Narcissists, psychopaths, and other bad guys

A patient of mine recently observed that the increasing use of the the term "psychopath" in popular media is really a disguised way of criticizing selfishness.  Dressing up selfishness as an odd and frightening clinical disorder — slapping a diagnostic label on it — makes for catchy news copy, and grants pundits emotional distance between themselves and those monsters who look just like us, but who lack the empathy and remorse that make us human. I immediately thought of how narcissism had its heyday in popular culture very recently as well, and to similar ends.  Narcissists and psychopaths care only about themselves, and have no qualms about hurting and sacrificing others when it suits their purposes.  These are dangerous people lurking among us; all the more reason to publish lightweight magazine and newspaper pieces on how to spot them in the wild.

Both labels sound like psychiatric diagnoses, but actually they're not.  According to Heinz Kohut and other theorists, narcissism is a quality everyone has to a greater or lesser degree.  It normally develops in infancy: the sense all babies have that the world revolves around them.  However, we gradually learn that we are not the center of the world, and that other people, including our primary caregivers, have their own goals and perspectives separate from our own.  Infantile narcissism is thus tempered by the reality of healthy relationships, although its vestiges are present in our self-pride, and perhaps in our proven tendency to overestimate our own efficacy and performance.  Pathological narcissism in this view is infantile normality carried abnormally into adulthood.  It only becomes a psychiatric diagnosis when the condition fulfills certain observable criteria and impairs social and/or occupational functioning.  Likewise, psychopathy is a personality trait, not a diagnosis.  Renowned psychopathy researcher Robert Hare notes that "psychopathy is dimensional (i.e., more or less), not categorical (i.e., either or)."  DSM-IV doesn't include a diagnosis called "psychopathy" or "sociopathy."  Instead, there is antisocial personality disorder, which overlaps with psychopathy but is not the same thing.

These terms, psychopath and narcissist, are loosely applied personality labels when popularized in the media.  What do they add over simply calling someone callous or selfish?  First, they offer an explanation — a pseudo-explanation really — of frightening and/or mystifying behavior.  Our feeling of powerlessness is eased by the label, as though now that the threat is identified, we may be able to do something about it.  Second, such labels imply that misbehavior is a function of one's character, a categorical determination.  Yet categorical psychiatric diagnosis, especially of personality, is controversial in general.  Moreover, we often overestimate personality factors and underestimate situational ones (the "fundamental attribution error") in explaining the behavior of others.  Using a label like psychopath or narcissist to describe another person (whom we've only heard about in the news, and haven't formally evaluated) reaches for a premature conclusion about the cause of that person's behavior.  In a way, we are falsely reassured.

Third, the label adds power to our verbal disapproval.    We have a long history of abusing psychiatric labels in the service of putting others down.  Consider "idiot," "moron," and "imbecile," all originally coined as official categories describing low IQ.  Or "cretin," which originally referred to physical and mental disability due to congenital thyroid deficiency.  Or the casual use of "crazy" and its synonyms.  Some patient advocates argue further that any diagnostic label used as a noun is demeaning, i.e., calling someone a schizophrenic, a neurotic, a borderline, etc.  Instead, it is more respectful to refer to a person (or patient) who has schizophrenia, or a narcissistic personality.  But that's exactly the point of the popular use of terms like psychopath and narcissist: To show disrespect and disdain, to disapprove.  And to underscore the difference between ourselves and the person with the label.

Our earliest social categories are "good guys" and "bad guys," defining one against the other.  From "cops and robbers," to team sports, to bipartisan politics, to our allies and foes on the world stage, we divide self and other at every level, calling the former good and the latter bad.  Callousness and selfishness are in all of us to some degree, and it hurts to admit it; it damages our self-image.  Instead, we psychologically defend against this realization in ourselves by projecting these traits onto others using a broad brush and pejorative terms.  While some people truly are unusually callous or selfish, the popular use of scientific-sounding labels serves our own psychological needs by identifying "bad guys" and making us feel better about ourselves.

On responsibility

I'll leave the "sloppy thinking" series for now, although I expect to return to it in the future.  In this post I'll share some thoughts about personal responsibility, especially as it pertains to the insanity defense.  It's a topic much in the news lately, due to tragic actions by now-household names such as James Eagan Holmes and Jared Loughner.  The matter goes much further though.  We normally assume that adults are responsible for their actions, and that these actions are freely chosen.  The extent to which we treat this as absolute versus a matter of degree determines our fundamental political views, and how we view our neighbors and ourselves. Many facets of everyday life are premised on personal responsibility.  The criminal justice system is the most obvious example.  In a wider sense our willingness to live in community with others depends on each person taking responsibility for his or her behavior.  Nonetheless, we've recognized exceptions to this default assumption for centuries.  Adults who are severely sick or injured may temporarily be unable to assume responsibility for themselves.  Likewise, infants and young children lack the ability to make informed choices and to exercise personal responsibility.  Non-human animals are exempt from personal responsibility and are never considered guilty of a crime — well, not anymore.

English common law recognized that the same lack of responsibility extended to insane adults:

By the 18th century, the British courts had ... developed what became known as the "wild beast" test: If a defendant was so bereft of sanity that he understood the ramifications of his behavior "no more than in an infant, a brute, or a wild beast," he would not be held responsible for his crimes.

The history of the insanity defense then records the trial of Daniel M'Naughten in 1843, where inability to distinguish right from wrong was established as the crucial legal test. This became the standard, both in Britain and the US, for more than 100 years; the "M'Naughten rule" is still the legal standard in many states.  Later modifications tended to liberalize its application, as with the "irresistible impulse" and "diminished capacity" doctrines, until the pendulum swung the other way in the wake of John Hinkley's attempted assassination of President Reagan in 1981.

As a society, we seem to be losing our inclination to forgive the mentally ill, and children, when they commit horrific acts of violence.  Even young teens are now tried as adults when an alleged crime is bad enough.  And although insanity defenses are rare in U.S. courts, and their successful use often results in involuntary hospitalization longer than the prison sentence would otherwise have been, there is nonetheless a popular view that the insane "get away with it."  Jared Loughner recently plea-bargained for life imprisonment despite clear evidence of mental illness and the possibility of an insanity defense.  The court will decide whether James Holmes has severe psychosis, an antisocial personality, or just a very bad attitude.  As in Loughner's case, this determination is unlikely to make a difference in terms of public safety — Holmes won't be freed for decades, if ever.  But the way we handle the question of legal insanity bears on how our society views itself.

Now that we are in a presidential campaign season, we hear rhetoric that cleaves the major parties around the question of personal responsibility.  "You didn't build that," a slightly misspoken point by President Obama about the government's role in promoting business, became a rallying cry for Republicans in defense of the entrepreneur.  Yet both sides have a point:  The government makes and maintains highways (and founded the internet); individuals create trucking companies (and online businesses).  It's really a matter of emphasis, and yet this emphasis is what most of the fighting is about.

Decades ago, social psychologists coined the term "fundamental attribution error" to highlight our tendency to over-apply dispositional or personality explanations to others, in the same circumstances we apply situational explanations to ourselves.  E.g., if others are unemployed we often imagine they are lazy or unqualified (personal factors), whereas if we are unemployed, we often blame a tough economy and a lack of jobs (situational factors).  Of course, some of the unemployed really are lazy or unqualified, just as some killers really have the criminal intent (mens rea) to be convicted of murder.  The question is whether and to what extent we allow for exceptions in cases other than our own.  Denying such exceptions flies in the face of our own legal tradition, our recognition of the fundamental attribution error, and our human kinship — the idea that we humans are more alike than we are different.  We are wise enough not to punish infants or "wild beasts" even if they hurt us; the severity of their behavior and its consequences has no bearing on whether they are personally responsible.  A person who cannot tell right from wrong due to severe psychosis is operating at the same level, and should be treated, not punished.  Personal responsibility is a strong enough concept that it can withstand some nuance and flexibility — especially when that happens to reflect reality.

Jury duty, a psychiatric perspective

I just finished a day of jury service in criminal court, and have some thoughts about the whole process.  Some relate to me as a psychiatrist, some are more generic.  I'll start by admitting I've never served as a juror in an actual trial.  Doing so would interest me, and I do appreciate the role of juries in our legal system, yet the hassle of missing work and other obligations outweighs these factors in my mind.  Thus, I'm happy I've escaped so far.  Years ago I wrote to be excused whenever I received a jury summons.  I argued that my patients needed me more than the legal system did.  That argument worked once or twice in the distant past:  I was excused for the year without having to appear at all.  However, the last couple of times I tried it my request was denied.  I was instructed to show up like everyone else.  So I don't fight it anymore, although I still feel the argument has some merit. Do psychiatrists, and possibly other mental health professionals, have a valid claim that their jury service risks hurting their patients?   As described here, jury duty presents a unique uncertainty for psychiatrists and patients, one that isn't the same as a planned vacation or even a sudden illness.  (The issue is also discussed toward the end of this 1996 article in the New York Times.)

In my jurisdiction, the recipient of a jury summons is "at risk" for a week, and must call each evening to learn whether to appear the next morning.  Canceling patients for this entire week would be incredibly wasteful, resulting in many treatment disruptions and the forfeiture of a week's income, usually for no good reason.  The alternative is to warn patients in advance that they may be canceled the evening before their appointments — which is less advance notice of cancellation than a psychiatrist typically expects of his or her patients.  Some patients react poorly to last-minute cancellations, some cannot reschedule (or the psychiatrist has no other times to offer); as a worst case scenario this may constitute a "last straw" that ends a treatment.  Even when bad outcomes are avoided, it adds a wrinkle to the treatment of all affected patients.

When I warned my patients that I might be away for one or more days last week, several expressed surprise that I would receive a summons at all.  Realistically, there's no reason I wouldn't.  Potential jurors are selected randomly from voter and DMV lists; it's a pretty safe bet that one's psychiatrist is on such lists.  Perhaps this is another instance of patients having difficulty imagining their psychiatrist living a normal life outside the office.  In other words, it's a transference phenomenon.

Psychiatrists are rarely kept on juries.  The procedure for selecting a jury for a given trial is called the voir dire.  Prospective jurors state their names, occupations, and other key facts.  The attorneys then ask questions to elicit potential bias that would be unfavorable to their side.  The attorneys use peremptory challenges or challenges for cause to excuse problematic jurors.  Each time I've made it to the voir dire, I've been excused by peremptory challenge, which means no reason was given.  Attorneys prefer not to have "experts" on juries, i.e., legal experts such as other attorneys or police officers, or mental health experts who, they fear, may "see through" their arguments, or come to our own conclusions regarding the thoughts and motivations of the involved parties.  In any event, it's frustrating to cancel or reschedule a day of patients, and languish at the courthouse for most of the day, when I'm virtually certain never to serve on a jury.

While I was languishing, I contented myself by observing the process and the people involved.  Like mass transit and some public events, jury service offers a cross-sectional look at one's neighbors.  Adults of all ages, levels of education, and political views answer the call.  A 20 year old sits next to a 70 year old, a professor next to a factory worker.  Everyone gets along, mainly by benign indifference — and all of us are clearly subordinate to the people who work there: the bailiffs, the attorneys, and of course the judges.

A few potential jurors stand out by revealing their hatred of jury service.  Several have interesting stories or perspectives to relate in the voir dire.  A young woman is wary of police since her partner runs a medical marijuana dispensary.  A young man feels gun laws are too restrictive.  There were a surprising number of tech-workers — maybe I shouldn't have been so surprised.

The "presumption of innocence" in a criminal trial (i.e., innocent until proven guilty) seemed lost on many jurors; judges and attorneys must find it tedious to repeat over and over that a criminal defendant need not offer evidence or argument of any type to be acquitted.  But the main thing I found fascinating was how jurors in the voir dire defend their capacity to be unbiased and objective, even after they express overtly biased views, and even when they presumably would prefer to be excused from service.  Bias sounds like a weakness, a character flaw.  Perhaps for this reason many jurors declare themselves neutral and completely open-minded when that cannot possibly be the case.  I wonder to what degree the whole institution of trial by jury relies on pride — the pride of individual jurors in their own objectivity, and a social pride we feel in the "wisdom of the common man," despite clear evidence that basic legal tenets, like presumption of innocence, are often unappreciated.

I would prefer to avoid too much pride myself.  Psychiatric work is not the easiest kind to set aside for the obligations of jury duty, but I doubt it's the hardest either.  I don't plan to ask for special exemptions in the future.  All the same, I don't mind if attorneys continue to believe we can see through their arguments, and read the minds of their clients.  A little transference can be a good thing.

Image: "Justice," Edwin Austin Abbey (American, 1852 - 1911)

The commodification of psychiatry

Several recent articles, blogs, and even my participation in HealthTap (discussed in my last two posts) have led me to think about how psychiatry, and mental health treatment generally, are increasingly viewed as commodities.  In the language of economics, a commodity is a physical good, such as food, grain, or metal, which is interchangeable with any other product of the same type.  Commodities are carefully specified, e.g., "Wheat, No.1 Hard Red Winter, ordinary protein, FOB Gulf of Mexico," but the supplier is immaterial.  Everything one needs to know about a commodity is in the specification.  Based on that alone, a smart buyer seeks the lowest price. Much has been written lately about the psychiatric "med check," a 10 to 20 minute encounter every few months for patients who take psychiatric medications.  A New York Times profile of one such high-volume practice generated notoriety for this approach, well deserved in my view.  Even the profiled doctor had reservations, but succumbed to the lure of higher income as compared to the traditional model of one patient per hour.

Although psychiatric medication management can be done well, the "med check" is often critiqued as an assembly-line approach that treats collections of symptoms, not people.  The assembly-line metaphor highlights the commodification of both parties.  On an assembly-line, each "part" moving down the line can be treated as any other. Likewise, each worker is interchangeable with any other having the same qualifications.  In commodity psychiatry, any fully specified "Major depression, single episode, moderate severity" can be treated as any other.  Mental health workers of a given specification (psychiatrist, nurse, counselor) are interchangeable as well.  The only thing left is to let the marketplace (or government) set the price of this commodity transaction.

While commodity treatment is easiest to recognize in the stereotypical "med check," it is rampant in the rest of the field as well.  Suicidal patients should immediately be sent to the ER, yes?  Because all patients who declare themselves suicidal are the same, just like "Wheat, No.1 Hard Red Winter, ordinary protein, FOB Gulf of Mexico."  Well, no.  In supervising residents and talking with colleagues, I'm amazed how often patients cool their heels, and spend thousands of dollars, in three-day inpatient stays triggered by a threat of suicide.  I claim no magical gift for curing depression or suicidal urges, and I've had my share of patients who scream, "I'm heading for the Golden Gate Bridge right now!"  Nonetheless, I can't recall the last time I hospitalized anyone for suicide risk, and I've never had a patient die by suicide.  Why?  Because it means something when someone threatens suicide, and that meaning varies from person to person.  "Suicidality" isn't a commodity specification, and it should not be treated as such.

Nor is psychotherapy immune from commodification.  "You have social anxiety?  We offer a 16 session cognitive-behavioral treatment for that." As though people who are anxious in social situations are interchangeable — and as though any practitioner who conducts a brand-name 16 session intervention is the same as any other who offers that brand.  The specification is all that matters, the supplier is immaterial.  Perhaps the ultimate example of therapy as commodity is when there is no therapist at all, as in this recent article about a smartphone app designed to decrease social anxiety.  Here, however, the app really is a commodity: Every copy of the app works the same, and it treats all users exactly the same as well.

With an ever-expanding diagnostic manual, and with a pharmaceutical, electronic, or scripted cure for every ill, psychiatry speeds toward a future where it no longer matters who has symptoms, it only matters what the symptoms are.  Likewise, practitioners are interchangeable and thus should be chosen for the lowest cost, just as a buyer spends the least possible on a certain grade of wheat.  It makes no sense to pay for an expensive psychiatrist or psychologist to perform psychotherapy, when psychotherapy is a commodity that can be supplied by people who charge less, or perhaps by a computer program, website, or smartphone app.

To be sure, there are areas of medicine well-served by rote protocol.  Thankfully, no one stops to "customize" CPR during a cardiac arrest.  But in most health care scenarios, treating patients as commodities is dubious.  And in the subtle realm of emotional health it's tragic.  As I wrote in my post about nomothetic versus idiographic thinking in psychiatry, western medicine derives its considerable power from lumping patients into a disease category, and then applying statistically proven treatment to members of that category.  For example, in psychiatry we are not forced to approach a new case of bipolar disorder in complete ignorance; among other things, we know lithium is apt to relieve the signs and symptoms.  But if we stop there, at the nomothetic level of knowledge, we are treating the bipolar disorder, not the patient.  The "supplier," the person suffering the disorder, is immaterial.  We are doing commodity psychiatry.

The alternative is not to abandon the hard-won knowledge of western medicine and nomothetic research.  It is to acknowledge that every person sharing a diagnostic category is unique — that no individual experiences major depression or bipolar disorder in quite the same way as anyone else.  Understanding and enhancing each patient's unique experiential reality is the essence of psychiatric practice, and mental health care generally.  Since these nuanced goals cannot be accomplished without considering the "supplier" — the person with the disorder, as well as the person offering care — the commodity model will forever shortchange psychiatrists and their patients.

"Do you analyze everyone you meet?"

People sometimes wonder whether I "analyze" everyone I meet. This is usually asked with some fear that as a psychiatrist I can "see right through them" and instantly know things about their innermost thoughts they'd prefer to keep hidden.  Although this is true (just kidding), I try to reassure them with the following analogy. Imagine an architect whose business and personal life includes walking into and out of buildings all day. Does the architect "analyze" every building —  home, coffee shop, office, gym — all day long? I doubt it. Perhaps if a particular construction is especially creative, or unusual, or singularly beautiful or ugly.  But most of the time an architect relates to buildings the same way everyone else does: for the personal reasons he or she visited there.  (If there are any architects out there, please confirm!)

In my experience the same is true of psychiatrists and other mental health practitioners. We deal with people all day, both professionally and personally.  When working, our attention is directed in a certain way, toward understanding the person in front of us.  After all, this person paid good money for us to focus our attention exactly this way.  Other than this, though, we deal with loved ones as loved ones, colleagues as colleagues, store clerks as store clerks, and so forth.  It is only when someone's personality or behavior is noteworthy and unusual that we may find ourselves viewing them momentarily through our "psychiatrist glasses."

I've heard it works similarly for doctors and medical diseases.  Occasionally a case of acromegaly, cerebral palsy, rheumatoid arthritis, or psoriasis can be diagnosed in a stranger on the street, or in a crowded elevator.  Most of the time, though, people are just people.

The question about analyzing everyone often seems to harbor some anxiety.  It feels threatening to have possessors of mystical and limitless insight lurking among us, wantonly tearing holes through the public persona and self-image of each innocent bystander.

Fortunately, this is a fantasy.  Being a psychiatrist doesn't make me a mind-reader.  It usually takes an hour of formal intake interviewing before I begin to have a sense of a person's personality.  Often it takes more than one session. While it's true that people, not just psychiatrists, can pick up clues to personality early in a conversation, psychiatrists aim more for accuracy than speed.   Instant on-the-fly psychiatric diagnosis or case formulation is fraught with uncertainty and error because it is based on insufficient data.  As professionals, we are trained not to shoot from the hip, and for good reason: because our opinion should mean something.  If the considered views of psychiatrists are to matter more than the hunches of untrained persons, we must refrain from offering half-baked, "cocktail party" assessments.  I cringe when I hear a colleague spouting off about a politician or celebrity known only through the media.  A detailed study of someone not personally interviewed, e.g., a psychohistory, may be defensible; an off the cuff opinion cloaked in psychological jargon is not.

"Analyzing everyone we meet" is literally impossible, and as in the case of the architect, would be a huge distraction from everyday life.  Moreover, even attempting it is unprofessional.  We should reserve any such analysis for the clinical office, where the setting is conducive, and the data sufficient, to make a meaningful assessment.