How to promote nonviolence — (1) The problem

Prompted by the Sandy Hook shootings and Boston Marathon bombings, a bumper crop of articles about our violent society has sprouted in recent weeks.  I was particularly drawn to this opinion piece in the New York Times.  Author Todd May, a Clemson University professor of Humanities, articulates well the crucial underpinning of a nonviolent world view: "the recognition of others as fellow human beings, even when they are our adversaries."  Drawing on the philosophy of Immanuel Kant, who said that the core of morality lay in treating others not simply as means but also as ends in themselves, May argues that the key to a nonviolent society is "to see our fellow human beings as precisely that:  fellows.  They need not be friends, but they must be counted as worthy of our respect, bearers of dignity in their own right." May is surely correct about this.  A morality based in respect for others, and in recognition of our duties and obligations to others, underlies most of the defensible arguments favoring nonviolence.  (The major alternative, a utilitarian morality based on outcomes and consequences, will forever argue that the ends justify the means, even if the means are violent.)  The Golden Rule "do unto others..." and biblical admonitions to "love thy neighbor as thyself" are based on this type of reasoning, called Kantian or deontological.

At the philosophical level, then, the challenge is to convince ourselves and each other that deontological respect for our fellow human beings is itself a concept worthy of respect.  To put it mildly, this is not so easy.  Everyone from Confucius to Jesus to Gandhi has tried.  Yet "peace on earth, goodwill to men" still sounds like a pipe dream, lovely words that have no bearing on real life.  Even the many of us who claim to accept this precept often act otherwise.  Why does this perspective, favored by virtually all world religions — as well as secular humanists — and argued most compellingly by our greatest thinkers, nonetheless fail to gain traction?  The answer to this central question of human existence: psychology.

Sadly, we humans don't always behave sensibly.  Our feelings often precede and even dictate our thoughts.  This was first brought home to me when, as a college student witnessing a political protest, I suddenly realized that the emotional fervor expressed by both sides had very little to do with thinking the issue through.  Indeed, it seemed people who understood the subject the least had the strongest feelings about it, pro or con.  Moreover, it appeared that people become emotionally invested first, and only later bolster their positions with post-hoc reasoning.  Around the same time, I helped with a well-known psychology experiment on confirmation bias, our human tendency to grant greater weight to evidence that supports what we already believe.  In the experiment, subjects who already had strong opinions pro or con about the death penalty reviewed exactly balanced "evidence" — I should know, I fabricated it — and reached opposite conclusions.  That is, both sides felt more justified in their prior belief by weighing more heavily that portion of the evidence that agreed with their existing position.  Those already in favor of the death penalty became more in favor, those already opposed became more opposed.  Both the political rally and this experiment figured centrally in my decision to pursue a mental health career.  Here was proof that people simply aren't rational — and that's fascinating.

While fascinating, this reality bodes poorly for reasoned arguments aimed to influence others.  As a society we argue endlessly over social issues:  the role of government, whether private gun ownership increases or decreases one's safety, the legitimacy of gay marriage, how we should treat undocumented immigrants.  Selected (i.e., biased) facts, statistics, and images are lobbed back and forth.  Those who already agree with a particular bias applaud; those who are opposed become annoyed and counter with facts, statistics, and images of their own.  For the most part, everyone feels vindicated by their confirmation bias.  Very few minds are changed.

Nonviolence is an especially poignant case.  Nearly everyone claims to be on the side of discouraging and decreasing violence, yet there is vehement disagreement over how to achieve this.   Moral directives to "do unto others" or "love thy neighbor" are dismissed as naive.  Here in the real world it's "peace through strength," "the best defense is a strong offense," and "a pacifist is someone who hasn't been mugged yet."  Violence is treated emotionally as axiomatic, a given, with post-hoc justification that "they deserve it" or "they started it," or that committing violence now prevents more later.  It is a necessary evil, an entrenched part of the human condition.

In part two, I will pick up from here.  Given that moral reasoning alone rarely changes anything or anybody in the real world, what can?  Is there a meaningful way to promote nonviolence?

Going to the APA meeting?

The annual meeting of the American Psychiatric Association (APA) is in San Francisco this May.  I've attended twice before as I recall, both times when it was here.  I enjoyed it, and even felt it was worth the $1000 we non-members pay to get in, although in my opinion it's not worth doubling that for airfare and lodging to attend in another city.  The presentations were generally of high quality, and so plentiful that I always found something worthwhile to attend.  Up to 50 CME (continuing medical education) hours are available over five days, enough to maintain a California medical license for two years.  This year, in addition to the other presentations, the new DSM-5 will be unveiled and discussed, so we can anticipate hearing a lot that is new and essential for clinical practice.  Bill Clinton will give the keynote speech. Yet it's a hard decision for me to attend this meeting.  The APA and its annual meeting reflect aspects of psychiatry that concern me.  In 2006 the drug industry accounted for about 30 percent of APA's $62.5 million in financing, half through drug advertisements in its journals and meeting exhibits, and the other half sponsoring fellowships, conferences, and industry symposia at the annual meeting.  Every year the annual meeting features a huge exhibit hall of lavish booths courtesy of the pharmaceutical industry.  In past years I watched my fellow psychiatrists line up for branded coffee mugs and similar swag; although voluntary restrictions by the Pharmaceutical Research and Manufacturers of America (PhRMA) in recent years have curtailed this, the APA itself welcomes such giveaways according to this year's information sheet for exhibitors.  This year there are industry sponsored "Product Theater" presentations most days around lunchtime (six sessions total, up to 250 attendees per session), and "Therapeutic Update" meetings at dinnertime (three two-hour sessions) — pure marketing vehicles that are not approved for CME, that lack any pretense of scientific balance or neutrality, and that come with a nice free meal to tickle the limbic systems of the recipients.  In fact, there's a surprisingly wide range of promotional and marketing opportunities at the meeting (pdf here) that the APA sells to industry.  We participants may sign up for the scientific presentations and collegiality, but the APA invites us for the millions of dollars we bring in.

Of course, individual attendees aren't forced to take a seat at a "Therapeutic Update" and may never set foot in the exhibit hall.  So what's the problem?  Can't attendees enjoy an educational experience free of commercial influence?  Unfortunately, with APA selling everything from sponsored wi-fi, to plasma-screen billboard space, to branded do-not-disturb signs at the hotel, the industry flavor will be hard to miss.  Registrants are warned that our names, titles, mailing addresses, and email addresses will be "shared" (i.e., sold) to meeting exhibitors.  Perhaps there's an unpublicized opt-out I'm not aware of.

Whatever one thinks of this blizzard of advertising to a highly selected, captive audience of over 10,000 psychiatrists, it hardly needs to be said that the practice of psychotherapy will have no deep-pocketed sponsorship; healthy nutrition, exercise, lifestyle balance, and introspection will enjoy no "Product Theater" or "Therapeutic Update."  If this year's meeting resembles those I attended in the past, many presenters will mention the importance of psychosocial factors in mental health, and, if one seeks them out, there will be talks by some of the luminaries in trauma research and psychological treatments.  But this will be in the context of blaring signs promoting the newest antidepressant, mood stabilizer, and anti-psychotic — which nowadays may all be the same product — and a zeitgeist of DSM diagnoses leading to pharmaceutical remedies.

Speaking of DSM, the unveiling of DSM-5 ought to be interesting.  DSM diagnosis is an integral part of most mental health (not just psychiatric) practice, as treatment authorization and reimbursement by health plans often hinge on the DSM disorder for which the patient "meets criteria."  Both the process of creating the new DSM-5 and its conclusions have come under repeated attack from a range of reputable critics, including the chair of the DSM-IV Task Force Dr. Allen Frances, Division 32 of the American Psychological Association (the "other" APA), the British Psychological Society, the American Counseling Association, and others.  One common criticism is that diagnostic categories are being loosened (or widened), such that more patents will meet criteria for a mental disorder, and in turn more psychiatric medications will be prescribed.  Dr. Frances charges that the APA treats publication of DSM-5 as a "cash cow," citing the hefty cost ($199 hardcover, $149 paperback) of this instant and inevitable best-seller.  My own feelings about the DSM are mixed, and I'm curious to see how the newest edition turned out, particularly the section on personality disorders.

Despite my concern about undue commercial influence, misplaced priorities, and its controversial diagnostic manual, I plan to go to the APA meeting this year.  There's too much of value to me in all those presentations.  But when I pass the anti-psychiatry protesters at the entrance, I know I will wish for some way to declare myself neither anti-psychiatry nor, despite appearances, in full agreement with the spectacle within.

The lure of rapture

Fundamentalist Christian minister Harold Camping of Oakland, California, has widely publicized that today is the day of the Rapture, when according to some interpretations of the New Testament true believers ascend to heaven to escape impending misery and turmoil on Earth.  I am writing in the afternoon, and can't guarantee just yet that Camping is mistaken.  But let's assume he is: He was wrong before, and he is just the latest in a long string of mistaken end-times prophets.  I promise to post a prompt, heartfelt apologetic retraction if he turns out to be right — and if the internet and I survive the initial cataclysm. I have a few reflections on end-time prophesies, starting with the admission that I've always found them oddly alluring. As a child, I knew I would be alive in the year 2000.  In my young mind this futuristic date glittered with flying cars, modular glass homes, one-piece unisex jumpsuits that somehow didn't look absurd, and one or more Moon colonies.  But in addition, I had repeatedly heard predictions that Christ's Second Coming would coincide with the new millennium.  Although there is plenty of theological controversy on this point even within Christianity, and even though I was not raised to believe anything of the sort, it always struck me as exciting that  such a grand moment might actually take place in my lifetime.

With the year 2000 come and gone, most end-time attention has since moved to 2012, when, among other things, the Mayan calendar supposedly runs out of dates.  Even so, I wonder whether Mr. Camping, who is 89 years old, is consciously or unconsciously motivated by the possibility that this greatest of historical events might occur in his remaining natural lifetime.  Perhaps it is human nature both to hope and to believe that we live in a unique time.  A touch of narcissism perhaps?

Psychologists and others have wondered, and occasionally studied, how believers deal with mistaken prophesy.  What will Camping and his followers do or say tomorrow?  Leon Festinger's classic 1956 study "When Prophesy Fails" suggests that rather than recanting his beliefs, Camping is apt to rationalize his failed prophesy.  For example, he may realize his calculations were off, or declare a divine 11th hour reprieve for the world.  Of course, some followers, perhaps the majority, are apt to feel disillusioned and humiliated.  The "Great Disappointment" of 1844 offers the historical precedent of a similar failed prophesy.

There is a non-religious definition of rapture: "n. the state of being carried away with joy, love, etc.; ecstasy."  In a larger sense, we all seek to connect with something bigger than ourselves.  For many, it is religion and its connection with God.  Others find connection and larger purpose in humanitarian or political work.  Playing music or team sports with others can satisfy this need to some extent, as can being part of the crowd at a concert or other event.  Even mobs and riots satisfy this need, albeit in destructive ways.  The lure to belong, to share experiences with others, to have a larger purpose, to be "in a groove" seems innate.  I once saw a greeting card that read, "People who never get carried away... should be."

It is really no surprise that doomsayers capture headlines and our attention.  Whether we expect to rise to heaven today with God's Chosen, or join others in ridiculing the gullible — or blog to readers on the internet — we all can be part of a grand spectacle.  It makes this sunny Saturday more special than it would otherwise be, and ourselves a bit more connected to feelings, purposes, and forces greater than ourselves.

Healthcare reform & psychiatry

The recent debates over U.S. healthcare reform are long overdue, yet still sadly inadequate.  (The discussion is about health insurance, actually, not the care itself.  But I titled this post "healthcare reform" since that is what everyone is calling it.)  There is no need to rehash the plentiful evidence that the current system is broken: millions of uninsured, job lock to maintain health coverage, unwarranted claim delays and denials, whole industries devoted to medical paperwork and reimbursement, and the near impossibility, given a pre-existing condition, of purchasing non-employment based insurance at any price.  Hardly anyone across the political spectrum argues for the status quo. The national debate centers on how to provide universal, or universally available, coverage to all Americans.  Some argue that with proper incentives, private insurers could cover everyone.  Similar to health coverage in the Netherlands, this proposal aims to preserve the private insurance industry and competition in the marketplace.  Others argue that health care does not follow classic supply-demand principles, and that competition among private insurers has not controlled costs.  A publicly funded, government-sponsored option is preferred to remove the profit motive and gain efficiency through standardization.

Universal health coverage is the norm in virtually all developed countries.  I believe Turkey and the U.S. are the only remaining exceptions.  Some nations, Britain for example, have nationalized health care — doctors are government employees.  Others, like Canada, use public funds to pay doctors in private practice, much as Medicare currently operates in the U.S.  These systems are not perfect.  In particular, there are longer waiting times for elective procedures, sometimes on the order of months.  But surveys repeatedly show that citizens (and doctors) of these countries are happier with their health services than Americans are with ours.  And studies also show their health outcomes are the same or better than ours, for far less money.

There are many places to read about health insurance reform that do a better job than I can (e.g., here).  From my reading, I believe a single-payer plan such as those in  Australia, Canada, and Taiwan would greatly improve health care in the U.S., while preserving patients' ability to choose their own doctors, and also doctors' ability to work in the private sector.  It's a pity this option, so popular across the globe, is a political third-rail here.  In my view, publicly funded health insurance (think Medicare) is no more "socialist" than the public funding of highways, police departments, and firefighters.

In a nutshell, that's my view of publicly funded health insurance in general medicine and surgery.  But what about psychiatry in particular?

Universal coverage would be a boon for the seriously mentally ill.  Schizophrenia and severe chronic mood disorders render many sufferers unemployable and ineligible for private insurance.  Some eventually qualify for Medicare and/or Medicaid, the limited forms of public health insurance that already exist.  The additional stigma attached to using public programs due to severe disability would abate if public health insurance became a mainstream reality.  Others with debilitating but less severe forms of mental illness do not qualify for Medicare or Medicaid, but cannot maintain private insurance due to frequent job loss, chaotic lives, depression, and so forth.  The affordability of care and treatment is a constant stress atop an already stressful existence.

Universal health coverage would change all that (see this report from the California Endowment).  Canadians talk about their comfort in knowing their friends, acquaintances, coworkers — fellow citizens — have access to health care regardless of circumstance.  Healthy Americans might feel this way, too, when the chronically mentally ill among us are assured access to care.

At the other end of the psychiatric spectrum are relatively healthy individuals who seek psychotherapy for help in living a life that is basically stable, but is unfulfilling, frustrating, anxiety-laden, or sad.  In the U.S., most health insurance, private or public, limits coverage for this type of treatment.  Many private plans cap the number of treatment sessions to 20 or fewer per year; Kaiser Permanente additionally requires that a mental health professional "believes the condition will significantly improve with relatively short-term therapy."  Medicare does not cap the number of visits, but covers only half its "allowed fee" — the patient or supplemental insurance pays the other half.

It should be noted that traditional dynamic psychotherapy, the kind I do, considers it beneficial when the patient pays for therapy himself.  Directly paying for therapy focuses the dynamics between patient and therapist by excluding distracting intermediaries.  It matters more (to both parties) that the patient gets what he or she is paying for.  Sometimes patients express unstated feelings toward their therapist in how they pay their bill; this can be interpreted as transference, moving the treatment forward.  Moreover, dynamic psychotherapy is an intensely private undertaking:  Many patients choose to forgo insurance coverage even if they have it, to avoid a public record of the treatment, or the need to document it with third parties.

All that said, many more people can benefit by psychotherapy than can afford to pay for it directly.  A universal health plan that covered therapy in a substantial way (say, as Medicare does now) would make this service available to many who could not receive it before.  Third-party payment issues are handled all the time in dynamic therapy even now.  And not all therapy is psychodynamic; I know of no concerns regarding CBT (cognitive behavioral therapy), for example, being paid by third parties.

In short, U.S. healthcare — more accurately, health insurance — reform that universally covered mental health treatment would revolutionize care of the mentally ill in this country.  Benefits could be as visible as fewer homeless on the streets and in the jails, as subtle and pervasive as a comforting sense that Americans care about each other both in body and spirit.  I hope we have the will and the wisdom to make it happen.

NY Times roundup

Here are three recent New York Times articles that caught my eye. On March 13th, Tara Parker-Pope's health blog "Well" reprinted "The 12 Most Annoying Habits of Therapists." Actually, the list comes from PsychCentral, a blog written by psychologist John M. Grohol, and in my opinion reads better there. I won't list all 12 habits — you can look for yourself — but they include starting sessions late, eating in session, falling asleep, and so forth. The voluminous comments on both blogs relate the sad state of so much therapy out there, including professional lapses far worse than the listed 12. I plan to use the blog post itself, and some of the commentary, as a teaching handout when I lead a psychotherapy seminar later this year. Even beginning therapists should not make these mistakes. Speaking of psychiatry training, on March 16th, psychiatrist Richard A. Friedman M.D. wrote about a growing lack of confidence in psychiatry residents, citing their inability to make clinical decisions in routine cases, e.g., when to hospitalize or medicate patients. He blames faculty over-concern:

The fault, I believe, lies with medical educators like me. In the pursuit of patient safety, we have deliberately prevented residents from acting independently on their own judgment in situations where a patient poses a theoretical risk.

I share his concern to this point. I encounter resident insecurity much more often than overconfidence. I also agree that one reason for this may be a medical culture that increasingly recognizes a single right (or safe) way to proceed; independent judgment is discouraged.

But Friedman then goes on to blame "a series of reforms that began in the 1980s with limits on residents’ work hours." The current limits set by ACGME include an 80-hour workweek with a maximum shift of 30 hours. Friedman apparently feels such a schedule lacks "ample opportunity to stand on your own — and risk making a mistake."

I beg to differ. Sleep deprivation is not a teaching tool. There is no evidence it trains anyone to make decisions with more accuracy or confidence, although it is often justified this way post-hoc. Conflating confidence-building with hazing oversimplifies a complex issue. We don't need to toughen up residents, we need to help them make confident decisions. Two different things.

Besides, psychiatry residents generally worked fewer hours than residents of other specialties even before the ACGME limits. In other words, the recent limits have had less effect in psychiatry than in specialties such as surgery or ob-gyn. Could it be that psychiatry pays a bit more attention to how people think, feel, and learn, and therefore we were ahead of the curve?

And speaking of being ahead of the curve, today the Times reported that the American Psychiatric Association is ending industry-financed medical seminars at its annual meeting. President Nada L. Stotland, M.D. said the APA was not aware of any other organization that had made a similar decision on seminar sponsorship. Perhaps we psychiatrists will start a trend in medicine. (Neither the article nor the APA website says whether this change will occur in time for the annual meeting held here in San Francisco this May. I imagine not.)

I confess that I attended one of these seminars when the huge APA meeting was in San Francisco some years ago. Normally I avoid all industry largesse, but I was curious and justified it as research. Ironically, although it was lavishly catered and slickly presented, it was perhaps the least biased industry-sponsored talk I've ever heard. The smaller local ones are much worse in my experience, presumably because the level of scrutiny is so much higher at the annual meeting. There is press coverage, for example.

In any event, this is the right direction for psychiatry and medicine in general. But speaking of press coverage, I am curious about one detail. The Times, as well as Reuters, reported the APA policy change today, yet blogger Daniel Carlat M.D. scooped them by almost a week. Do official news agencies wait for press releases, while bloggers do the real investigative reporting?