psychiatrists in general. We have a hard and challenging profession, given how hard it is to research the brain and connect that with the mind and possibly spirit or soul.

Anyways, how then do I want to be remembered? At times, I have thought about an epigraph: “He Tried to Stay on the Ethical Way,” meaning both professionally and personally that I generally succeeded in that quest, as is searched for, not quite successfully, in the song “The Impossible Dream” from the musical “The Man of La Mancha.” But now, my son is exploring artificial intelligence (AI) and its relationship to religion and even psychiatry. So, he is experimenting with asking AI to write new articles about topics in my style, about topics he knows I am interested in, like the Psychiatry of Torah Study.

Di Nicola: Here is a follow-up question to wrap up our dialogue: Do you believe in an afterlife?

Moffic: My son’s experiment and my sense of being divinely inspired leads me to 2 answers. I can perhaps have an afterlife of sorts as an AI generated presence. But that is not really what you are asking. It is too much faith to say I believe in an afterlife, but I would say that I hope for an afterlife with some sort of connection to this life.

Thank you so much for this social psychiatric opportunity to react to such important personal and professional questions, Vincenzo. It has been a blessing to get to know you as a valued colleague and friend, always challenging and supporting me as necessary.

Di Nicola: For myself and on behalf of our PT readers, thank you, Steve, for your remarkable series of volumes on religion and spirituality in psychiatry (to which I had the privilege of contributing^11,12). Your legacy is already established for following “the ethical way” and keeping us on track as American psychiatry’s social conscience.

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. In 1997, he was asked to write the first book on the ethical issues in managed mental healthcare, titled The Ethical Way: Challenges & Solutions for Managed Behavioral Healthcare (Jossey-Bass, 1997). He presented the third Rabbi Jeffrey B. Stiffman lecture at Congregation Shaare Emeth in St. Louis on Sunday, May 19, 2024. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He has edited 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.

Dr Di Nicola is a child psychiatrist, family psychotherapist, and philosopher in Montreal, Quebec, Canada, where he is professor of psychiatry & addiction medicine at the University of Montreal. He is also clinical professor of psychiatry & behavioral health at The George Washington University and president of the World Association of Social Psychiatry (WASP). Dr Di Nicola has received numerous national and international awards, honorary professorships, and fellowships. Of note, Dr Di Nicola was elected a Fellow of the Canadian Academy of Health Sciences (FCAHS), given the Distinguished Service Award of the American Psychiatric Association (APA), and is a Fellow of the American College of Psychiatrists (FACPsych). His work straddles psychiatry and psychotherapy on one side and philosophy and poetry on the other. Dr Di Nicola’s publications include: A Stranger in the Family: Culture, Families and Therapy (WW Norton, 1997), Letters to a Young Therapist (Atropos Press, 2011, winner of a prize from the Quebec Psychiatric Association), and Psychiatry in Crisis: At the Crossroads of Social Sciences, the Humanities, and Neuroscience (with D. Stoyanov; Springer Nature, 2021).

References

1. Moffic, HS, Gogineni, RR, Peteet, JR, et al, eds. Eastern Religions, Spirituality, and Psychiatry: An Expansive Perspective on Mental Health and Illness. Springer Cham; 2024.

2. Di Nicola V. Letters to a Young Therapist: Relational Practices for the Coming Community. Atropos Press; 2011.

3. Di Nicola V. “A person is a person through other persons”: a social psychiatry manifesto for the 21st century. World Social Psychiatry. 2019;1(1):8-21.

4. Andolfi M, Di Nicola V. “On the threshold”: a relational dialogue between Vincenzo Di Nicola and Maurizio Andolfi. Terapia Familiare. 2014;106:93-111.

5. Di Nicola V. A relational dialogue with Maurizio Andolfi: master family therapist and social psychiatrist. World Social Psychiatry. 2024;6(1):6-13.

6. Pattison EM. A prayer for psychiatrists. Pastoral Psychol. 1987;35:187-188.

7. Moffic HS, Peteet J, Hankir AZ, Awaad R, eds. Islamophobia and Psychiatry: Recognition, Prevention, and Treatment. Springer Cham; 2019.

8. Di Nicola V. Who’s afraid of Islam? A social psychiatric perspective on contemporary challenges of faith. In: Moffic HS, Peteet J, Hankir AZ, Awaad R, eds. Islamophobia and Psychiatry. 2nd ed. Springer Cham; in preparation.

9. Moffic E. First the Jews: Combating the World’s Longest-Running Hate Campaign. Abingdon Press; 2019.

10. Moffic HS. The Ethical Way: Challenges & Solutions for Managed Behavioral Healthcare. Jossey-Bass; 1997.

11. Di Nicola V. Looking at the West looking at the East: the radical western search for self through the faith of imagined others. In: HS Moffic, et al, eds. Eastern Religions, Spirituality, and Psychiatry: An Expansive Perspective on Mental Health and Illness. Springer Cham; 2024:277-287.

12. Di Nicola V. At the Sufi tavern: adventures in African and Eastern spirituality. In: HS Moffic, et al, eds. Eastern Religions, Spirituality, and Psychiatry: An Expansive Perspective on Mental Health and Illness. Springer Cham; 2024:291-303.