Like the proverbial moth drawn to the flame, I am attracted irresistibly to unanswerable questions. I’m in good company; as philosopher Hannah Arendt stated, “Man’s need to reflect encompasses nearly everything that happens to him, things he knows as well as things he can never know.”¹ Yet we can benefit by thinking more clearly about our perplexity.

My colleague Roger Verdon’s brilliantly poignant blog post on Amy Winehouse’s fatal addiction inspired the present post. The question, “Can’t or won’t?” was an implicit subtext throughout Roger’s reflections: Can’t stop using or won’t stop using? 

This question pervades our clinical practice: Can’t or won’t stop smoking, drinking, drugging, spending, thieving, bingeing, worrying, obsessing, counting, checking, avoiding, withdrawing, cutting or attempting suicide? Can’t or won’t stop being arrogant, oppositional, obstructionistic, submissive, self-sacrificing, self-defeating, reckless or impulsive? In my view, this can’t/won’t question strikes at the core of a quandary about our professional identity: Are we technologists or ethicists?

Intending to be provocative, and expanding on a previous post,² I will state the polar extremes in caricature form in this post, hoping to evoke conflict. In a subsequent post, aspiring for moderation, I’ll search for some middle ground.

Can’t stop?

Ostensibly, we mental health professionals make our living on the “can’t” side of this quandary: You are ill; let us treat you with our scientific technology. The number of human problems we diagnose as psychopathology has increased with each new iteration of the Diagnostic and Statistical Manual of Mental Disorders, now in its fourth edition.³ This enterprise is scientific: Through research,

• we distinguish among disorders;
• we develop technology to treat them (i.e., treatment manuals); and
• we study the effectiveness of the treatments.

Neuroscience now drives home the point that these disorders are real—addictions included. All in your head, indeed, but increasingly evident in altered brain structure and function.

Won’t stop?

Now for won’t: not enslaved by illness but rather making bad choices. Here’s a book title that rankles me: Depression is a Choice.⁴ In this vein, decades ago, psychiatrist Thomas Szasz⁵ caused an uproar with his outrageously titled book The Myth of Mental Illness. If one had any doubt, neuroscience now demonstrates that mental illness is no myth. But I never thought we needed neuroscience to refute the idea that mental illness is a myth; clinical observation was enough to do so for me. Hence I couldn’t stand Szasz’s book—until I read it recently.

His extremism notwithstanding, Szasz made a compelling point in arguing that psychotherapy is not suited for treating (mythical) illness but rather for addressing problems in living. More specifically:

Psychiatrists are not concerned with mental illnesses and their treatments. In actual practice they deal with personal, social and ethical problems in living.

Here is a point I find persuasive: “Psychologists and psychiatrists deal with moral problems which, I believe, they cannot solve by medical methods.”

In light of Szasz’s provocative claim, I find it fascinating that, two millennia ago, what we now call psychotherapy was the province of ethicists. In her illuminating book The Therapy of Desire, philosopher Martha Nussbaum⁶ documented the venerable history of psychotherapy in the practice of ancient Greek and Roman philosophers, as exemplified by Socrates.

Using collaborative discourse as a therapeutic tool, the classical ethicist worked with individuals as well as groups. Consider the following problems in living addressed in ancient ethics: dependency, love, sexuality, jealousy, anger, resentment, loss, death and suicide. Sound familiar? Long antedating Freud in their struggles to promote self-exploration, the Romans and Greeks were attuned to unconscious conflicts, including unconscious resistances to self-knowledge and to change.

To put the point most provocatively, as philosopher Charles Taylor⁷ has done, we mental health professionals are part of a social movement that is converting sin into sickness. Karl Menninger⁸ made a similar argument earlier in his powerful book Whatever Became of Sin? Stating it somewhat less provocatively, we have aspired to put science and technology in place of philosophy and ethics. I have no doubt about the potential benefits of this conversion, but I worry that we’ve gone too far. I think our justifiable fascination with neuroscience can contribute to the imbalance to the extent that we become excessively enthusiastic and reductionistic, caught up in biomania.⁹ The extreme version of can’t: My brain made me do it (or prevented me from doing it).

In pursuit of scientific explanations, do we want to shed responsibility? With responsibility and choice comes dignity. Might we be better off opting for won’t?

References

1. Arendt H. The life of the mind: I. Thinking. New York: Harcourt; 1971.

2. Allen JG. “What’s become of sin?” SayNoToStigma.com. Houston: The Menninger Clinic; 2010.

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, D.C.: American Psychiatric Association; 2000.

4. Curtiss AB. Depression is a choice. New York: Hyperion; 2001.

5. Szasz TS. The myth of mental illness: Foundations of a theory of personal conduct (Revised Edition). New York: Harper and Row; 1974.

6. Nussbaum MC. The therapy of desire: Theory and practice in Hellenistic ethics. Princeton, N.J.: Princeton University Press; 1994.

7. Taylor C. A secular age. Cambridge, Mass: Harvard University Press; 2007.

8. Menninger KA. Whatever became of sin? New York: Hawthorn Books; 1973.

9. Allen JG. “Biomania: A protest.” SayNoToStigma.com. Houston: The Menninger Clinic; 2010.

A recent article in the New York Times entitled “Talk doesn’t pay, so psychiatry turns instead to drug therapy” has created quite a stir among my psychiatric colleagues, rightly so in my opinion.

Limited practice, limited help

Dr. Levin in a New York Times photograph

The Times reporter features a Pennsylvania psychiatrist, Donald Levin, MD, who contends that in order to sustain his income, he has been forced to limit his practice to 15-minute sessions in which he only prescribes and adjusts medications. Dr. Levin is quoted saying he had to train himself “not to get too interested” in his patients’ problems and that he now feels “like a good Volkswagen mechanic.” What a sad state of affairs, but one all too common in much of medicine today – just review the daily schedule of your primary care physician, and you’ll see the same breakneck pace of daily practice.

A comprehensive approach

Psychiatrists are physicians, and psychiatric disorders are complex medical illnesses. But psychiatrists are taught to try and understand the full scope of human behavior – not just the illness, but also the person who has the illness. Many patients need medication, and psychopharmacological knowledge and experience are crucial components of psychiatric treatment.

Evidence has taught us, however, that psychotherapy is not just random “talk therapy,” but, rather, an effective treatment for many psychiatric disorders, and a biological treatment at that, which can change the brain.  Psychiatrists are taught to look through a biopsychosocial lens to understand and treat patients, and to monitor the effectiveness of that treatment. The day I disregard the psychosocial part of the picture, or, to put it in the words of Dr. Levin, choose “not to get too interested” in my patients, is the day I should take down my shingle.

Editor’s note: Dr. Oldham is president-elect of the American Psychiatric Association. He is also the chief of staff and senior vice president of The Menninger Clinic and executive vice chair of the Menninger Department of Psychiatry & Behavioral Sciences at Baylor College of Medicine.

As a forensic psychiatrist who worked in a jail for ten years, sometimes evaluating murderers and on one occasion a mass murderer, I have often wondered what we can do to mitigate or prevent disasters such as the tragedy that just occurred in Tucson.

I can think of no better answer than the letter written in a recent issue of the New York Times by a federal judge who is professionally experienced in the aftereffects of violence. His words speak both to the nature of the problem, and implicitly to our responsibility as psychiatric professionals. Here’s his letter:

To the Editor:

I disagree with the premise that attackers almost never telegraph their intentions ahead of time (“Real Threats Are Said to Rarely Give Warning,” news article, Jan. 12).

Reports that Jared L. Loughner’s bizarre behaviors were known to law enforcement, schoolmates, friends and, perhaps, his family should have raised a red flag that some form of intervention was appropriate before the attack on Representative Gabrielle Giffords.

I almost never had a child abuse case in Family Court that did not involve antecedents such as excessive absences from school, violence in the home or prior contacts with child welfare officials. Similarly, federal crimes are rarely spontaneous and may well be predictable, if not always preventable.

The challenge lies in connecting the dots and implementing appropriate measures before tragedy occurs, including raising public awareness about how to identify dangerous behaviors.

Richard M. Berman
New York, Jan. 12, 2011

Editor’s note: for more on the tragedy in Arizona, check out:

• To stop violence, we must start with ourselves
• Thoughts on a tragedy, with help from Jon Stewart and Dr. Walt Menninger
• Giffords shooting calls for measured, rational response

As it says in my bio, I like to read; it’s one of the few hobbies having a 2-year-old allows me to keep up with. Aside from traditional works of fiction and non-fiction (and the nigh constant Sandra Boynton books), I read a lot of comics (a genre that deserves its own de-stigmatizing blog if there ever was one) and, since this is a hobby I quite enjoy and therefore take seriously, I keep up with several comics related websites.

Thanks to this obsession healthy interest, I came across a post, Batman vs. Psychiatry, which discusses various Batman foes who also happen to be psychiatrists (and psychologists, but I’ll use the former as a catch-all for this post). It’s an interesting topic that I wish I had thought of first. Instead, the author is responding to a question posed by an 8-year-old girl. (If this is the kind of thinking they’re teaching in grade schools, I am no longer worried about future generations.)

Batman as society

If you’re wondering why this topic is worthy of a blog post, it’s probably because you:

1. don’t read comics,
2. think they’re for kids and
3. don’t care who Batman fights on a monthly basis.

To this I would reply:

1. you’re missing some great stories
2. they’re actually aimed at adults these days and
3. how could you not care?

Batman is the most popular superhero in the United States in a time when superheroes are in the mainstream.  The Dark Knight made over $1 billion worldwide, and you and I both know you saw it and enjoyed it. No one would much care if this was Aquaman’s rogues gallery, but this is Batman we’re talking about. Batman looks at all those Chuck Norris facts and thinks, “That sounds like a lazy Sunday afternoon.”

The super villains we read about in comics and see in movies are often portrayed as “crazy,” right? Lex Luthor is a narcissist and a xenophobe. The Green Goblin had a psychotic break and (in the movie) developed a second personality after being exposed to super-steroids (or something like that). The same goes for Harvey Dent/Two Face after his fiancee was killed and half his face burned off. The Abomination (the monster the Hulk fought in his most recent (and underrated) movie) is the id unleashed. The Joker…I honestly have no idea what he has.

It had never occurred to me that so many comic book villains came from the world of mental health. Of course, fiction likes to pick on scientists in general; we wouldn’t have the Hulk, the Fantastic Four, Spider-man or Captain America if it weren’t for a scientist making a mistake. Until I read Batman vs. Psychiatry, I hadn’t given the psychiatrist angle much thought.

Batman’s shrinks?

Scarecrow

Scarecrow: His look in the comics changes constantly, but you’ll recognize him from this picture (unless you’re one of the 26 people who hasn’t seen Batman Begins or The Dark Knight). Dr. Jonathan Crane was so obsessed with the psychology of fear that he created a chemical gas that makes his victims experience their worst nightmares. He uses it to get whatever he wants, and then usually gets punched out by Batman because, after all, he’s just a skinny, nerdy dude in a homemade scarecrow costume.

Harley Quinn

Harley Quinn: Dr. Harleen Quinzel was a criminal psychiatrist working at Arkham Asylum when she was tasked with treating the Joker. She fell in love with him and became his psychotic sidekick. (Clearly, the employee screening process at Arkham is less than rigorous.) Unlike Scarecrow, she doesn’t really use her psychiatric training to commit crimes. Instead, she prefers to use old-fashioned violence.

Hugo Strange

Hugo Strange: While he’s not a character a lot of people know about, Dr. Hugo Strange is an important figure in Batman’s story. Strange predates the Joker and Catwoman, and was one of the first bad guys to deduce that Batman and Bruce Wayne were one and the same. Obviously, the only thing the good doctor could do with that info was to try and kill Batman so Strange could take his place. That makes sense, right? I believe Strange is dead in the comic world, so this plan worked about as well as you’d expect.

Arkham hallway

Arkham Asylum itself is more than a little problematic. It can’t seem to keep the criminally insane behind bars and sees more breakouts than a dermatologist. Second, the Arkham family was probably not the best clan to start a psychiatric hospital. Founder Amadeus Arkham murdered a man and was subsequently committed to his own hospital. Dr. Jeremiah Arkham, the most recent administrator, recently adopted a supervillain persona himself (and was of course then punched out by Batman).

On top of the dubious family tree, the institution itself is always drawn to look like a straight-up prison. Metal bars on the windows, steel cages around the nurses station and every other prison stereotype you can think of has been drawn into Arkham Asylum. Take a look at a couple of screenshots of the recent video game Batman: Arkham Asylum to see what I mean. A place like this couldn’t rehabilitate a jaywalker.

Batman: Arkham Asylum won several Game of the Year awards and has been hailed as the best superhero video game ever. A toy company is releasing action figures based on the game, and a sequel is already in the works. Hundreds of thousands of game players now think this is what a mental hospital looks like. 

The points made in the article linked to earlier are good ones (Batman’s whole deal is to intimidate bad guys using psychology, his world is a good place to tell stories with a psychological bent, etc.) so I encourage you to give it a quick read. I could go on and point out more evil psychiatrists, but that’d be even more self-indulgent.

But what does this mean?

I bring all this up because I can’t help but think there’s something deeper at play here. There’s a reason why there are so few good examples of psychiatrists in popular escapist fiction, and so many bad examples to point to.

I think we’re scared of psychiatrists in a way that’s different from the way we’re scared of dentists.

We know the physical pain caused by someone rooting around in our mouths will eventually fade. We’ll leave feeling bad about not flossing or relieved because we don’t have to sit through another exam for six months or so but, unless we have seven cavities or something, there aren’t a lot of lasting effects.

We can’t say the same if we give someone else access to our minds. We’re vulnerable when we see a psychiatrist in a much different, much scarier way than at any other time.

At the dentist, we open our mouths.  At the psychiatrist, we open ourselves.

And that’s terrifying.

It doesn’t matter that we learn skills to help us function better. It doesn’t matter that psychiatrists help us understand ourselves and why we behave or think the way we do.  It doesn’t matter that we know how much psychiatrists can help us. In the end, we’re simply projecting our self-doubt, our fear that we’re not good people on the inside, onto the very people who can help us.

So Batman stands in for his readers, punching out doubt and fear in the guises of a scarecrow or a dude with a creepy smile and a sweet beard. Unfortunately, these “victories” over psychiatrists aren’t always satisfying because, while the external foe is vanquished, the internal villain persists.

Because there’s only person who can really beat Batman, and that’s Batman himself.