New website. New look. New experience.
Dr. Griffith, Chair at George Washington University and frequent lecturer on human rights, advocacy, resilience, and hope modules, joined the AASP Board in May.
AASP signs on with the March for Science, and joins an amicus brief in a case of two physician researchers detained on the travel ban Executive Order.
Andres J. Pumariega, M.D., Eugenio Rothe, M.D., Ayesha Mian, M.D., Lee Carlisle, M.D., Claudio Toppelberg, M.D., Toi Harris, M.D., Rama Rao Gogineni, M.D., Sala Webb, M.D., Jacqueline Smith, M.D., and the American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI)
The United States faces a rapidly changing demographic and cultural landscape, with its population becoming increasingly multiracial and multicultural. In consequence, cultural and racial factors relating to mental illness and emotional disturbances deserve closer attention and consideration. This Practice Parameter outlines clinical applications of the principle of cultural competence that will enable child and adolescent mental health clinicians to better serve diverse children, adolescents, and their families.
Download the complete document (PDF format).
The symposium was co-chaired by R Rao Gogineni MD, President of AASP and Driss Moussaoui MD, President of WASP.
Dr. Mufti presented a review of Afghan refugees plight, psychosocial issues, caring of them by his team of workers and training of workers and fruits of the care and work.
Dr. Mihajlovic reviewed PTSD, traumatogenic effects of Yugoslavian refugees.
Dr. Roth presented Cuban Exiles' psycho-social aspects of emigration/immigration, generational dynamics.
Dr. Thompson's presentation focused on Bhutanese refugees in Pittsburgh and integration and repatriation of them into local community.
Dr. Pumariega discussed, summarized all the presentations.
By H. Steven Moffic, MD
In some expected and unexpected ways, the year 2012 seemed to be a watershed year for psychiatry. Some might even go so far as to say it was a crisis, which in Chinese meaning, would be both danger and opportunity.
Crucial changes occurred that will greatly influence the organization of services, reimbursement, and diagnosis. It even ended in an exclamation point, as the tragedy in Newtown, Connecticut (see last month's blog, Mass Murder and Psychiatry) punctuated the need for improved mental healthcare services. That also added the question mark of what the role of psychiatry should be for such societal social issues as gun control. Perhaps this was another confirmation, as unwanted as that may have been, that this decade is indeed becoming the decade of the social for psychiatry, as I tentatively predicted in a earlier blog.
With the Supreme Court's blessing of sorts, and President Obama's re-election, it is now clear that healthcare reform will continue to roll out. Although exactly what that will mean for all of psychiatry is not exactly clear, more people will have health and mental healthcare coverage, the private for-profit insurance companies will manage more of those lives, and organized healthcare systems will grow with more integration of health and mental health.
At its best, this Affordable Care Act (ACA) suggests that more people will be able to receive adequate, well-coordinated, and integrated preventive services and care. At its worst, it will be like HMOs on steroids, with more for-profit control of care, despite more governmental controls in place for the worst abuses of managed care.
On January 1, 2013, the Current Procedural Terminology (CPT) codes for reimbursement began. Even so, it appears that many healthcare organizations and private practitioners are scrambling to find out exactly what criteria will meet what new billing codes.
At its best, these new CPT codes will not only increase the low reimbursement for psychiatrists, and bid good riddance to the unpopular 15-minute med check, but also recognize the extra value of counseling and medical expertise of psychiatrists. At its worst, it will lead to inappropriate coding and auditing penalties, and doing even more in less time.
In December 2012, the APA approved the new edition of the DSM, to roll out at the annual meeting in May.
Certainly, DSM-5 has had a massive share of criticism, most cogently presented in a series of Psychiatric Times blogs by the chair of the previous DSM, Dr Allen Frances.
At its best, the DSM-5 will indeed reflect advances in psychiatric understanding of mental disorders, including the relationship between grief and depression that Dr Ronald Pies has discussed in recent Psychiatric Times articles and blogs. At its worst, it will be confusing, misleading, and more of a moneymaker for the APA than a benefit for the public and patients.
These developments, put into motion by separate entities, have the potential to be quite promising for psychiatry. However, adjusting to major changes in systems, reimbursement, and diagnosis in less than a year is quite a challenge, especially for those psychiatrists who have become increasingly burned out in recent years. And there's the rub, so to speak. Will these changes distract us from helping patients get better? Moreover, any advances in treatment are the one crucial aspect of care that's missing in these major changes. How about a Treatment and Statistical Manual, a TSM—maybe next year?
At best, the status quo in treatment will be applied in better ways for recovery. At its worst, the anti-psychiatry critics will have more to criticize.
Challenges for 2013
For the superstitious, these social psychiatric challenges will seem like a sign that this will be an unlucky 13th year of this century. On the other hand, others may feel that we make our own luck. Certainly, scientifically inclined psychiatrists will feel that 2013 can indeed turn out to be a happy new year for psychiatrists. And, Happy New Year to you.
By H. Steven Moffic, MD
There has been increasing publicity about the imminent end of the world on December 21, 2012, as possibly posited in the Mayan Calendar. What we do know for sure, is that for all the young children and adults who were killed in Newtown, Connecticut, their world ended a week earlier, on December 14th.
As the play of the same name by Thornton Wilder, Newtown Is Our Town.
The perpetrator must be, in some way, everyman. We must be our brother's keepers. Any field that can contribute to the understanding and prevention of the increasing numbers of attempted and successful mass murders in the United States must work on this for the next weeks, months, and years. Psychiatry is surely one of these.
Amidst all the initial speculation on the reasons for the tragedy, my wife noticed an e-mail from a psychiatrist that struck us as possibly revealing deeper issues, some perhaps indirectly relevant. The subject was "Autism not a Mental Illness." Autism was one of the initial diagnoses associated with this killer. Beyond such premature diagnostic speculations, the e-mail was reacting to a CNN coverage in which a physician and a reporter discussed that autism may not be an illness, since NIMH was considering autism and other mental conditions as "neurogenerative." Perhaps, the e-mailer suggested, if autism was not considered to be a mental illness, would that be better because then, if the murderer did not have a mental illness, mental illness could not be blamed for the mass murder.
This argument, though cumbersome, leads us to take a step back and take a bit of a detour. First of all, there are no mental illnesses, at least so far as the terminology goes for the DSM and ICD classifications of mental conditions. This is more important than mere semantics. These conditions are called disorders, not illnesses or diseases. The prime definition of disorders, in my Webster’s dictionary, is "confusion."
However "disorder" is defined, it causes mental conditions to appear to be different from medical illnesses. It implies that clinicians other than psychiatrists can be expert in the diagnosis and treatment of those disorders. Indeed, that is one of the issues that I was concerned about in the March 10, 2010 blog, "The DSM Process: More Questions Than Answers." The cautionary statement as to who can make a diagnosis reads: "It can be used by a wide range of health and mental health professionals, including psychiatrists and other physicians, psychologists, social workers, nurses occupational and rehabilitation therapists and counselors."
So much for the medical expertise of psychiatrists in making a diagnosis. As far as I know, that consideration will not change in the upcoming DSM-5.
This is a scenario that is more likely to lead to an inadequate diagnosis or missed diagnosis. Moreover, diagnosis, though necessary for reimbursement, research, and a general sense of what is wrong, should only be the necessary, but not sufficient, step in understanding an individual. Adequate time and analysis is required. As the bio-psycho-social model implies, we have to look far and wide to try to understand anyone. If indeed the perpetrator of the Newtown tragedy fell on the Autism spectrum, how often does a mass murderer have that diagnosis?
As so many have commented, the ease of obtaining automatic weapons can indeed contribute to mass destruction. If someone has untreated mental problems, the risk also increases. Adding guns and knowing how to use them, to someone with apparent mental problems, surely increases the odds of something bad happening.
Any positive reinforcement of gun use, outside of controlled situations such as hunting, may cause more unnecessary harm than benefit. Certainly, we have a lot of positive reinforcement and modeling of a gun culture in our Constitution, our seemingly endless war, and violence in the media. The more impersonal ways of relating on the internet may veer us more toward the social deficits and lack of empathy that is characteristic of the Autism spectrum.
I never used the term evil professionally or personally until I worked in prison part time at the end of my clinical career. For many of the inmates I saw, mental disorders, including substance abuse, seemed to play a significant role in their crimes. Gang involvement, where self-esteem and identity, was enhanced through group process, was another significant factor for many. On a rare occasion, neither a mental disorder, including antisocial personality disorder, nor gang behavior, seemed to be enough of an explanation.1 That is when I began to think more seriously of evil, as did many in the aftermath of this recent tragedy. The Governor of Connecticut claimed that "evil visited this community . . . ." Later he expanded that to mental illness dressed in evil. Perhaps that can be further expanded to mental illness dressed in evil and a holster.
Soon after the tragedy, one of the fathers of a child killed tearfully pleaded for society to learn from what happened in order to prevent future mass murders. Here's what I think psychiatry can contribute:
- Autism, Asperger, and most every other mental condition worthy of our prime focus should be called diseases, not disorders
- All such diagnoses should be made or certified by a psychiatrist to qualify for medical insurance coverage
- Do not make public diagnoses of anyone not personally examined, per our Goldwater Rule
- This tragedy, following too many others, should spur further study of where criminal behavior ends and psychiatric disease begins, if indeed there is even such a line
- All psychiatrists should spend some clinical time in a correctional institution, either during residency or later for continuing education
- Find better ways to educate the public about the early signs of homicidal risk
- Advocate for a system of safe reporting of those felt to be at- risk for homicidal behavior
- Provide better resources in order to improve early treatment of homicidal ideation
- Convene a representative body of those injured by public violence and loved ones of those murdered, to work on a national Task Force to reduce mass murder
- Advocate for a special anniversary date or holiday, December 14th, to not only remember the Connecticut tragedy or others like it, but also as a way to monitor how we are doing as a nation and a profession in trying to prevent more such tragedies.
1. Moffic HS. Better Off in Prison; 2011. Psychiatric Times. http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1850954. Accessed December 17, 2012.
Dr. Robert Jay Lifton was honored by the American Association for Social Psychiatry with the Humanitarian Award at the May Meeting of the American Psychiatric Association in Philadelphia on May 7, 2012. Dr. Lifton was recognized for his devotion to promoting the social dimension of our work as psychiatrists.Dr. Lifton's recent book, Witness to an Extreme Century, is a must read. Participants at the award presentation included R Rao Gogineni, M.D., Abraham Halpern, M.D, Robert Jay Lifton, M.D., Steven Sharfstein, M.D., Steven Moffic, M.D., Driss Moussaoui, M.D, and Henri Parens, M.D.
Brittany Albright, M.D., M.P.H.; Betty Skipper, Ph.D.; Shawne Riley, B.A.; Peggy Wilhelm, R.N.; William F. Rayburn, M.D., M.B.A.
Academic Psychiatry 2012;36:457-460.10.1176/appi.ap.11070134
Objective: The study objective was to determine whether medical students' attendance at a rehabilitation residence for pregnant women with substance-use disorders yielded changes in their attitudes and comfort levels in providing care to this population.
Methods: This randomized educational trial involved 96 consecutive medical students during their obstetrics and gynecology clerkship. In addition to attending a half-day prenatal clinic designed for women with substance-use disorders, every student was randomly assigned either to attend (Study group) or not to attend (Control group) a rehabilitation residence for pregnant women with substance-use disorders. The primary objective was to measure differences in responses to a confidential 12-question survey addressing comfort levels and attitudes, at the beginning and end of the clerkship.
Results: Survey responses revealed improvements in students' comfort levels and attitudes toward pregnant women with substance-use disorders by attending the clinic alone or the clinic and residence. Those who attended the residence reported becoming more comfortable in talking with patients about adverse effects from substance abuse, more understanding of "street" terms, and stronger belief that patients will disclose their substance use to providers. Residents expressed more openly their hardships and barriers while trying to set therapeutic goals.
Conclusions: Medical students became more comfortable and insightful about pregnant women with substance-use disorders after attending a rehabilitation residence in addition to a prenatal clinic dedicated to this population.
(see article on Academic Psychiatry)
We are very happy to inform, our Senior Fellow Professor RS Murthy has been awarded the coveted Juan José López Ibor Award for 2012. The Award was created by The Juan José López-Ibor Foundation in order to recognize and honour individuals or institutions that made significant scientific contributions leading to a better understanding of psychiatric diseases while being actively engaged in activities enhancing the human dignity of patients and their families. The Award, which is granted every two years, rewards initiatives of research, study, promotion, and communication carried out by individuals or institutions. It consists of a diploma, a token, and 40,000 Euros.
Our heartiest congratulations to Prof Murthy for this great honour, which he has so richly deserved.
By H. Steven Moffic, MD
It must be my age. . . or retirement. . . or my Rabbi son attending so many funerals. Because I paid especially close attention to the "In Memoriam" list in the August 3, 2012 issue of Psychiatric News-- the APA's official news publication.
The subtitle was "APA honors the following members whose deaths were reported April 1, 2011 to March 31, 2012." I wondered what was meant by "honors," given that only the names of the deceased were listed. Though hard copy space is increasingly hard to come by these days, it still seems fitting to include something brief and positive about the career of the deceased. You know. . . a short tribute to their labors and lasting contributions . . . a miniature psychiatric eulogy.
As I read the names, I realized I knew -- in one way or another -- quite a few of those listed. Maybe you do, too? In the brief comments that follow, in alphabetical order, here is how I would honor their lives as psychiatrists. If you’d like to add your comments to mine, you are welcome to do so in the comment box below.
Doris A. Berlin, MD (aka Dr Doris Berlin-Acker)
When I began my medical career 40 years ago, psychiatry, particularly the psychoanalytic field, was about the only medical specialty in which women were prominent. Dr Berlin was one of those early women psychiatrist pioneers, especially in my beloved area of community psychiatry.
Paul E. Chodoff, MD
Dr Chodoff was an unseen mentor to me of sorts. His important work on the psychological effects of the Holocaust, psychiatric ethics, and the need to support psychiatrist political dissenters, were early areas of concern for me. I learned much from his writings.
Alfred M. Freedman, MD
Dr Freedman became President of the APA during my psychiatric residency years and led the landmark movement to declare that homosexuality was not a mental illness. He was also a strong proponent of community and social psychiatry; he created a program for addicts in East Harlem in 1959, where such programs did not exist. His broader expertise was apparent as co-editor for the long time standard and monumental text, Comprehensive Textbook of Psychiatry.
Jack E. Geist, MD
Not nearly as well known nationally as Drs Berlin, Chodoff, and Freedman, Dr Geist was nevertheless a giant in the private practice of psychiatry in Milwaukee for 50 years. He was winding down when I moved to that city, but I thought that if most psychiatrists in the area were as gentle, warm, and kind as he, that I would love being here.
Leston L. Havens, MD
Most psychiatrists know of the unique and influential ideas that Dr Havens presented on the psychotherapeutic process, including with psychotic patients. On death itself, he once wrote:
"Death is like great beauty, fame, or money in the self-consciousness it pulls from the observer."
Stuart Keill, MD
Although he was well-known for his administrative expertise, making a major contribution to the landmark "Textbook of Administrative Psychiatry," what I remember most fondly were his presentations on "Madness in Opera" at the annual APA meetings in the 1980s. He even had at least 2 records on the subject. He died on Sunday, March 25, 2012, so might have just missed the APA deadline for last year. On that day, my wife and I saw Aida at the Lyric Opera of Chicago. In retrospect, I'll dedicate that performance to Stu.
Ari Kiev, MD
It is hard to believe that one psychiatrist could make all the contributions to the field that Dr Kiev did. He was a master at investigating and understanding all varieties of culture--from ethnic groups to athletes to Wall Street traders. His book Magic, Faith and Healing was a well-worn and underlined guidepost for me in my early fascination with cross-cultural psychiatry. His thirst for knowledge even led him to earn a law degree in 1988--a path I too briefly considered, but dropped.
Sheldon Miller, MD
Dr Miller was the Chair of the Department of Psychiatry at Northwestern for many years, after being a leader in the establishment of the subspecialty of addiction psychiatry.
Melvin Sabshin, MD
Anyone even remotely knowledgeable about the APA as an organization is, of course, familiar with Dr Sabshin, the long-term Medical Director, who successfully led the expansion of American psychiatry.
Herbert S. Sacks, MD
Another former President of the APA, Dr Sacks turned out to be a (usually) friendly debater with me on the merits (my view) and demerits (his view) of managed care. Although I don’t have any idea if this accounts for the differences in our opinions, he was the son of a Rabbi, and I am the father of a Rabbi.
Herbert Spiegel, MD
The prominent father of the prominent psychiatrist David Spiegel, MD, Spiegel senior was an early advocate for the scientific use of hypnosis.
Thomas T. Tourlentes, MD
Dr Tourlentes became a leader in community psychiatry not only nationally, but in his local community of Galesburg, Illinois. Reflecting his national and local interests, he was a President of the American Association of Psychiatrist Administrators, as well as of the Knox-Galesburg Symphony. He must have been exactly what President Kennedy had in mind to lead the development of community mental health.
In passing, I noticed the ages of the psychiatrists I knew. Half were in their 90s and the average age in the upper 80s. Is this just by chance or is there something about being a psychiatrist that helps us to live longer? I hope it’s the latter.
R.I.P. Rest Inspiring Psychiatrists. I am grateful for having known you.
21st Century Global Mental Health is a comprehensive and authoritative text on the subject of global mental health and its integration with public health and primary care. The book thoroughly examines the progress to date and the challenges that still remain. In five sections, it explores:
- Global Mental Health Epidemiology and Diagnostic Systems
- The Determinants of Health/Mental Health
- Populations' Health/Mental Health
- Evaluating and Strengthening Health/Mental Health Systems
- Human Rights, Stigma, Mental Health Policy and the Media.
Click here to download the flyer.
About the Editor
Eliot Sorel, MD, DLFAPA, is an internationally recognized global health leader, educator, health systems policy expert and practicing physician. He is co-chairman of the non-communicable diseases (NCDs) and integrated care task force of the World Psychiatric Association and co-chairman of the scienti!c committee of the WPA 2013 Bucharest Congress on integrating primary care, mental health and public health for Eurasia and Southeast Europe. He holds professorial appointments in Global Health, Health Services Management and Leadership in the School of Public Health as well as in Psychiatry and Behavioral Sciences in the School of Medicine at George Washington University.
Dr. Sorel is the Founder of the Conflict Management & Conflict Resolution Section of the World Psychiatric Association and of the World Youth Democracy Forum at the Elliott School of International Affairs of the George Washington University. He is the Senior Adviser to the Ion Ratiu Democracy Award (IRDA) at the Woodrow Wilson International Center for Scholars in Washington, D.C.
Dr. Sorel is a former President of the Medical Society of the District of Columbia, the World Association for Social Psychiatry, the Washington Psychiatric Society and has served as a United States National Institutes of Health/Fogarty International Center grants reviewer. He is a Life Member of the American Medical Association, a Fellow of the American College of Psychiatrists, and a Distinguished Life Fellow of the American Psychiatric Association.
In July 2010, Dr. Sorel convened the Black Sea & Caspian Sea Area Studies Network, a Euro-Atlantic, universities partnership that developed the Bucharest Consensus on Higher Education, Innovation & Development. In June 2008, he participated as PAHO/WHO advisor, in the WHO Europe Health & Finance Ministers' meeting on Health Systems, Health & Wealth in Tallinn, Estonia, that rati!ed the Tallinn Charter.
In October 2009, Dr. Sorel was awarded the Doctor Honoris Causa by Carol Davila Medical University in Bucharest, Romania. The President of Romania awarded Dr. Sorel the Star of Romania Order of Commander in 2004.
Steven H. Moffic's new blog, Sad in Psychiatry, is now online on Robert Whitaker's Mad in America website. Mr. Whitaker wrote the book Anatomy of an Epidemic, which has caused an uproar due to its caution about the long-term use of most psychiatric medications.
Sad in Psychiatry: Affectionately called a "gadfly," and known as "da man in psychiatric ethics," Steven Moffic writes about what makes him sad about modern day psychiatry, and how to "treat" that condition so that we will become glad about what psychiatrists can do to help.
Eliot Sorel, M.D., D.L.F.A.P.A
Eliot Sorel, M.D., D.L.F.A.P.A., is an internationally recognized medical leader, educator, health systems policy expert and practicing physician. He is co-chairman of the non-communicable diseases (NCDs) and integrated care task force of the World Psychiatric Association and co-chairman of the scientific committee of the WPA 2013 Bucharest Congress on integrating primary care, mental health and public health for Eurasia and Southeast Europe, strengthening health systems, to take place in Bucharest, Romania in April 2013, accessible at www.wpa2013bucharest.org. Dr. Sorel is the Founder and Chairman of the Career, Leadership and Mentorship Program of the Washington Psychiatric Society. He has professorial appointments in Global Health, Health Services Management and Leadership in the School of Public Health as well as in Psychiatry and Behavioral Sciences in the School of Medicine at George Washington University. Dr. Sorel is the Founder of the Conflict Management & Conflict Resolution Section of the World Psychiatric Association and of the World Youth Democracy Forum at the Elliott School of International Affairs of the George Washington University. He is the Senior Adviser to the Ion Ratiu Democracy Award at the Woodrow Wilson International Center for Scholars in Washington, D.C.
Dr. Sorel is a former President of the Medical Society of the District of Columbia, the World Association for Social Psychiatry, the Washington Psychiatric Society and has served as a United States National Institutes of Health/Fogarty International Center grants reviewer. He is a Life Member of the American Medical Association, a Fellow of the American College of Psychiatrists, and a Distinguished Life Fellow of the American Psychiatric Association. He did his psychiatric training at Yale University, obtained his B.A. from New York University, and M.D. from the State University of New York. He has developed and led health systems in North America and the Caribbean, has consulted and taught in more than twenty countries in Africa, Asia, Europe and the Americas. Dr. Sorel is the author of more than sixty scientific papers and book chapters and the editor of six books. His most recent scientific paper, The Integration of Psychiatry & Primary Care was published in the International Review of Psychiatry, in February 2011 and his most recent book, The Marshall Plan: Lessons learned for the 21st century was published by OECD in Paris in 2008, is accessible at www.oecd.org.
In July 2010, Dr. Sorel convened the Black Sea & Caspian Sea Area Studies Network, a Euro-Atlantic, universities partnership that developed the Bucharest Consensus on Higher Education, Innovation & Development. In June 2008, he participated as PAHO/WHO advisor, in the WHO Europe Health & Finance Ministers' meeting on Health Systems, Health & Wealth in Tallinn, Estonia, that ratified the Tallinn Charter.
In October 2009, Dr. Sorel was awarded the Doctor Honoris Causa by Carol Davila Medical University in Bucharest, Romania. The President of Romania awarded Dr. Sorel the Star of Romania Order of Commander in 2004.
The American Association for Social Psychiatry is very excited and pleased about the inauguration of our website. AASP, founded by Dr. John Schwab, has been in existence since 1971. The mission of AASP is to study, teach and promote consciousness of social factors in the psychiatric disorders of our patients and promote an understanding that social factors are core to all behavioral health issues. Since its inception AASP was presided by socially conscious social psychiatry and psychiatry leaders: John J. Schwab, Milton Greenblatt, John J. Carleton, Paul L. Adam, Stanley Dean, Alvin Friedland, Robert Cancro, Gene Usdin, Harold M. Visotsky, Robert L. Leon, Gerald Sarwer-Foner , Roger Peele, Leah Dickstein, Steven Moffic, Pedro Ruiz, Abraham Halpern, Larry Hartmann, Zebulon Taintor, Steven S. Sharfstein, Beverly Fauman, and Charles Huffine. Many of them, and other affiliate AASP members have published and presented on important social psychiatric topics like trauma, immigration, influence of technology and managed care on psychiatry, violence, etc.
The current AASP leadership decided to join our world body, the World Association for Social Psychiatry (WASP) to connect internationally and to allow all our AASP members to become members of WASP. We also decided to bring the organization up-to-date and establish a state of the art website for access to members and those interested in social psychiatry. We are planning to start an ejournal.
APA accepted all four of our submissions to the annual meeting to be held in Philadelphia May 5-9, 2012. The major theme of this year’s presentations is humanism and human rights. We are proud of bestowing our 1st Humanitarian Award on Robert J. Lifton, M.D. on May 7th during the APA Meetings.
AASP is dedicated to addressing various social psychiatric issues of all our patients, minorities, women, immigrants, LGBT, families, children, adolescents, young adults, older adults, etc. and promoting "social" in psychiatry.
We invite you to join us and promote our AASP.
By Robert Jay Lifton; New York: Free Press; 2011 • 448 pages
Reviewed by H. Steven Moffic, MD
Dr Moffic is a Tenured Professor in the departments of psychiatry and behavioral sciences and of family and community medicine at the Medical College of Wisconsin in Milwaukee. He is a regular blogger on www.psychiatrictimes.com
Although memoirs have become all the rage, they are rarely written by anyone in the field of psychiatry . . . and for good reason. The nature of our clinical work generally should be quite private.
Witness to an Extreme Century is an exception. Early in his career, the now 85-year-old psychiatrist Robert Jay Lifton recognized that regular clinical work took away too much emotional energy from his scholarly projects, so privacy was much less of a concern. Fortunately, though, Dr Lifton was able to maintain the perspective of an ethical and healing clinician in his research interviews.
His decision not to focus on his personal life leaves us with a series of expeditions, in what turns out to be a Campbellian heroic journey. Think of him as the Indiana Jones of the mind; Connecticut Bob, if you will. He encounters what he deems to be manifestations and ramifications of evil as he revisits the prize-winning books, notes, and memories of those "brainwashed" by Chinese thought reform; fallouts of the atomic bombing of Hiroshima; Viet Nam protests; surviving Nazi physicians; and more.
Along the way, we also meet too many fascinating people to name, who spur him on, one way or another. A surprising absence, though, is any mention of the famous psychiatrist who was a concentration camp prisoner, Viktor Frankl, who survived to write the classic Man’s Search for Meaning. It seems like this journey could only be accomplished by a psychiatrist—someone with the necessary medical training, credentials, and identity. Given that, it may follow that his research has translational relevance for our daily clinical work, including pathological narcissism, sociopathy, trauma, and group cohesion. Lifton's in-depth review also inspires us to reflect on cross-cultural therapy, refugees, prison inmates, and the ethical challenges of managed care. In fact, his findings could apply to managed care systems, because his description of a dissociative "doubling" in Nazi doctors adds a new twist to how managers and medical directors of today can calmly put profit over patients. Given the extraordinary breadth and depth of Dr Lifton's work, it seems greedy for me to have desired explorations into other arenas, such as prisons, which are a kind of natural laboratory for the type of evil he examines. In his interview of the Nazi leader Albert Speer, it seems that Dr Lifton is ambivalent and uncertain whether Speer had really changed for the better after 20 years in prison. I also wish he had mentioned our climate crisis as a potential world threat, especially given his earlier role as an activist for Physicians for Social Responsibility (PSR). PSR had won the Nobel Peace Prize in 1985 for its work on nuclear proliferation, but now PSR concludes that the more insidious risk of global warming may be as dangerous to people and the planet. It would have been informative if Dr Lifton had interviewed fossil fuel executives associated with environmental disasters (eg, someone from BP).
Given the unique path Dr Lifton took in his memoir, how can his work be summarized? He is more than a social psychiatrist, although he gave one of the earliest seminars on that topic. He is more than a cultural psychiatrist, although he successfully used interpreters. He is more than a political psychiatrist, even though his analyses included political leaders and he became a political activist. He mentions the term "historical psychiatrist," but psychohistory can venture into some wildly speculative areas. He goes beyond the Freudian, Jungian, or existential perspectives. He has apparently been unencumbered by any strong ties to professional organizations or sources of funding. Put this all together, and Robert Jay Lifton might be our first global psychiatrist, dedicated to the survival of intellectual freedom.
By H. Steven Moffic, MD
Many will recall "The Decade of the Brain," when President George H.W. Bush declared that the 1990s would be dedicated to research on neuroscience. If there were landmark findings from that decade, I'm not sure what they were. Probably less will recall "The Decade of Behavior." This was the nickname that the American Psychological Association gave for the 2000s. There were 5 major goals: improving health, increasing safety, improving education, increasing prosperity, and promoting democracy. I haven't been able to find any outcome reports, but it seems obvious that prosperity has decreased for most in the United States, and if the conflict between Democrats and Republican politicians is any indication, maybe promoting this kind of democracy was not such a great goal.
Undaunted, we are now in the beginning years of what has been termed "The Decade of the Mind." Begun by a group of leading American scientists, it seeks to emphasize the mind beyond the brain within the context of neuroscience and psychology. Complementing that, In May, former 8-term Democratic congressman from Rhode Island, Patrick Kennedy, launched a campaign known as "The Next Frontier, One Mind for the Brain."
If you’re familiar with the "biopsychosocial" model, it's obvious what is missing from these decades: the "social." Physician George Engel developed the biopsychosocial model in 1977, preceding these dedicated decades. It attempted to turn medicine away from a pure biomedical model to include a wider range of relevant variables. Put simply, the bio referred to our body (and brain), the psycho to our psychology (and mind), and the social to the natural and man-made environments around us. By using all 3 references in one term, it implied their overlap and interactions. If one wanted to divide these somewhat artificial categories further, there is general systems theory—and more recently, complexity theory—but such further divisions are practically difficult to keep in clinical mind. Of all the medical specialties, the biopsychosocial model seemed to fit psychiatry the best, as we historically seemed to pay more attention to all 3 variables. After all, bio reflected the medication and related medical problems, which is why psychiatrists went to medical school; the psychological to the understanding of the psychology of our patients and in providing psychotherapy, innovated by the psychiatrist Sigmund Freud; socially, we knew our work was provided in a social context.
However, despite such a perfect fit, our focus seems to have become as reductionistic as the rest of medicine. In 2005, American Psychiatric Association president, Steven Sharfstein, MD, claimed we were in a bio-bio-bio model, dominated by a "pill and an appointment." Interestingly, looking back before the last century, psychiatry was mainly a social-social-social model because treatments were limited and the best we could do was to provide a moral and humanistic refuge in the best of asylums.
More recently, the biopsycho part of the model has gained some resurgence as psychiatry tries to reemphasize psychotherapy, especially in the training of new residents. Even though many of us do not do much—or as much—psychotherapy anymore, we often do interact with other disciplines that do psychotherapy. And, of course, even very brief "med checks" are loaded with psychological implications—if we look for them.
About the only place the social is supposed to get our attention is in Axis IV of the DSM. This part of the "Multiaxial Assessment" is designated for "Psychological and Environmental Problems" that may affect the diagnosis, treatment, and prognosis of mental disorders. These include relationship, educational, occupational, and economic problems, as well as problems with access to healthcare services.
Sounds good and important, doesn't it? Unfortunately, in reviewing the records of my colleagues across the country, and, I'm embarrassed to say, my own records, the problem I've noticed with Axis IV is that is addressed quite variably, perfunctorily, and often minimally. This seems so even though there are increasing social problems with access to mental healthcare as a result of fragmentation, economics, and for-profit managed care.
Isn't it also ironic that the social has been disappearing from our models when it is dominating our technology in terms of "social media"? These new technologies are changing the way we communicate and maybe even how our brains work.
How, then, can we pay more attention to the social variable? One option is to change what this model is called. The conceptual and practical problem with making the "social" the equivalent of the "biological" and "psychological" is that it does not include formal treatment options like the biological and psychological variables do.
Oh, sure, at times we've had therapeutic communities when inpatient stays were longer, or the recovery movement led by our consumers, but those "treatments," if we can call them that, pale before the prominence of medications and psychotherapies. That should make the social less relevant to us clinicians. It is more that what influences how the biological and psychological variables are understood and used depends on the social resources and values. Hence, I would recommend the name change to better reflect how these variables are relevant: reframe it slightly to the "bio-psycho-in the social" model.
Let's also look to the mental health organizations most devoted to the social. There seems to be a resurgence in the American Association For Social Psychiatry (AASP). The AASP is now revitalizing in recognition of the need. In the works is a Web site, new book, and presentations. In fair disclosure, I was a prior president of the AASP at the end of the last millennium. I also have to confess that I missed the opportunity then to start a decade (or millennium) for the social then. Maybe I'm trying to make amends and relieve my guilt now. Accordingly, this blog is not necessarily presenting the collective views of the current AASP.
Of course, social workers are the largest group of mental health professionals. Historically, social work was a profession devoted to social welfare, change, and justice. In mental heath care, however, they have veered towards providing psychotherapy and administration.
Social psychologists research how social situations influence human behavior. There has been a variable connection with the field of sociology over the years. Since this bio-psycho-in the social model can only be clinically relevant when clinicians use it, it may need new publicity. In this regard, maybe social psychiatrists, social psychologists, and social workers can lead a coalition to use social media to establish The Decade For The Social. Care to join us?