Category: Lessons

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Lessons Nonfiction Reading

How to Avoid Becoming an Agent of Social Control: Viktor Frankl

In our ongoing study in how governments have used psychiatrists as agents of social control (and how psychiatrists resisted these pressures), let’s learn about Viktor Frankl.

Viktor Frankl was an Austrian man who was Jewish. He worked as psychiatrist and is best known for his book, Man’s Search for Meaning. (It’s a slim book and worth a read.) In it he describes his experiences in Nazi concentration camps and the development of logotherapy.

Before the Nazis deported Frankl, he worked in the Neurological Department of the Rothschild Hospital in Vienna. His title was apparently “Jewish Specialist”; it was one of the last places Jews could work.

The Viktor Frankl Institute notes that, in 1940,

In spite of the danger to his own life he sabotages Nazi procedures by making false diagnoses to prevent the euthanasia of mentally ill patients.

though I am unable to find other evidence to support this.

There is more evidence that Frankl worked with people who had tried to kill themselves. Most of his Jewish patients attempted suicide because they had received deportation orders. Certain death was already awaiting them.

Frankl does not discuss in Man’s Search for Meaning how he tried to save these patients from suicide. Others do. Mikic writes:

Frankl tried to bring the suicidal patients back by injecting them with amphetamines, but it didn’t work.

And so, Frankl bored holes in the skulls of his Jewish patients, who had taken overdoses of pills in the hope of escaping their Nazi tormentors, and jolted their brains with Pervitin, an amphetamine popular in the Third Reich.

Pytell also comments:

… in the circumstances of Nazi oppression suicide was often considered a viable option if not a form of resistance, and [Frankl] was therefore undermining the choice of people who made such a difficult decision.

Frankl tried to protect the lives of Jewish people. The Nazis did not like this (or maybe they did?); they also did not like him.

In the preface to the 1992 edition of Man’s Search for Meaning, Frankl shares:

The reader may ask me why I did not try to escape what was in store for me after Hitler had occupied Austria. … Shortly before the United States entered World War II, I received an invitation to come to the American Consulate in Vienna to pick up my immigration visa. My old parents were overjoyed because they expected that I would soon be allowed to leave Austria. I suddenly hesitated, however. The question beset me: could I really afford to leave my parents alone to face their fate, to be sent, sooner or later, to a concentration camp, or even to a so-called extermination camp? Where did my responsibility lie?

Frankl writes that “this was the type of dilemma that made one wish for ‘a hint from Heaven’.” He describes the following as a sign:

… I noticed a piece of marble lying on a table at home. When I asked my father about it, he explained that he had found it on the site where the National Socialists had burned down the largest Viennese synagogue. He had taken the piece home because it was a part of the tablets on which the Ten Commandments were inscribed. One gilded Hebrew letter was engraved on the piece; my father explained that this letter stood for one of the Commandments. Eagerly, I asked, “Which one is it?” He answered, “Honor thy father and thy mother that thy days may be long upon the land.” At that moment I decided to stay with my father and my mother upon the land, and to let the American visa lapse.

Ultimately, his father, mother, and wife all perished. The Nazis killed them all in concentration camps.

From this, it seems that Viktor Frankl held fast to a set of values. We can never fully know all the intentions people hold in their hearts, but we can make educated guesses from their behaviors. He had an internal compass.

From his behaviors we can surmise the points of his internal compass:

Frankl valued the lives of his fellow Jewish people. If it is true that he made false diagnoses to prevent euthanasia, he used the power that he had to protect those who had less. One can argue that Frankl abandoned his professional duties by making diagnoses meaningless. However, the purpose of diagnosis is to guide treatment. If a government uses diagnosis to assign death, then the purpose of diagnosis has already been perverted.

Frankl had a clear vision of what medicine he should practice. If suicidal behavior was the enemy, Frankl used all the tools he had—including cranial surgery and stimulants!—to combat this. I don’t know what amount of amphetamines (or skull boring) can stop people from killing themselves. But if a government is going to execute you anyway for who you are, it seems like no amount will be enough.

Frankl valued his parents. He, his wife, and his parents, all Jewish, knew what the Nazis were doing. He could have escaped. He chose not to. It’s hard for any of us to understand what it means to die. Even if he only understood genocide as an abstraction, it was a consequence he was willing to accept. Being with his parents was a priority to him.

Perhaps the lesson we can learn from Viktor Frankl is to know what your values are. Understand what your priorities are and why. Once you have clarity on your values, then you will be less susceptible to corruption.

Those who live by cunning and duplicity may comment that integrity doesn’t matter if you are dead. Sure, but do you really want the alternative of an exhausting, joyless, and meaningless life?

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Lessons Nonfiction Systems

How to Avoid Becoming an Agent of Social Control: Anatoly Koryagin

Psychiatrists are always at risk of becoming agents of social control. In most U.S. states, we have the power to force people, under specific conditions, into psychiatric hospitals. (Washington State is one of the few states where psychiatrists cannot do this. We have to call someone else with that authority.)

A Very Important Person in the U.S. government has said, “… we live in a world, in the real world … that is governed by strength, that is governed by force, that is governed by power.” The federal government has manifested this intention in both internal and external affairs.

As a result, I have growing concerns that the U.S. government will use psychiatrists as tools for force. This has happened before. How have psychiatrists in the past resisted these pressures? How can I prepare myself to do the same?

The Lancet published a paper in 1981, “Unwilling Patients“, by Soviet psychiatrist Anatoly Koryagin. Dr. Koryagin (stationed in the then state of Ukraine…) wrote this paper

to analyze the conditions in which healthy people in the U.S.S.R. are pronounced mentally ill and are condemned to exist as such.

Dr. Koryagin describes conditions that encouraged psychiatrists to become extensions of the government:

The government passed laws that recognized “anti-Soviet” speech and activities as crimes.

Law enforcement officials at all levels of government picked up people for violating these laws. They then brought them to psychiatric hospitals for observation or evaluation. If psychiatrists diagnosed them as mentally ill, then compulsory treatment followed.

Some people, brought in by law enforcement, were detained even though no psychiatrist ever evaluated them. This means one of two things happened:

  • psychiatrists in the community signed detention orders without ever meeting the person, or
  • hospital psychiatrists automatically signed detention orders when law enforcement arrived.

Psychiatrists shifted clinical definitions.

At that time in the U.S.S.R., the clinical meaning of “socially dangerous” was a person “in danger of committing acts which would endanger his own health or that of people around him.” This is largely consistent with the detention threshold now in the United States.

However, some U.S.S.R. psychiatrists began detaining people because they were “capable of harming the social system as a whole”. This was a judicial interpretation of “socially dangerous”. Thus, for detention to occur, both the referring psychiatrist and accepting hospital psychiatrist substituted the judicial definition for the clinical one.

Even though the only symptoms these patients exhibited were “‘anti-Soviet’ attitudes, expressions, and actions”, most people were diagnosed as “psychopaths (70%) or schizophrenics (30%)”. (A.I. tells me that the DSM-5 equivalent of “psychopath” in the Soviet Union in the late 1970s is antisocial personality disorder.) One Soviet forensic psychiatrist wrote of a patient, “No normal person can be opposed to the Workers’ and Peasants’ State.”

Psychiatrists acquiesced and transformed hospitals into sites of punishment, not treatment.

Once people were hospitalized, “the main aim of these confinements to hospital was the isolation of the patient and not treatment of mental illness”. Gallows humor emerged: The term for this was apparently “wall therapy”.

For those who received medical interventions, they were severe:

  • “insulin comas”
  • “intensive course of injections with neuroleptic drugs for a week”

A 16 year-old girl reported that she was “severely beaten by the medical staff” after she tried to escape. She then was “subjected to treatment with neuroleptic drugs”.

Psychiatrists gave up on patient care and abandoned their professional duties.

Dr. Koryagin notes:

Not one of these people has said that the health authorities or, more particularly, the doctors at psychiatric clinics, have helped them in any way whatsoever.

Given the context, these were not disgruntled patients. Doctors almost always have more power than patients. It is easier to identify abuses of power, like when doctors inflict harm on their patients.

However, not using the power one has is also a misuse of power. Pressure and coercion from the government are always overwhelming. To yield to that pressure creates a vacuum that those who covet strength, force, and power race to fill.

The psychiatrists Dr. Koryagin describes abandoned their power and authority as physicians. Their “patients” suffered the consequences. Thus, Dr. Koryagin reminds us (emphasis mine):

A doctor is obliged to take an active interest in all the patients on his list, so that he may help them in legal and social, as well as medical matters.

In my view this guidance applies not only to the patients who are under our care now, but also to those who were and those who will be. This is why it is vital to advocate for the health and well-being of all. Even—and especially—if the government thinks some people are undeserving.

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Consult-Liaison Lessons Nonfiction

Approach, Don’t Avoid.

I don’t think the crisis center had been open for even one week. There were dozens of staff and fewer than five patients. Most of the staff were young, eager, and brand new to social services. Only the nurses and I had experience working in higher acuity settings.

One late afternoon, an elderly woman using a walker got a hold of a pair of scissors. One arthritic hand wielded the scissors while the other gripped the walker. Her feet were heavy; she plodded across the floor, chanting, “Kill, kill.” The walker swiveled because her torso wobbled with each step.

Our colleagues fled; doors to staff-only areas clattered shut. A nurse and I looked at each other when we realized we were the only people left in the room with this patient. We both sighed. I used my chin to signal that I would follow him.

Later, I asked to meet with all the staff working that shift. Why did you all leave the scene?

“Because she had scissors and was talking about killing people,” they said. “She had a weapon.” We were fearful that she was going to kill us, dummy!

Because this was my first job as a medical director, I thought I always had to “direct”. I didn’t realize that I could keep asking questions:

  • How do you know that she wanted to kill other people?
  • What else might have happened if everyone left her alone with a pair of scissors?
  • What realistic damage could she have done with the scissors?
  • What unspoken message did we send to each other when we all left?
  • What unspoken message did we send to her?
  • Are there things we could have said to get more information from her?
  • What steps could we have taken to separate her from the scissors?

You can’t always believe what you think.

(To be fair, people who don’t know what to do often run away. Avoidance is a common strategy to cope with fear and anxiety.)

The nurse approached the elderly woman from one side. He took three steps for every one step she took.

“Hi. Can you put the scissors into the basket of your walker, please?” he asked.

“Kill, kill,” she continued to chant, holding the scissors in the air. She continued to plod forward.

“Hi. Put the scissors here, please,” I echoed, pointing at the basket.

Her forward movement stopped. The scissors remained in her raised hand. We stood in stillness together.

Mumbling, she dropped the scissors into the basket. I plucked them out. After thanking her, we asked her to please sit down. “And please don’t do that again. It scares people.”

“Please don’t leave when things like that happen,” I said, directing the team. “When there’s a situation, approach. People might need you to do something. Your presence alone can help de-escalate situations. And someone will send you away if it gets too crowded. But don’t immediately leave.”

For the remainder of my time there, staff never disappeared again during a crisis.

(inspired by claims that RFK, Jr., left the scene of Oval Office medical emergency)

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Lessons Reflection

Your Six-Foot Radius.

I don’t think I was that mouthy during my medical training.

Some East Asian women are shy, deferential, and taciturn. It’s no wonder some people were surprised when critical comments came out of the mouth that is attached to my face.

Advocacy comes in different flavors. My initial attempts were salty.

While I didn’t occupy the lowest rung on the neurology service (that honor went to the medical students), I was but an intern. Furthermore, I wasn’t even an neurology intern. I was training to become a psychiatrist.

The attending neurologist, who looked like those doctors exalted in enormous oil paintings that adorn the hallways of hospitals, had too many letters after his name. He also riffed on too many subjects unrelated to neurology during our morning rounds.

Rounds in academic medical centers serve two main purposes: To organize care for patients, and to educate trainees. The team, under the guidance of the attending physician, executes the plan of care for each patient following rounds.

One autumn morning we stood in a circle outside of a patient’s room. Rounds were just starting. Patients—and a whole lotta work—awaited us.

“It’s the season for soup,” the attending neurologist opened, smiling. “Chief Resident, what is your favorite kind of soup?”

I couldn’t restrain myself.

”Can we not talk about soup? There are patients waiting and work we need to do,” I snapped. My fellow intern, a future emergency physician and more accepting of reality than me, didn’t stifle his laughter in time.

Both the chief resident and frowning attending physician shot me a look. “I know you’re focused on getting work done, Dr. Yang,” the chief resident chided, “but there is time to talk about other things.”

My cheeks burned. But no one spoke more of soup. We started talking about the patient waiting in the room. 



Three years later, I myself became a chief resident. Junior residents shared with me that one of the attending psychiatrists, another decorated physician considered a national expert in his field, wasn’t meeting with them for supervision. This was one of his responsibilities. Esteemed professors were supposed to spend time with us trainees so we could learn from them. He wasn’t doing his job.

Chief residents have some responsibility to advocate for junior residents. Annoyed, I asked to meet with him. This flavor of advocacy was spicy.

He didn’t ask for an agenda ahead of time and I didn’t think to provide one. After sharing with him what residents told me, I said, “It is your responsibility to meet with residents for supervision. Why isn’t this happening?”



Well, you can imagine how that went. He became shouty, waved his arms, and wondered how I, a mere resident, had the audacity to talk to him that way.

My cheeks burned again. However, he didn’t deny the allegation.

My program director was dismayed—maybe embarrassed on my behalf?—when I told her what happened. “You didn’t need to tell him yourself!” she exclaimed. “You could have told me and I could have spoken with him.”

The junior residents told me later that he had reached out to schedule regular supervision with them all. 



With additional experience (read: missteps and errors), my advocacy is now more mellow. I’ve learned to ask more questions, orient people ahead of time, and be more mindful of power and status. When all else fails, be direct.

The word “advocacy” often conjures political images: chanting slogans at rallies or calling elected officials.

But those aren’t the only ways to advocate for ideas you value. Effective advocacy can happen within our six-foot radius. It’s asking questions or making statements. Sometimes, it only takes a short conversation to start shifting long-held assumptions:

“Quite frankly, I wish the president would give us a purge [of homeless people]. Because we do need to purge these people.”

“I wonder what the parents and friends of homeless people would think of that plan. What hopes and dreams do you think they had as kids? Surely they didn’t aspire to be homeless.”

“Every time I find one of these lunatics, I take away their visas.”

“When you say ‘lunatic’, what does that mean? What is the process for applying for a visa, anyway? It’s following the law, right?”

“The probability of a trans person being violent appears to be vastly higher than non-trans.”

“I don’t think that’s true, but let’s look at the data together. Where can we look to learn accurate information?

Advocacy can look like curiosity. At its sweetest, advocacy illuminates the humanity of others. Such reminders can take just a few seconds.

To be clear, this doesn’t mean talking to anyone and everyone who enters your six-foot radius. A small minority of people are not curious and not interested in dialogue. They seek targets for their frustration and anger. If you’ve tried to make a connection in good faith, but the effort is not reciprocated, stop. Sometimes, quitting is the best option.

In times—these times—when problems feel too big for us to understand or solve, when we feel like nothing we do makes a difference, speaking up still matters. Your statements (or silence!) affects other people.

Advocacy doesn’t have to involve bullhorns or giant signs. Do not obey in advance. Have faith in what you can accomplish within your six-foot radius.

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Lessons

On Mental Endurance.

Although “mental endurance” is more wordy than “grit”, I prefer the extra syllables. “Grit” sounds difficult and uncomfortable: Jaws clenched, the jagged surfaces of molars grinding together, or granules of sand scratching the surface of your eyeball.

“Grit” also suggests firmness and unyielding. It doesn’t matter what the conditions are: I will not change my strategy or tactics. I will not bend, even if I might break.

“Mental endurance” offers more flexibility. There is room to breathe. Maybe you can keep more enamel on your teeth.

When Things Are Hard, how can we unclench our jaws? When we run psychological marathons we did not sign up for, how can we keep moving without falling down from exhaustion or heartache? How can we practice and manifest mental endurance?

Build and commit to routines. If the word “ritual” is more pleasing to your ear, build and commit to rituals. This includes the essentials of eating, sleeping, and other healthful activities. (Without a basic foundation, any type of endurance is hard to achieve.) Creating and sticking to routines brings comfort when most things seem out of control. Rituals help us feel like we have agency over something. To start, the less profound the ritual, the better:

  • Make the bed every morning.
  • Always say “thank you” to the bus driver, even if they don’t make eye contact with you and look like they’re grinding the enamel off of their teeth.
  • After you put your kids in the car and shut their door, make a point of taking three full breaths before you get in to drive.

No one has to know what your routines are or the reasons behind them. Maybe you run because you actually want to run away from your problems. Maybe you watch the same video on YouTube before bed because it increases the chances that you will fall asleep. Maybe you behold the cereal in your bowl and say thanks to all the nameless people who transformed and transported the cereal to you.

What matters is that you created a ritual. You’re choosing to do it. Within is freedom and power.

Pace yourself. Or, it’s okay to take a break. When Things Are Hard, we often want to get through All Of It as soon as possible. Who wants to feel psychologically uncomfortable?

However, the logical conclusion of this approach doesn’t make sense: Life is hard. If we want to get through the Hard Stuff as fast as possible, that means we should try to get through life as fast as possible. This is impossible. (Puberty over in 24 hours! bone fracture healing in five minutes! grief resolved in two seconds!)

Yes, there are often external pressures: The boss wants us to do something. The kids have a need that only you can fulfill. There isn’t enough money to deal with The Thing the way you’d like to deal with The Thing.

It’s okay to take a break. If you were able to think your way out of this problem, you would have already thought of the solution. Spending 30 minutes thinking about something else is nothing when you spend hours dwelling on The Thing. Your mind will welcome the break, too, because it needs it. (Epiphanies seem to arrive when we give our mind a break: showering, doing our laundry, etc.)

Talk with people you trust. Many burdens are not meant to be carried alone. If someone is able and willing to help lift the burden from your mind, or at least shift it so you can adjust your psychological grip, not only are you blessed, but you are also letting someone help you. Sometimes our grip is so tight on The Thing because we insist on bearing it ourselves. (What would it mean if we let someone help us? Does it mean that we’re weak? unreliable? a failure?) Olympians and chess grandmasters all have coaches and esteemed colleagues. Amateur chefs share their dishes with tasters and amateur writers share their words on blogs. While it may be true that no one in your social circle has been through what you’re going through, that doesn’t mean that they are useless. Support, attention, and care from others has value. It’s okay to unclench.

Remember that everything changes. Things may not change as fast as we want them to, but everything changes. What feels intolerable now will one day be a memory. We ourselves change because of The Thing; our values will shift and we will make different choices. With heartbreak, we might ultimately discover more love flowing through our lives. Instead of the friction associated with grit, there can be a softening, a light, gentle expansion of our hearts. There is room to breathe. Our bigger hearts will buoy us forward for whatever changes await us next.