Do patients avoid psychiatrists for fear of legal holds?

Over on the Shrink Rap blog I got caught up in an off-topic debate.  The post was on why psychiatrists avoid insurance panels, something I've written about myself.  But the commentary wandered into exorbitant fees, inadequate mental health services for the poor, income disparity between psychiatrists and patients, a generation that expects something for nothing, and so on.  After a week, prompted by minor irritation with San Francisco's transit system the night before, I finally posted a comment.  I wrote that buses and taxicabs perform roughly the same service, but for many riders who can afford it, a cab is worth the extra money.  I acknowledged that the analogy to mental health care was flawed: bus and cab fares are both regulated, and psychiatric care is often more urgent and critical, and definitely more expensive, than an optional ride downtown.  Nonetheless, the comparison made the point that more affordable mental health services are inevitably "bus-like," and that there is a legitimate role for higher-cost "taxi-like" services for those willing and able to pay for them. It's important to realize that all analogies are flawed.  They only highlight certain similarities between two situations.  There will always be differences too, the salience of which are inevitably disputed by partisan debaters.  For this reason analogies illustrate far better than they convince.  One commenter noted that even "bus-like" mental health services are not always available.  A psychiatrist pointed out that many of us accept reduced fees or otherwise "come to some agreement" with cash-strapped patients in ways taxi drivers don't.  Then another commenter who frequently writes about forced psychiatric treatment argued that coercion never occurs with buses or cabs, rendering my analogy "shallow at best."

Going off-topic, I replied that forced treatment, e.g., being subjected to a 72-hour legal hold (the "5150" here in California), is uncommon in office psychiatry, and in any case didn't bear on the point I made.  I later added that a number of non-psychiatrists are also authorized to apply the 5150 in California, and in many instances would be far more likely to do so than a psychiatrist in a private office.  My interlocutor, and at least two others, pressed on: the mere possibility, however remote, of being placed on a legal hold is a threat that evokes fear in current and potential patients.  This fear keeps some who "truly need psychiatric intervention ... from even attempting to access 'help'."

I had already let it drop when our host asked everyone to return to the topic of insurance panels.  But it's a point that bears discussion, here if not there.  Do patients avoid office psychiatrists for fear of being placed on a legal hold?

I'm sure the answer is yes, at least sometimes.  In the first place, many patients do not know what triggers a 5150.  Movies, popular culture (such as the depicted t-shirt), and history itself prime the public to think a padded cell readily follows from a few ill-chosen words.  Often I've reassured patients that ideas or feelings, however destructive or horrific, never in themselves lead to involuntary commitment.  Patients are free to divulge fantasies of mass murder, elaborate suicide scenarios, gruesome torture, etc. without risk of being locked up.  Indeed, talking in confidence about disturbing ideas or feelings is a good way to defuse their emotional power.

But there's much more to this than simply not knowing the law.  In my experience a great many patients fail to distinguish feelings and actions.  They try unsuccessfully to control troubling feelings, and somehow equate this with uncontrolled behavior, a very different thing.  Yet the distinction is hugely important in life, and with regard to legal holds.  Feelings never justify a hold, whereas behavior, or its "probable" likelihood, does.  If this distinction is unclear, even feelings seem dangerous.

At a more subtle level, patients with hostile or self-destructive feelings often expect to be punished for them, or they unconsciously feel guilty, i.e., that they should be punished.  Indeed, people avoid psychotherapists of all types, imagining the therapist will condemn or humiliate them for the ugliness of their inner world.  Unconscious mixed feelings, i.e., simultaneously fearing and seeking a harsh response, are common as well.  A crucial part of dynamic psychotherapy is gradually trusting that the therapist won't fulfill this fantasy.  Seeing a psychiatrist evokes these usual fears of being judged and punished, heightened in some by the psychiatrist's power to diagnose and to initiate a legal hold — even if the risk of the latter is virtually zero.

I hasten to add that we psychiatrists don't make this any easier for ourselves or our patients when we are sloppy about applying legal holds.  Patients' fears of subjectivity and loose criteria are partly based in reality.  A casual "better safe than sorry" attitude may send the wrong message, trampling the treatment alliance and savaging trust.  Meticulous care in applying the 5150 is a "frame issue" as central to therapeutic success as any other treatment boundary.  As a profession we can never count on being afforded more trust than we have earned (and sadly, often less).

Of course, there are circumstances when we rightly apply a legal hold in the office.  A patient who believably voices, or behaviorally telegraphs, intent to die or to kill others should expect a trip to the psychiatric ER for further evaluation in a secure setting.  Conversely, there are presumably people intent on suicide or homicide who consciously avoid seeing psychiatrists who could thwart their plans, just as they avoid telling their family or the local police.  Such people, however, are not seeking psychiatric assistance to avoid dying or killing.  If they were, they would accept help, including inpatient treatment if needed.

I once had a patient who came to see me, he said, so I could convince him not to die.  If I failed, he would kill himself.  I quickly replied that I wouldn't play this game, although I was more than willing to talk with him about his suicidal feelings.  We met five or six times; he wasn't truly interested in overcoming suicidal feelings, and I wouldn't engage in the no-win challenge he set up.  He left — no hold applied — and months later I learned he was still very much alive.

Similarly, those who rail against the completely predictable response of psychiatrists to voiced threats of harm are enacting a "death by cop" scenario.  The paradigm is someone who brandishes a weapon in front of police, who then react the only way they can — and usually with great regret.  Fantasies of punitive authority, forcing the hand of those in power, and/or getting one's just desserts, are made real.  Patients who force their psychiatrists to take control of their behavior likewise sacrifice adult autonomy in order to enact a primitive unconscious fantasy.  Unlike most patients who are relieved to be protected from their own frightening impulses, these few harbor antagonisms that may feel more vital to them than life itself.

Loss of privacy and the new psychic numbing

I grew up in the era of the nuclear arms standoff.  Thousands of warheads on land, at sea, and in planes stood ready to obliterate most of the human race if the Soviets, Americans, or a rogue third nation launched a nuclear "first strike."  Authors of that era wrote of the psychological effects of living under such a threat (not that it is gone now, but it certainly felt different back then).  Some said it rendered life fundamentally meaningless.  Why indulge personal hopes or dreams when we, our community, our entire culture could be gone in an instant?  Psychiatrist Robert Jay Lifton coined the term "psychic numbing" for the denial we employed, individually and collectively, to allow us to live our lives while faced with the real and ever-present risk that our world might end that very day. Psychic numbing was curious yet undeniable.  We all knew the danger was real.  But because the unimaginable horror of World War Three was coupled with an apparent inability to do anything about it, we told ourselves the likelihood was low and somehow pushed it aside.  Instead of being the top priority it arguably should have been, nuclear annihilation lurked like an ominous cloud at the periphery of consciousness.  We and our comedians made nervous jokes about it.  A few idealists joined peace and disarmament groups.  Meanwhile, the rest of us watched warily out of the corner of our eye, weighed down by a pervading fatalism and learned helplessness.

The dynamic of psychic numbing is repeating itself today.  This time it is not the existential risk of nuclear war, but the reality of losing our privacy.  Revelations that our own government monitors our private telephone conversations and tracks our vehicles, allegations that a few years ago would have been waved off as paranoid rantings, are now headline news.  We now know that our email is scrutinized for keywords (and possibly collected and stored in its entirety), and our cellphones are used to track our locations.  Like the nuclear threat of the 1970s, it feels as if we can't do anything about it.  Our discomfort lurks like an ominous cloud at the periphery of consciousness.  We and our comedians make nervous jokes about the NSA.  A few idealists join activist groups to oppose the scrutiny of innocent citizens.  Meanwhile, the rest of us watch warily out of the corner of our eye, weighed down by a pervading fatalism and learned helplessness.

The theft of privacy has been opportunistic and widespread.  The 9/11 terrorist attack justified not only "security theater" at airports, but also a trading away of everyday privacy in the name of national security.  Video cameras monitor public areas in major cities; license plates of highway traffic are scanned en masse and recorded by local and state police; the FBI can activate your laptop's webcam remotely and secretly (with a court order).  Meanwhile, quite apart from national security or law enforcement considerations, internet privacy has become an oxymoron.  The social web, an aspect of Web 2.0, promoted living one's life in full view of "friends" and others.  Facebook and Twitter distribute micro-doses of fame to monetize the formerly private lives of their users.  Younger people post photos of themselves in compromising situations while failing to appreciate the permanence of these images.  Older people use online health and mental health support sites, not realizing their "private" conversations are archived and publicly searchable.  A great many advertisers and others track web activity for commercial purposes, amassing huge databases without users' knowledge or consent.  Whether on actual highways or the quaintly-named information superhighway, the distinction between public and private is quickly eroding away.

Is privacy passé, a luxury we can no longer afford?  Psychic numbing tells us to shrug and bear the new reality.  As many thought 30 or 40 years ago about the nuclear arms race, loss of privacy appears to be the price of living in our modern world.

Don't believe it.  The forces that now seek to strip us of individuality and dignity have always been here.  New technologies present novel challenges, but human nature hasn't changed.  It took decades to realize we weren't forced to live with Mutual Assured Destruction hanging over our heads.  When we overcome our psychic numbing this time, we will re-discover that nervous humor, wary sidelong glances, and helpless fatalism are not effective ways to deal with a real problem.  We will re-discover the value and honor in self-respect.

How to promote nonviolence — (2) Necessary elements

In my last post, I outlined the fundamental problem facing advocates of nonviolence: Despite nearly universal conceptual agreement with this goal, human psychology conspires to make peace elusive and strife apparently unavoidable.  Our emotions trump our rationality, biasing assessments of real-world evidence and leading to post-hoc justification of whatever our "gut" feels.  Unfortunately, and rightly or wrongly, our gut feels scared or mistreated much of the time.  Violence is often the result, whether construed as self-defense or justified retribution.  This occurs with individuals, groups, and nations, and behaviorally ranges from brief verbal expressions of contempt to weapons of mass destruction and genocide. Gut reactions cannot be overcome by rational argument alone.  "Fight or flight" responses to threat, and urges to inflict retribution or punishment, start at the emotional level.  Since it is unrealistic to hope for a world without emotional triggers — without perceived threats that "demand" violent self-defense, or injustice that "demands" violent retribution — those who advocate nonviolence must accept the reality of emotional provocation.  Another reality is that even those who endorse a nonviolent philosophy are saddled with the same emotional reactivity as everyone else.   Given these constraints, how can nonviolence be promoted an emotional level?

Safety

It has often been said that our physiologic response to stress serves us well in situations for which it was originally designed, e.g., an attack by a wild animal, but that it is misplaced in our modern world of "attacks" by time deadlines, career pressures, and miscommunication by loved ones.  Autonomic stress responses — increased pulse and blood pressure, outpouring of stress hormones, faster reaction time —  may save our lives in dire situations, but only hurt and exhaust us when activated chronically and without purpose.  Many effective ways of managing unhealthy stress do so by enhancing feelings of safety and relaxation, emotions that are incompatible with the stress response.

In many respects, violence is similar.  With rare exceptions, it is a reaction to a perceived threat.  It may be said that violence serves us in situations "for which it was originally designed": self-defense against a warring enemy or a criminal intent on killing us.  Yet it only hurts and exhausts us individually and as a species when activated chronically.  Enhancing feelings of safety and relaxation helps us be less violent and more peaceful; conversely, a heightened sense of danger and tension promotes violence.  While dangerous threats exist in the real world, they trigger violence emotionally, not rationally.  Being cut off in traffic may constitute a real physical threat, but our urge to respond with verbal or physical violence arises from a complex stew of imagined contempt by the other, anonymity in our vehicle, an assessment of the likelihood of further escalation, how much we feel they "deserve" it, and similar factors.  Emotional safety is complex and not easily assured.  Yet it is a necessary element in our closest relationships, in our work, in our communities, and on the world stage.  When it is lacking, violence often results.

Humanization of the Other

This is perhaps better stated in the negative: It takes dehumanization to commit violence.  From schoolyard putdowns to racial epithets to "the enemy" in wartime, our thoughts and language serve to make emotionally driven violence acceptable.  It is hard to treat another person as expendable or deserving to suffer while imagining his or her grieving parents or children — so we take pains not to.  Seeing each other as cherished, capable of suffering, and harboring a unique view of the world — in a word, human — is another necessary element for promoting nonviolence.  Without it, people are means to an end, not ends in themselves.

Role Models

Depicted with the prior post was Mahatma Gandhi, the first to apply nonviolent principles to politics on a large scale.  Gandhi's nonviolent philosophy, which he termed satyagraha, would likely have had little influence without his personal actions and role-modeling that led to political change in India and elsewhere.  Gandhi modeled nonviolence working.  Role models such as Gandhi, Martin Luther King, Jr., and Jesus of Nazareth show others a peaceful path by modeling not only behavior, but also emotion: the courage to act according to ideals, without succumbing to fear that might otherwise justify violence.

A similar role model is depicted with this post.  Morihei Ueshiba (often called O Sensei, or Great Teacher) founded the Japanese martial art of aikido.  Based on earlier violent styles, aikido aims to neutralize violent attack while leaving the attacker unharmed.  Aikido's core principle of harmonizing one's physical and spiritual energy with the attacker's would be little more than esoteric philosophy if not for its practical application.  As Gandhi did in politics, Ueshiba modeled nonviolence working, in this case against literal physical attack, and in a manner that can be learned and practiced by others.

Early Learning

Patterns of emotional reactivity are established in early childhood.  While a propensity to violence may be inborn, nonviolent alternatives can be introduced quite early as well.  A society dedicated to nonviolence would teach this in preschool, introducing more sophisticated and challenging scenarios in grade school and beyond.  Such a curriculum would not pretend that the world is a peaceful place.  Maintaining a nonviolent stance in a world that seems to demand the opposite is a lifelong challenge.  All the more reason to start confronting this challenge as soon as possible, ideally before personality is codified and harder to influence.

Practice

It's one thing to aspire to an ideal, quite another to behave accordingly.  There is no substitute for practice, "walking the walk" as well as "talking the talk."  Emotion may trump rationality, but intentional action (and well-chosen cognitions) can shape emotion.  Practicing peaceful conflict resolution may occur in daily life, of course.  But in addition, dedicated training or exercises may be necessary elements.  For example, disciplined participation in nonviolent political action, or in aikido training, may instill peaceful "reflexes" in a way that merely hearing or reading about these practices cannot.

In this post I outlined ways of promoting nonviolence, taking into account emotional and worldly realities.  This list is very general and far from exhaustive, and is offered in the spirit of collaboration and discussion.  Instead of dividing ourselves by tactics — more guns laws or fewer? death penalty or not? — common ground seems a better place to start.  Most of us seek peace, yet most of us share emotions that feed violence.  This makes a peaceful world an elusive yet worthy goal we can work toward together.

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?