Category: Systems

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Lessons Nonfiction Policy Systems

How to Avoid Becoming an Agent of Social Control: Communist China.

The Year of the Horse has arrived! How delighted I was to see the New York Times show Lunar New Year Across America (free gift link). I remain struck with how representation matters. It is some kind of dazzling to see people who look like me in a major newspaper celebrating the same holidays I do! (For the past few years, Asian representation has looked more like this. I admire R. Kikuo Johnson’s art, though that vibe is the antithesis of the joy and connection of Lunar New Year.)

With Lunar New Year festivities about over, it’s time to talk about China using psychiatrists as agents of social control. There are many similarities between China and the Soviet Union (see the post I wrote about Anatoly Koryagin). The Human Rights Watch and Geneva Initiative on Psychiatry describes this in Dangerous Minds: Political Psychiatry in China Today and its Origins in the Mao Era.

In the Soviet Union, the government passed laws that recognized “anti-Soviet” speech and activities as crimes. In China, “political dangerousness” was incorporated into Chinese psychiatric diagnoses. This creation of “political-psychiatric dangerousness” allowed psychiatrists to detain people for psychiatric reasons. It also resulted in law enforcement charging people with crimes, amplifying

the more intractable problem of the Chinese authorities’ longstanding insistence upon viewing the peaceful expression of dissident or nonconformist viewpoints as constituting “political crimes” that must be sternly punished by law.

The authors further note:

most of these people should not have been arrested or brought for forensic psychiatric evaluation (formal or otherwise) in the first place, since in the overwhelming majority of recorded cases their only “offense” was to have expressed views or beliefs which served to offend the political sensitivities of the Chinese Communist Party.

Like psychiatrists in the Soviet Union, Chinese psychiatrists shifted clinical definitions:

individual mental problems soon came to be seen, in simplistic and reductionist fashion by the ultra-Maoists, as being not merely reflective of, but actually caused by, incorrect or deviant political thinking on the part of the sufferer.

One of the Chinese psychiatrists, Yang Desen, was a whisteblower. He said:

Eventually, [the ultraleftists] began claiming that the real reason people became mentally ill was that their heads were filled with an “excess of selfish ideas and personal concerns” and that it was the product of “an extreme development of individualism.

Believe in the wrong political system and the authorities believe there is something wrong with your mind.

Psychotic disorders were most associated with this political and psychiatric dangerousness:

the most frequent diagnosis made by police psychiatrists in this context is of either “schizophrenia” or “paranoid psychosis” leading to the following kinds of “crimes” by the alleged sufferers: “sending reactionary letters,” “writing reactionary slogans,” “petitioning and litigating,” “shouting reactionary slogans” and “spreading rumors to delude the masses.”

Mental acrobatics are necessary to argue that these individuals were dangerous to others. But, once the government defines anti-government speech as a crime and evidence of a mental illness, a warped internal coherence follows. The “police psychiatrists” concluded:

Cases of political crime created by the mentally ill usually exert a highly negative influence in society and have extensive ramifications. They take up large amounts of human and material [police] resources and pose a definite disruptive threat to the normal functioning of state offices and to the political stability of the country.

Ideas are potent. It’s hard for one person to kill hundreds of people at once. The police never have to worry about that problem. It’s far easier for one person to introduce ideas to hundreds of people at once through books, radio, and television (and, these days, social media!). Even a man silently holding a sign on the street has the potential to “infect” dozens of people. A government ruled by fear, not confidence, wants to quash the expression of diverse ideas.

Like in the Soviet Union, the goal of detention wasn’t humane treatment. There was “a very high patient-to-doctor and nurse ratio, severe underfunding by the government, and serious lack of capacity leading to a dense overcrowding of inmates” and

the form of psychotherapy actually used from early 1996 onwards consisted of increasingly intense political indoctrination sessions in which mental patients were exhorted to cure themselves by studying the works of Mao and adopting a “proletarian” political outlook.

The US government has yet to outlaw free speech (and may we work together to prevent this from happening!).

May we continued to recognize and insist on the value of free speech. May we all continue to act with courage, even as those in power have tantrums and rely on violent tactics. Let us use the power that we do have. Everyday heroes may be nameless to you, but they are everywhere: people with integrity who are doing the right thing within their six-foot radius of influence. You can be one of them, too.

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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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Homelessness Policy Public health psychiatry Systems

Loud Music Is Disorder. What About Memecoins?

I read this provocative essay about “disorder” when it was first published in September 2024. I found myself alternating between nodding and frowning. It’s not a short essay, but I do encourage you to read it. (For those who lean left politically, the author is a thoughtful conservative commentator named Charles Fain Lehman, a fellow at the Manhattan Institute.) I considered writing up my reactions at the time, but I deferred. My reactions felt squishy. I didn’t have data to back up my reasons for frowning.

I still don’t have data, but the increasing disorder at the federal level frustrates me.

To summarize: Lehman opens by citing statistics that crime has indeed fallen in the US. Many Americans, though, feel that crime is rising both in their communities and across the nation. He then argues that “disorder” is increasing and offers these as examples of “disorder”:

  • A man blasting loud music from his phone in a subway car;
  • Teenagers spray-painting graffiti on a public park;
  • A large homeless encampment taking over a city block;
  • A man throwing his trash on the ground and walking away;
  • A group of women selling sex on a street corner.

From this, he proposes a definition for “disorder”: domination of public space for private purposes.

He goes on to argue that engaging in disorderly behavior is the rational choice, but most people do not contribute to disorder. Why? He attributes this to

“social control”—the regulation of individual behavior by social institutions through informal and formal means.

Lehman says that the Covid pandemic, in particular, weakened social control (e.g., fewer “eyes on the street” due to increasing remote work; reduction of law enforcement numbers due to the George Floyd murder and defund the police efforts). He adds that “the core to combating disorder is restoring public control of public space.”

To his credit, he doesn’t offer law enforcement as the sole solution. Lehman briefly describes changing the environment with intention (e.g., broadcasting deterrent music, putting pressure on landlords to clean up spaces). But, once informal efforts fail to restore order, then formal systems must intervene. In his view, law enforcement is the primary formal system.

Most of my professional work has been with people experiencing homelessness and mental illness. But I’m not actually cool with people living outside. I feel discouraged and unsettled when I see tents blocking lengths of sidewalks. When I see people slumped on the sidewalk due to fentanyl, my first thought is, “I wish you would stop using drugs.” I am not a fan of disorder.[1]

I like Lehman’s definition of disorder. While not comprehensive, “domination of public space for private purposes” is a reasonable starting point.

What I don’t like is how many of his examples are associated with poverty (homeless encampment; prostitution; loud music on public transit, a space rarely used by wealthy people). Yes, these are visible and common examples of disorder. But what about the disorder associated with people with wealth and power? Just because we don’t see it every day doesn’t mean people with money and influence are paragons of morality. Why no commentary on that?

Is it disorder when the President visits golf resorts that he owns? He profits from his Secret Service detail staying in his hotels. Isn’t that the domination of public funds (our tax dollars!) for his private, profit-building purposes?

Likewise, is it disorder when the President and his wife launch their own memecoins? Isn’t their use of public office to collect millions of dollars a form of disorder?

Is it disorder when the deputy chief of staff in the White House redirects ICE agents to enact his own anti-immigration agenda?

Is it disorder when the federal administration cuts millions of dollars from scientific research funding because language in the grants references race, gender, and sex? Isn’t this the domination of public resources for a private, anti-DEI ideology?

Is it disorder when the federal administration wants to cut billions in Medicaid funding so that people with extraordinary wealth will get tax breaks? How is that not domination of public resources for private purposes?

None of these actions had occurred by September 2024. Regardless, I wonder if Lehman had considered the intersection of power with his definition of disorder. Lehman says early on in his essay that

critics [contend] that disorder is just another word that the powerful use for whatever it is the non-white, poor, and otherwise marginalized do.

This criticism, combined with Lehman’s omission of power, illustrates who does and does not get to define “disorder”.

We are seeing nauseating abuses of power in this Presidential administration. If blasting music on a bus is disorder, but funneling public money into personal projects is not, then we’re not defining disorder. We’re excusing power.

[1] I am a fan in believing that people can change. And they do! People stop drinking and using drugs. They start taking medication, and they learn how to manage their symptoms sooner. Again, just because we don’t see that change every day doesn’t mean it isn’t happening.

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Policy Systems

The Word “Mental” in Project 2025. (ix + x + xi)

The ninth, tenth, and eleventh instances of the word “mental” in Project 2025 are on page 875 in the section about the Federal Trade Commission:

Protecting Children Online. The FTC has long protected children in a variety of different contexts. Internet platforms profit from obtaining information from children without parents’ knowledge or consent—and social media’s effect on the well-being of American children is well-documented. Around 2012, American teens experienced a dramatic decline in wellness. Depression, self-harm, suicide attempts, and suicide all increased sharply among U.S. adolescents between 2011 and 2019, with similar trends worldwide. The increase occurred at the same time that social media use moved from rare to ubiquitous among teens, making social media a prime suspect for the sudden rise in mental health issues among teens. In addition, excessive social media use is strongly linked to mental health issues among individuals. Several studies strongly support the notion that social media use is a cause, not just a correlation, of subjective well-being and poor mental health.

This harkens back to the second time the word “mental” appears in the text, where the authors accuse Big Tech of engineering social media for industrial-scale child abuse. The punchline is, yes, the authors of Project 2025 have legitimate and evidence-based concerns about the adverse effects of social media on kids. I appreciate that this section here at least includes people of all ages (i.e., parents) in asserting that “excessive social media use is strongly linked to mental health issues among individuals”.

After this brief foray into children’s mental health, the text veers back towards its point: Trade and contracts.

Targeting children to create potentially harmful contracts or making parents responsible for such contractual relationships is an unfair trade practice.

… leading to this recommendation:

The FTC should examine platforms’ advertising and contract-making with children as a deceptive or unfair trade practice, perhaps requiring written parental consent.

While a perspective of interdependency views everything as being related to everything else, bringing up the mental health of children within the context of the Federal Trade Commission is curious. As we will see in the next instance of the word “mental” in this document (we’re nearing the end — “mental” only shows up 16 times), there’s ambivalence in this chapter about the role of the FTC. Children’s mental health is used chiefly as a potential subject of regulation. Who is better poised to regulate social media and its effects on children? The government? Or parents? Surprisingly, this seems open to debate in this section. (This entire chapter on the FTC uses notably less inflammatory language, too.)

It is clear, just from reviewing the appearance of the word “mental” in this text, that the authors of Project 2025 have opinions about who should have the power and authority to regulate other people. It is apparent who they believe should (cis male, heterosexual fathers) and who should not (women, children, and everyone else). Because Project 2025 makes multiple references to the authority of Judeo-Christian faith, which worships the Father (dude), the Son (dude), and the Holy Ghost (do spirits have genders?), this is presumably why.

Instead of struggling with how to reconcile the agency that all humans can and could have at this current time and place, the authors of Project 2025 have elected an “all or nothing” approach. This is also reflected in the black-or-white, provocative language used in many portions of this enormous document.

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Medicine Policy Systems

The Word “Mental” in Project 2025. (viii)

The eighth instance of the word “mental” in Project 2025 is on page 648 in the section about the Veterans Health Administration:

Examine the surpluses or deficits in mental health professionals throughout the enterprise, recognizing that the department needs a blend of social workers, therapists, psychologists, and psychiatrists with a focus on attracting high-quality talent.

This chapter advocates for “Veteran-centric” care and wants military veterans to have easier access to high quality services. This recommendation is part of a list that calls for bolstering health care personnel to reduce wait times for veterans. This is completely reasonable.

(There are some highly biased comments in this section, such as “the Left’s pernicious trend of abusing the role of government to further its own agenda”, even though the preceding sentence is literally “rescind all departmental clinical policy directives that are contrary to principles of conservative governance”, as if “conservative governance” isn’t an agenda???)

I do wonder how the arbiters will know what numbers of mental health professionals are a “surplus” versus a “deficit”. Most (all?) health systems struggle with a “scarcity” or “substantial shortages” of behavioral health professionals. Perhaps the authors of Project 2025 are aware that mental health professionals, such as psychiatrists, are far more likely to be registered Democrats. The VA directives they want rescinded are ”abortion services and gender reassignment surgery”, so perhaps the “surplus” of mental health professionals are the pernicious Lefties who support those services.

Like most other physicians who trained in the US, I spent time in residency and fellowship working in VA hospitals. (As a medical student I did not train at a VA, but was instead sent to an Air Force base for part of my pediatrics rotation!) We were in the midst of the Iraq War. The VA patients under my care at that time were around my age. (How did fate send us on such different paths, only to intersect in the hospital?) The psychological wounds of these young men from fighting in the war were still gaping. I also saw Vietnam War- and World War II-era patients whose memories were deteriorating, their bodies not yet as infirm as their minds.

Apart from one unfortunate experience, I found my work experiences at the VA meaningful. I know it sounds corny, but it truly is a privilege to provide care to people who have served in the military. (We’ll put aside for now the vexing reality that trainees spend so much time learning their health care profession on patients who don’t have much money in publicly-funded institutions. Never did I nor a colleague treat an Admiral, Commander, or other high-ranking, presumably not poor, officer.) While not routine, I continue to encounter veterans now who are homeless and have significant psychiatric conditions. My primary goal in those instances is to get them connected to the local VA if possible, since the VA, for all of its bureaucratic problems, often offers many more resources than other public programs.

When I consider the provision of mental health services at the VA, I can’t help but think that the best way that we can protect the mental health of veterans is to limit their exposure to war. We can’t prevent all bad things from happening, but war is an especially bad thing. It messes people up. I’m not even talking about formal psychiatric disorders. War induces heartache. I think about the various veterans I’ve worked with as colleagues (some as health care professionals, most not), and what stands out to me is how much loss they carry. They’re “fine”: They are married, they have kids, they have fun hobbies, they do satisfactory to exemplary work at their jobs, some have even achieved high status in their professions.

And then I see artifacts from a comrade who died, sense their guardedness, hear their reluctance to speak about their time in service.

There are things that civilians may never understand. Here I agree that veterans deserve high quality health care. The issue is that the authors of Project 2025 apparently believe that some people do not deserve certain kinds of health care, high quality or not.