The Veneer of Civilization

Allan Tasman, MD

EDITORIAL

At the start of my residency, my supervisor and I were discussing a patient whom a fellow resident had evaluated for intermittent violent and aggressive behavior. At that early stage of training, I was confused because the patient was a successful man in his 40s who, outside of his periodic outbursts, had what seemed to be a successful career and a stable family. I don’t remember much of the discussion, but I do remember my supervisor’s last comment. A very experienced psychoanalyst and highly regarded community psychiatrist, he said something like this: “Allan, the world has not yet reached a condition of ego dominance, and the veneer of civilization is very thin.”

He was of course expressing something that doesn’t require psychiatric and psychoanalytic training to understand. People behave irrationally and sometimes violently, often against their own best interests. If an individual who has been violent or abusive is in treatment with us, we sometimes eventually understand the motivation behind the action . . . but often we can’t.

In the past several months, the national news has certainly confirmed the wisdom of my supervisor’s comment. We’ve come to expect that the news media will highlight the latest brutalities of crimes and wars. But, just when we think we know what to expect, we’re in for a surprise. I doubt that many of us would have been able to predict that multiple cases of domestic or acquaintance violence would dominate the headlines, even with the prominence of those accused.

It goes without saying that the widespread existence of domestic violence has been known to modern psychiatry for over a century. Freud based his early theories about psychopathology on the common stories of early childhood abuse he heard from his patients. Some believe, not without foundation, that had he not altered his theories more toward the supposition that these stories were fantasies rather than reality, 20th century psychiatry would have focused much more attention on the problems of family violence and abuse. We can’t change the past, but we must change the future and not accept as an immutable fact what we know already: those who have been abused or subject to violence are at greater risk for violent or abusive behavior than those who have not.

Unfortunately, the present-day managed psychiatric care approach of most third-party payers too often focuses treatment on symptom relief without an adequate, much less full, understanding of the antecedents of those symptoms. In the case of violent or abusive individuals or those who have been their victims, this lack of understanding has a clear negative impact on treatment outcomes. Moreover, even when we do understand the antecedents of abusive behaviors or their effects, we are limited by inappropriate restrictions on the care we can provide.

We are all familiar with the movement toward recovery-focused psychiatric treatment. While there are many competing definitions, the recovery-focused approach emphasizes helping patients gain adaptive capacities that foster increased self-awareness and improved self-regulation of feelings, thinking, and behaviors; and enhancing existing or learning new adaptive capacities, ie, enhancing resiliency. We know, of course, that all these outcomes are the ultimate goal of psychotherapy and psychosocial rehabilitation and should be part of treatment for many of our patients. Unfortunately, the recovery model has primarily been implemented only in treatment of the most severely and chronically ill patients.

Furthermore, funding cuts in public sector programs and restrictions on reimbursement, which wouldn’t be tolerated in any other branch of medicine, have limited our ability to provide recovery-focused treatment even to those most severely ill individuals. Why isn’t this commonsense model of care readily available to other patient populations and especially to those who suffer the effects of violence and abuse-both those who commit the acts and those who survive them?

Psychiatrists and other mental health professionals know that the long-term effects of violence and abuse produce societal costs across generations that are orders of magnitude higher than the costs of recovery-focused treatment. We need to join forces with our natural allies: the patients we treat and their families, as well as enlightened government, community, and business leaders, to make addressing the impact of violence and abuse one of our highest public health priorities.

It is clear that a major public education initiative, in conjunction with developing and paying for greater access to needed care, is of the highest priority. I know as well as anyone that few psychiatrists have the time or the inclination to lobby decision makers, to argue with insurance companies more than we already do, or to focus attention on this treatment population amid the already overwhelming demands for our care. In spite of this, let’s not let this issue die in the public’s awareness with the coming of the next news cycle. Our patients and their families, and the rest of society, too, rely on us for this.