Categories
Education Lessons Public health psychiatry

Watch for the Political Abuse of Psychiatry.

The Lancet recently reported that women in Iran who disobey religious law by refusing to wear a hijab are being diagnosed with antisocial personality disorder. These women subsequently “undergo psychotherapy treatment” and must provide “mental health recovery certificates”.

The article also refers to this piece, Iran sentences unveiled women to jail, washing dead bodies in a cemetery and undergoing therapy, that reports a

ruling by a third criminal court in Tehran defining not wearing the veil as “a contagious mental illness that causes sexual promiscuity.” The defendant was sentenced to two months in prison and ordered to pay for six months of psychological treatment.”

(It’s unclear what “psychotherapy / psychological treatment” means. This is likely intentional.)

Do women in Iran who refuse to wear a head covering truly have antisocial personality disorder?

Here are the primary DSM-5 criteria, which are similar to the criteria in ICD-10:

A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following:

  1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
  2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
  3. Impulsivity or failure to plan ahead.
  4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
  5. Reckless disregard for safety of self or others.
  6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
  7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

The key here is disregard for and violation of the rights of others. I am unfamiliar with Iranian religious law, though it is hard to understand how a woman who is not wearing a head covering is disregarding and violating the rights of others. Is the argument that the hair of women impinges on the rights of men? What freedoms are taken from men when they see women’s hair? What freedoms are returned to them when women’s heads are covered?

However, it’s also not hard to see how one can twist the criteria for women to receive a diagnosis of antisocial personality disorder:

Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest. Women are required to wear a hijab by law. Women who don’t cover their heads are breaking social norms and the law.

Impulsivity or failure to plan ahead. Wearing a hijab requires planning. Only someone who is impulsive or short-sighted would forget to wear a hijab when going out.

Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. A responsible woman would consistently wear hijab.

Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. Women who refuse to wear a hijab are unapologetic about their behavior. They clearly don’t care about the disrespect they are showing to religious law.

That’s four criteria when only three are required. Though it’s still unclear whose rights are being violated, the twisting of criteria is easy to do to distract from the intentional distortion of context.

The Lancet article correctly notes that the “diagnosis” of women who refuse to wear hijabs and their subsequent “treatment” is political abuse of psychiatry. One of the authors, Robert van Voren, has written other articles on this topic, including Political Abuse of Psychiatry—An [sic] Historical Overview, where he teaches us that the Soviet Union was a major culprit:

Socialist ideology is focused on the establishment of the ideal society, where all are equal and all will be happy, and thus, those who are against must be mad. … The political abuse of psychiatry in the Soviet Union originated from the concept that persons who opposed the Soviet regime were mentally ill because there was no other logical explanation why one would oppose the best sociopolitical system in the world.

In a separate article, Ending political abuse of psychiatry: where we are at and what needs to be done, van Voren argues that regimes abuse psychiatry because “in most cases it is a combination of expedience and ideology.” He goes on to note:

Sending people to a psychiatric institution is particularly practical because hospitalisation has no end and thus, if need be, people can be locked away forever, or as long as they continue to have views that are considered politically or socially dangerous, or remain inconvenient to the authorities. … At the same time, declaring a person mentally ill provides a perfect opportunity not to have to respond to their political or religious convictions, as they are the product of an ill mind and do not have to be taken seriously.

He argues that the way to combat political abuse of psychiatry is similar to combating misinformation:

stimulating communication and access, providing training in issues of medical ethics and human rights, and translating key documents and manuals into local languages may make it impossible for the public to remain uninformed.

Why am I writing about abuses of psychiatry in Iran? With increasing overt conflict between and within nations, psychiatrists and other mental health professionals should know the history (some of it recent!) of the political abuse of psychiatry. None of us are immune to persuasion and coercion. Though I hope that governments and other authorities will never ask us to use our skills to harm people, hope is not a strategy. People in power can exhibit antisocial behaviors, too. Democracy may decrease the likelihood that psychiatrists will succumb to political pressure, though psychiatrists are still people. Most people avoid conflict, respond to incentives, and do not want their status to drop. Psychiatrists are not morally invincible.

The public also needs to know this history. (I recognize I am but a tiny fish in the ocean that is the internet. I appreciate that anyone is willing to give the gift of attention to my writing here.) If psychiatrists and other mental health professionals start “treating” people whose only symptom is having an opinion that diverges from the government’s perspective and propaganda, we need the public to call this out.

Hospitals have better food, softer linens, and more space than jail, but both places can restrict your movements and prevent you from leaving. Psychotherapy can be harmful and punishing. The stigma of mental illness and treatment, while decreased over the past few years due to the pandemic, persists and can be used to reject and dismiss people.

Civil disobedience doesn’t disregard and violate the rights of others.

Categories
Public health psychiatry

Killing and Mental Disorders.

Though over three years have passed since the start of the pandemic, we on Earth have yet to escape the specters of death and destruction. With murderous tragedies large and small happening around the globe, one might wonder, “All these people who are killing other people: There must be something wrong with them. Do they have a mental disorder?”

The Diagnostic and Statistical Manual, now in its fifth, text-revised edition, provides this definition for “mental disorder” (emphases mine):

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.

Let’s consider some examples:

The man who shot 18 people in Maine. There are accounts that he has heard voices in the recent past. It is unclear if these voices were related to his threats to carry out a shooting at a military base. Reporting suggests that these two events resulted in a psychiatric hospitalization.

If we assume that he is still experiencing now the symptoms he had over the summer, he has a disturbance in his cognition (hearing voices) and behavior (use of a firearm to kill other people). We don’t know if the voices have caused him distress. He is certainly experiencing major disability at this time, as it seems that he has no social connections at this moment and he isn’t able to engage in activities such as work and leisure. He has demonstrated socially deviant behavior that, at least the way it is reported, is related to a dysfunction inherent to him.

Thus, it seems likely that this man who has killed 18 people in Maine has a mental disorder.

The Long Island Sex Killer. This is the man who allegedly killed 11 women between 1996 and 2011 and put their remains on Gilgo Beach. This man worked as an architect in New York City, was married, and had children.

It is debatable if he had a clinically significant disturbance in his thoughts, emotions, and behaviors: No one in his life seemed to notice any disturbances. For 15 years he presumably didn’t exhibit concerning distress or disability, as he was able to maintain multiple roles in his life with success. No one knew of his socially deviant behavior until he was caught.

Under this framework and given what has been shared, the Long Island Sex Killer does not appear to have a mental disorder.

People fighting in wars. This can include a military attacking an opposing nation-state, an organization attacking a nation-state, or a nation-state attacking an exclave.

We’ve already encountered a barrier: Mental disorders, by definition, only occur in individuals, not populations.

So let’s broadly consider the leadership of these populations, such as elected officials and others with high rank and authority. Propaganda obscures whether any of them are exhibiting disturbances. Note that their followers would not interpret their leaders’ thoughts, emotions, and behaviors as disturbed. Any distress the leaders express is related to their rage towards the enemy. Anyone showing disability would likely be removed, as this would be construed as a vulnerability. Attacking the enemy is not socially deviant behavior. (Resisting such efforts is.)

Leaders who order the killing of other people, in this framework, do not have mental disorders.

(As you already know, those fighting and harmed in wars are at higher risk of developing mental disorders. It is unjust that once someone demonstrates disturbances, distress, and disability due to war, the consequences of a state action land solely on individuals who must bear the psychological burdens and stigma.)

So, if mental disorders are not the underlying reason why people kill other people, then what is?

(Evil?)

(If it is evil, that is not something psychiatrists can treat.)

Categories
Consult-Liaison Reflection

Killing and Suffering.

To become a doctor, one learns how to prevent disease and death. To do this, one first must become acquainted with them: What happens? What does disease and death look like? sound like? smell like? What are their textures and patterns? What shifts over time, until the patient has no more time left?

As medical students learn what disease and death look like, they witness human suffering. Many students are unprepared for this. The tears that physicians in training shed are not from recognition of the mechanisms of disease and death. They cry because of the human suffering that surrounds them, that submerges them.

We don’t cry because we recognize that the proteins in the coagulation cascade aren’t reacting fast enough. We weep because there is so much blood everywhere. We see how pale their skin is, hear their rapid heartbeat on the monitor, and feel the coolness of their skin.

We see the contortions of their loved one’s face. We hear them scream, their sobs escaping their throats.

If we cry when we witness the suffering of one or two human beings, won’t we still cry when this happens to multiple human beings who are infected with a pandemic illness?

What if the cause of death isn’t a disease, but is instead a person? How do we then react?

Some psychiatrists recently shared the mental model of projection to explain why people kill others. Briefly: Projection is an unconscious process. People generally don’t think of themselves doing “bad” things:

  • I would never hate people because of their religion.
  • I would never treat people differently because they are poor.
  • I would never deny someone a place to live.

… even though they may have fleeting thoughts or impulses that align with these.

In projection, someone will “project” negative thoughts and impulses onto someone else and deny that they themselves ever have them:

  • I’ve done the work and I don’t have implicit biases. That guy, though, hates anyone who belongs to that religion.
  • I’m open-minded and understand that people who are poor are still people. That person, though, thinks poor people are all lazy and stupid. Just a bunch of moochers.
  • Of course everyone deserves a place to live. That guy, though, thinks some people deserve to be homeless. He thinks they’re all criminals and deserve to die.

In projection, we (unconsciously) don the gown of righteousness. We can do no wrong. Our intentions and motives are pure. In projection, we (unconsciously) coat The Other Person in the rags of depravity. They are evil. They only want to do bad things.

We are nothing like them. We could never be like them. They could never be like us. Anything we do glows with virtue. Anything They do is wrong.

We crush cockroaches underfoot because we are nothing like them and could never be like them.

How different are They from cockroaches?

We can’t test for projection. This is supposed to be an entirely unconscious process. (If we were conscious that this were happening, we would (should?) be horrified. We could not tolerate this and would take steps to stop it.)

I don’t discount the idea of projection for killing, but because there is no way to validate it, this is not the first explanation I go to. There are also a lot of steps: I’m a good person, you’re a bad person, you’re so bad that I don’t think you’re a person anymore, so killing you isn’t actually killing a person.

The dehumanization that comes from neglect is more compelling to me than the dehumanization that comes from projection. Indifference can cause more harm. It can be a conscious choice.

It’s not that I think you’re subhuman or an animal. I just don’t think about you at all. Torturing and killing an animal, even a cockroach, means that I at least thought of you as something that can react. If I don’t think about you at all, then you already don’t exist. And what sort of reaction could you possibly have if you don’t exist?

What harm could torture, rape, and murder have on nothing? If you don’t exist, then I’m not killing anyone in hospitals and schools. There are no children. I’m just flattening buildings.

You don’t matter. You have no matter.

People, like you and me, weep around the world.

A man cries for his son who will not live to start school because of the cancer in his brain. A son cries for his mother who died in an accidental plane crash. Someone cries for a friend of 60 years because their heart stopped beating.

Death from disease and the random events of life already causes suffering. Do not cause more suffering by killing other people. You will not only destroy others, but you will also destroy yourself.

Categories
Homelessness Reading

Down and Out, On the Road.

It took me a couple of months, but I finally got through Down and Out, On the Road: The Homeless in American History (first mentioned in this post). Here are the main points I took from the book:

“Down and Out” refers to people who live in impoverished urban areas. More specifically, people who live on “skid row” are “down and out”. (The term “skid row” likely originated in Seattle. As noted in both the Underground Tour and Beneath the Streets Tour in the Pioneer Square neighborhood, tree logs cut from the hills were pushed down Yesler Way towards the waterfront. Logs skidding down Yesler Way led to the name “skid row”.) These days, “skid row” typically refers to centers of poverty in cities where homeless people often reside. This is paired with…

“On the Road” refers to people who were homeless and, in trying to search for work, rode the trains. They often did not ride in the train, but rather on or under the train. These same individuals might reside in “down and out” areas upon arriving in a city. During the 1800s, people who were homeless were often associated with riding the rails than living in skid rows.

The term “the jungle” has been used to describe homeless encampments for nearly 200 years. In recent years here in Seattle, “the jungle” has referred specifically to a large encampment tucked under many trees in an undeveloped area near Interstate 5. This “jungle” was also notorious in the local press for violence (and was subsequently razed, though it seems that there are evergreen efforts to revive it). Over the past 200 years, people who had no place to live set up camp in forested areas (“jungles”) outside of urban centers, which developed into communities.

Cycles of romanticizing and vilifying homeless people are not new. People with no place to live are poor. Because the working class recognized how similar their struggles were with people who were homeless, they were (and continue to be) consistently more sympathetic, empathetic, and generous to them. Other classes, though, have swung between perceptions that people who are homeless are harmless—perhaps even charming (see Norman Rockwell) to lazy, deviant, and dangerous. (Other indicators include The Way It Is and Mr. Wendal, both excellent songs.)

Homelessness is a consequence of poverty. When I first received the book, I confess that I was dismayed to see in the index that “mental illness” is mentioned on only four pages of this ~250 page text. Kusmer, the author, provides a compelling historical account that various systems, including government policy (or lack thereof), economic forces, and cultural values are the chief drivers that lead to people becoming poor. Poverty is a major risk factor for homelessness. (I know this from my own anecdotal experience: Most people who are homeless do not have a severe psychiatric illness like schizophrenia. People often develop psychiatric symptoms because of homelessness. Even if every single psychiatrist in the nation worked with people who are homeless, homelessness would persist: There are plenty of people who are unhoused who do not need psychiatric treatment. They need a place to live and ways to have money to pay for living expenses.)

There was a federal program to address homelessness! Homelessness has been and continues to be a nationwide problem (regardless of the size of the US throughout time) that requires a federal response. The Federal Transient Service (FTS) was the first (and only?) federal agency in US history whose goal was to aid people who were homeless and unemployed. It started in 1933 and only lasted two years, in part because it seemed “successful”: The number of homeless people dropped, so everyone thought the problem of homelessness was solved. FTS funds were swept to support public works and Social Security. (In theory, public works and Social Security seemed like better investments to prevent homelessness.)

The disproportionate number of homeless people who are Black is not new. This is another legacy of slavery. A number of minority populations (e.g., Native Americans, Mexicans, women) suffer from homelessness because of policies and practices related to economic and class exclusion.

Down and Out, On the Road: The Homeless in American History was published in 2002. My sense is that the author, when viewing the current state of homelessness in the US, would continue to argue that the forces that contribute to poverty remain the primary driver of homelessness. I think he would continue to view mental illness and substance use as distractions and not significant causes of homelessness. (To be clear, I don’t think he’s discounting psychiatric conditions as contributors to homelessness for specific individuals, particularly since psychiatric conditions, both directly and indirectly, can pull people into poverty.) I appreciate how he ends the text:

The compulsion to stereotype the homeless as dependent and deviant turns the poorest Americans into an abstract “other,” separate and inferior from everyone else. Although their problems are more severe, however, destitute people living on the streets and in homeless shelters are not so different from the rest of us. They never have been. Any genuine effort to end homelessness must begin with a recognition of that essential truth.

Categories
Blogosphere Medicine Systems

Brain Snacks.

It’s a short post this week, though the links will take you to nutritious brain snacks (or hors d’oeuvres, if you identify as classy):

24 Hours in an Invisible Pandemic. This is an excellent example of data visualization about the experience of loneliness in the US.

26.2 to Life. This documentary is about the San Quentin Marathon. The athletes are inmates at the San Quentin prison. The course is 105 laps around the prison yard. (The virtual premiere is this weekend.)

30 Days of Healthcare. Dr. Glaucomflecken’s series of short videos about the US health care system is accurate, devastating, and, when it can be, amusing.

We Are Not Just Polarized. We Are Traumatized. This long essay is provocative, thoughtful, and worth the time to read. (Side commentary: The term “trauma response” is a relatively new phrase and, as far as I know, isn’t rooted in robust psychological or biological principles. I worry that the usage of “trauma response” may also dilute the experiences of people who meet formal criteria for the diagnosis of PTSD.)