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Obama’s Condolence Problem

Posted on December 23, 2009
Filed Under political commentary | 185 Comments

Note: the following Op/Ed piece was published in The New York Times
on 12 December 2009

THE recent revelation that the families of service members who are
suicides do not receive presidential condolence letters created a stir,
evoking questions of fairness and raising concerns about a lack of
compassion from our leaders.

Yet the issue is far more complicated than that. Indeed, there is nothing
wrong with stigmatizing suicide while doing everything possible to
de-stigmatize the help soldiers need in dealing with post-traumatic stress
and suicidal thoughts.

The key question is to what extent any action we take after a suicide
inadvertently glorifies it. Early Christians realized that they were
losing too many believers to the attractions of martyrdom. A halt to this
epidemic of provoking martyrdom by suicide was brought about in the fourth
century when St. Augustine codified the church’s disapproval of suicide
and condemned the taking of one’s own life as a grievous sin.

Canonical law ultimately pushed civil law in too harsh a direction. Only
in 1961 did England repeal its law making suicide a crime. As late as 1974
in the United States, suicide was still considered a crime in eight
states.

Has the pendulum swung too far in the other direction? Now that first-rate
treatments for depression and post-traumatic stress have evolved and are
readily available, and people with emotional problems do not have to
suffer quietly, are we taking away the shame of suicide?

For more than 30 years, we in the mental-health field have been aware of
the prevalence of copycat suicides. Whenever the news of a well-known
figure killing himself hits the front pages, a significant bump in
suicides, reflecting copycat deaths, invariably follows in the next few
days. Strikingly, there is no corresponding decline in suicides in the
weeks after this bump — forcing us to conclude that the victims are
people who would not have otherwise killed themselves.

The hard truth is that any possible glorification of suicide — even
reports of suicide — make the taking of one’s life a more viable option.
If suicide appears to be a more reasonable way of handling life’s stresses
than seeking help, then suicide rates increase.

Certainly, a presidential condolence letter after one’s death is not
exactly the same encouragement for suicide as the purported Muslim promise
of a gift of 72 virgins after death. But the increasing number of suicides
in the military suggests that we need to find the right balance between
concern for the spouses, children and parents left behind, and any efforts
to prevent subsequent suicides in the military.

As a psychiatrist formerly working on college campuses, I, along with my
colleagues, was concerned with how we handled the funerals and aftermaths
of even accidental deaths of students. Compassion for those left behind
arose naturally; at the same time, we did not want to glorify the death to
a point that lonely, distressed students might consider death better than
life.

A difficult balancing act, to be sure. For people under 30, suicide is
highly correlated with impulsivity and suggestibility. Thus college
campuses and military installations, with their young populations, must be
particularly aware of the possibility of copycat suicides and the dangers
of a veneration of death.

President Obama, as commander in chief, has to balance the wishes of
families with the demands of public health. In light of the
condolence-letter controversy, the administration is appropriately
reviewing the policy that has been in place for at least 17 years — and
may indeed want to consider leaving it as it is. But as a country, let’s
focus our energies on doing everything we can to diminish inadvertent
incentives that might increase self-inflicted deaths.

Paul Steinberg, a former director of the counseling and
psychiatric service at Georgetown University, is a psychiatrist.

Psychiatrists, Express Thyselves

Posted on December 23, 2009
Filed Under mental health | 135 Comments

The one group that has been conspicuously absent from the discussion of the character and “psychodynamics” of Major Nidal Malik Hasan, the perpetrator of the massacre at Fort Hood, has been psychiatrists.  Not because we as a group have not wanted to speak up.  Unfortunately our ethical guidelines, in the form of the Goldwater Rule, do not allow us to speak up about individual cases without having professionally evaluated the person in question.  This rule is hopelessly outdated.

It’s time to get rid of the Goldwater Rule.  Because of this rule the people with the most knowledge and experience on psychological and emotional aspects of public figures have kept their mouths shut and their keyboards quiet for the past 44 years.

Pundits can weigh in, often quite astutely and sometimes absurdly, on the character and temperament of public figures with the help of information gathered by reporters. With Major Hasan having been a psychiatrist himself, his psychiatric colleagues have been able to provide significant background information about his interactions with fellow mental-health professionals and with his patients.  Ironically, practicing psychiatrists are the only people in the country who cannot provide commentary about what these pieces of information might mean.

The Goldwater Rule came into play after the 1964 Presidential election.  Earlier that year a national magazine sent out a survey to psychiatrists across the country asking them their opinion on the psychological health of Barry Goldwater, the Republican candidate for President running against Lyndon Johnson.  A large percentage of psychiatrists indicated that they considered Goldwater “crazy”.  After the election Goldwater sued the magazine and also sued the American Psychiatric Association, with his pointing out that no psychi-atrist could diagnose his psychological health without interviewing and examining him.

Goldwater won the case.  He was initially awarded all of one dollar in compensatory damages.  But he subsequently won punitive damages of $75,000, not an insignificant amount in 1965.  The Supreme Court decided against hearing the case although Justices Hugo Black and William O. Douglas, in an unusual challenge to the rest of the Court, made it clear that the case should indeed be heard and that the case had significant ramifications for the free expression of psychiatrists.

Nevertheless the American Psychiatric Association got spooked.  The psychiatric leadership issued the following dictum on medical ethics applicable to psychiatry – a dictum that still stands unchallenged today:

On occasion psychiatrists are asked for an opinion about an individual
who is in the light of public attention or who has disclosed information
about himself/herself through public media.  In such circumstances, a
psychiatrist may share with the public his or her expertise about psychiatric
issues in general.  However, it is unethical for a psychiatrist to offer a
professional opinion unless he or she has conducted an examination and
has been granted proper authorization for such a statement.

A helluva double-bind.  What self-respecting public figure, if still alive and well, would agree to go into the lion’s den of a psychiatric office to describe his inner life?  And what self-respecting psychiatrist would reveal intimate details of a public figure’s life without a clear-cut release of information – even long before the advent of HIPAA regulations in 2003?  No wonder that for the past 44 years psychiatrists and other mental health professionals have been strangely silent about the character and personalities of politicians, murderers, and others in the public eye.

Yet the world of media and politics has changed dramatically in the past four decades.  The public record has expanded exponentially.  We now may have TMI – too much information, about a person’s religious life, affairs, blow-jobs, drinking and drugging – all delivered in real-time, not coming out 30 or more years later as in the case of John F. Kennedy and other public figures from the 1960’s.

So, what can a reasonably thoughtful psychiatrist like myself say about Major Hasan and the killing spree?  We will obviously find out a great deal more about Hasan’s inner life if he takes the stand in his murder trial or if he is willing to be interviewed.  In the meantime, however, we can at least speculate about the profound impact of the death of his parents in 1998 and 2001, especially on a young man who appears to have been socially and sexually inhibited.

Death, or at least one’s first contact with the deaths of significant loved ones, can be a great debilitator and game-changer.  Death is something we never can quite make full sense of and master.

Virtually all of us come to some reconciliation with death without resorting to fundamentalist religious beliefs or any willingness to kill others.  In 2001, after the death of a second parent, however, Hasan may have started his first contact with a radical imam in northern Virginia.  There appears to be no question that ideas, initially meant to comfort and support him, led him to an act of unspeakable evil.  As John Maynard Keynes, the eminent economist, once pointed out, “. . . ideas. . . are more powerful than is commonly understood. . . it is ideas, not vested interests, which are dangerous for good or evil.”

As Marc Sageman, a psychiatrist and author of “Leaderless Jihad”, has noted, the prototypical Muslim terrorist in the 21st century is a highly educated man from a middle-class background who finds himself terribly alienated from the Western world he lives in, whether in western Europe or in the United States.  Like Muhammed Atta and now David Headley (aka Daood Gilani, now accused of plotting revenge against a Danish newspaper that published cartoons of the Prophet Muhammed), Major Hasan lived in two distinct worlds and ultimately gravitated toward the extremist Islamist world.

In what has been dubbed the “buddy theory” of terrorism, Sageman notes that fledgling terrorists make profound connections with fellow Muslims at mosques and elsewhere.  They feed off each other; and, out of a sense of loyalty and dedication to each other, they can end up committing heinous acts.  Hasan’s apparent connection with the Yemeni-American cleric Anwar al-Aulaqi helped resolve some of Hasan’s deep sense of alienation and provided a crucial incentive for Hasan to act on his beliefs.

Ah, the banality of evil.

Enough said.  We run the risk of spending too much time on the perpetrators of these mass killings, whether at Virginia Tech or at Fort Hood, than on the victims.  Bruno Bettelheim in a 1986 review of “The Nazi Doctors”, an otherwise excellent book by a fellow-psychiatrist Robert J. Lifton, may have said it  best, “Understanding fully may come close to forgiving.”  Bettelheim noted then that his own efforts to look at the Holocaust had pushed him to understand the psychology of the prisoners, not the psychology of the SS.

As far as I know, there are no other psychiatrists who have become killers, especially mass killers – despite the fictional villain Hannibal Lecter in “The Silence of the Lambs” and its sequel.  Fortunately we only have an “n” of one, in other words no way of coming up with a statistically significant way of understanding a psychiatrist who killed 13 people and injured dozens of others.  Please continue to visit your local friendly psychiatrist or mental-health professional, if need be.  And please – I say this to my profession as much as to the public at large – allow us psychiatrists to speak up about the character of victims and perpetrators, and other public figures as well.

Our Secrets and Our Passions

Posted on March 20, 2008
Filed Under mental health, political commentary | 90 Comments

spitzerIn his personal and political downfall from the call-girl scandal, former Governor Eliot Spitzer has provided some crucial lessons for all of us – male or female – to recognize and ponder. None of us is immune from learning from these lessons which include, to paraphrase an aphorism from Alcoholics Anonymous, “We and our relationships are only as sick as our secrets.” A certain kind of transparency is essential for any relationship to survive and flourish.

It is equally important for us to acknowledge how difficult it is for any of us to truly combine a sense of grounding in a relationship and, at the same time, a genuine sharing of passions. The so-called Madonna/whore complex applies almost equally to women as to men even though it may manifest itself somewhat differently in each gender.

On the public stage Spitzer joins a host of other leaders – former New Jersey Governor James E. McGreevey and former President Bill Clinton come immediately to mind – who have kept large secrets from their spouses. There seems to be no question that Mr. Spitzer was arranging his finances in such a way as to conceal his payments to the “prostitution ring,” the Emperor’s Club VIP. Presumably this concealment reflected an effort to conceal his sexual activities from his wife.

In light of the Spitzer public embarrassment, all of us may want to do some kind of inventory about the secrets we may be keeping from our partners. Admittedly our inner lives can be considered relatively sacred. No one should be forced to express his or her fantasies. In many instances our describing every one of our thoughts and feelings would potentially be downright cruel to our partners. The notion of “letting it all hang out” is a form of all-or-nothing thinking at its worst.

Actions are a different story. Hiring prostitutes (Spitzer), engaging in secret homosexual sex (McGreevey), getting secret blow-jobs from interns (Clinton) – these are the kinds of activities that should make us recognize that something is terribly amiss in our relationships. People from every conceivable social stratum, career path, and level of intelligence can engage in these activities, although they may never be outed in the public arena in the way that Spitzer and others have been.

When we recognize the extent of the secrecy in our lives, it is essential to get help, to recognize the extent of the “sickness” in our concealments. But to do so, we have to find some way to take away the shame, to take away what The Economist has recently called the “legalism and puritanism” that haunt our country and that, even in the 21st century, prevent people from getting the help they need.

How do we take away this shame? We do so by recognizing what a remarkable achievement it is for any of us to be in a relationship in which we feel both grounded and passionate. This achievement cannot be taken for granted: We all see plenty of relationships in which one or both partners feels grounded and nurtured whereas one or both experiences no sense of a sharing of passions, or vice versa.

Instead of being able to fully let ourselves go in a relationship, to open ourselves to both the grounding and the passion of a relationship, one can easily succumb to an almost unconscious fear that one will lose one’s identity – be overwhelmed and destroyed – in the midst of a committed relationship. In an unfortunate choice of metaphors, Sigmund Freud called this phenomenon “castration anxiety”. It has nothing to do with castration. Women are just as likely to experience this fear and this consequent compartmentalization of grounding and sharing of passions. A typical scenario might include a woman experiencing a sense of grounding with a nurturing and loving partner, indeed a “wonderful” husband and father while, at the same time, taking up with a dashing, irresponsible, and attractive guy whom she sees as a great passionate lover.

This compartmentalizing of two basic human needs – we all need grounding and we may tend to underestimate our need to share our passions – has its roots often in one’s growing up in a family in which one has had an overbearing or even abusive parent. In such an environment one can easily fear a loss of oneself, of one’s identity, that then carries over into our adult relationships. (Promiscuity can occasionally be associated with other conditions, such as one characterized by impulsiveness and a need for novelty and another condition associated with mania or a super-high energy state. None of these conditions appears to have been relevant in the cases of Mr. Spitzer, Mr. Clinton, or Mr. McGreevey).

By many accounts Mr. Spitzer “worshiped” his wife Silda. This worshipfulness can be a problem. How do you make love to a goddess on a pedestal, an earth mother who is all-giving to your children? How do you ask her to engage in what one of Mr. Spitzer’s prostitutes called “unsafe” sexual practices? No, these are activities reserved for one’s “whore,” not for one’s Madonna.

In the past week since the revelations about Mr. Spitzer, we have heard a plethora of silly things said about his relationship with prostitutes. Dr. Laura Schlesinger, a radio host, talked on the “Today” show of women “not treating them [their men] with the love and kindness and respect and attention they need.” Others have commented that leaders in government and business may be oversexed. Still others have wondered why a supremely intelligent man like Mr. Spitzer would do such a stupid thing.

Let’s get away from the blame and shame game. Cuckolded lovers need to stop blaming themselves for their partner’s indiscretions. The cuckolds themselves do not need to feel overwhelming shame about their indiscretions. They are not responsible for this susceptibility to losing their sense of identity; but they are very much responsible for getting help for this vulnerability.

In light of Mr. and Mrs. Spitzer’s troubles, we would all do well to take an accounting of the secrets in our relationships – and to take measure of where we are getting our grounding and where and with whom we are sharing our passions.

Surfing on the Waves of Reputation

Posted on March 6, 2008
Filed Under Uncategorized | 150 Comments

clemgrn.jpgOne of my wise Daoist friends used to point out that money is like water: It flows in and flows out, without our having as much control over it as we think we do. Recently I have begun to recognize that reputations are like water as well. They flow in and out. Just ask Roger Clemens and Alan Greenspan. They may have stayed on center-stage a bit too long.

Clemens was considered the best pitcher in baseball over the past two decades, a sure Hall-of-Famer until his reputation took a nosedive with the publication of the Mitchell Report which examined steroid use in baseball. Clemens was implicated as a steroid-user in the report; and he has been fighting hard to restore his reputation in the past few weeks in Congressional hearings and on television. In his effort to salvage his reputation, Clemens may have committed perjury during his Congressional testimony; and the Department of Justice may initiate an investigation of this possible perjury.

Greenspan was considered a financial god for his expertise in monetary policy and business cycles, for his managing the U.S. economy during his long tenure as Federal Reserve chief, through the administrations of four Presidents. His reputation has taken a major hit during the current lending crisis and economic downturn. His way of ushering the country through the bursting of the technology bubble and his heavy support for home ownership – his contributing to the present predicament of too many sellers and not enough buyers of homes and exotic loan instruments – have taken his image down more than a few notches. He is reportedly writing a book in an effort to restore his golden reputation.

Is it too much to ask ourselves to simply “go with the flow”, to use a phrase made famous by the novelist Ken Kesey and his Merry Pranksters? Quantum theory reminds us that waves can simultaneously be particles and particles can be waves. Perhaps instead of our seeing ourselves as tiny grains of sand, we can begin to see ourselves as particles that are simply part of a wave, part of an ebb and flow. All we can do is ride those waves – we are merely surfers in a sea of paradoxes and quantum fluctuations.

When our lives are going well, we tend to have the hubris to assume that our successes are simply a reflection of our extraordinary talents and intelligence. We tend to believe our press-clippings. When things go badly, we similarly have the hubris to assume that we deserve that fate as well. Recent medical research has shown that patients who believe that their disease is a punitive message from the gods have a poorer psychological and possibly physical recovery from serious illness.

The universe is fluid. Fixed mindsets – to use a term promulgated by Carol Dweck, a psychologist at Stanford – make no sense in this universe. Nothing is ever static, including reputations. We can never allow ourselves to see ourselves statically as gods or devils.

Earl Weaver, the former manager of the Baltimore Orioles, used to repeatedly point out that his team was never as good as it thought it was during a ten-game winning streak; nor was it as bad as it thought it was during a corresponding losing streak.

Clemens and Greenspan along with the rest of us are dealing with forces that we have no way of understanding. In his Epilogue to “War and Peace”, Leo Tolstoy (or his translator) describes these forces, in regards to Napoleon, as “chance, millions of chances”, all of which conspire and “collaborate” to give Napoleon unmitigated power and an “unbroken series of successes.” Then at some mysterious point the tide turns: “A succession of counter chances occur. . . and, instead of genius, stupidity and unprecedented baseness are displayed.”

So, we cannot blame the modern media for anyone’s fall from grace. Nor can we conclude that the media made the man in the first place. Roger Clemens was simply fortunate to live in an age in which throwing a ball fast and hard had unprecedented meaning and value. He also was unfortunate enough to reach the end of the prime of his career when various drugs became available and legally acceptable for potentially extending his career.

Likewise Alan Greenspan was fortunate enough to live in an age in which his “genius” in understanding monetary policy along with his energy and ambition could be heartily rewarded. At some point the bubble burst and a succession of counter chances occurred.

As human beings we would like to believe that we have significant control over the fluctuations in these chances and counter chances. Instead, given these flow-states, Roger Clemens and Alan Greenspan and the rest of us would be wise at times to follow the wisdom of Lao-Tse: “As for gain and loss, which is the more painful?. . .To know when you have enough is to be immune from disgrace.”

So, give it up, Roger; give it up, Alan. Just go with the flow.

Essay: The Hangover That Lasts

Posted on December 29, 2007
Filed Under Uncategorized | 103 Comments

BushKeep an eye out for my new essay, The Hangover That Lasts, appearing today in The New York Times Op/Ed Section. It concerns the long-term effects of past binge drinking and alcoholism on the decision making process. While I don’t mention any names, the implications of a recent study might just remind you of someone…

On the ABC news-program Nightline two weeks ago, George W. Bush acknowledged, while talking to a teenager in recovery from a drug or alcohol problem, that he himself had had a significant drinking problem, that his last drink was in 1986.  Ron Suskind in a book he wrote with the help of Paul O’Neill has talked about the efforts of the Bush extended family to get George W. sober in the 1980’s.  Billy Graham was summoned up to Kennebunkport; and Graham was instrumental in getting George W. to find religion and to become sober.

My article on 12/29/07 in the NY Times refers to the limitations of Mr. Bush, without specifically mentioning his name.  He is a bright, reasonably intelligent man, if not necessarily the most articulate.  Given the extent of his heavy binge drinking in young adulthood (Gary Trudeau has pointed out that, when at Yale, he and others counted on George W., then an upper-classman to get kegs for any parties), I think it is fair to say that George W. has had some of the inflammatory responses in his brain cells which I have described in the NY Times.  I can think of no better explanation for a reasonably intelligent man continuing to “stay the course” constantly in Iraq, on issues pertaining to Iran, especially when new data comes in on a regular basis.

Paul O’Neill reports that George W. often pointed out the the word “nuance” was and is his least favorite word.

Al Gore and The Assault on Reason

Posted on June 1, 2007
Filed Under political commentary | 254 Comments

GoreAlthough his answer ignores basic human psychology, Al Gore at least asks the essential questions for all of us to try to answer as he promotes his book The Assault on Reason in his country-wide book tour. Why did the American public not respond in any forceful way against the call for the Iraqi invasion in 2003 despite questionable motives for the war? In my own soul-searching, why did I, an inveterate protester against the Vietnam War in the 1960’s, feel at most ambivalent about the invasion of Iraq? Why did thoughtful commentators like Tom Friedman of the New York Times come out in support of the war despite significant reservations? The answer, my friends, lies in human nature, in a fundamental human drive “to turn passive into active” – to use the parlance of the mental health field.

The key provocation was 9/11. Never before, other than Pearl Harbor, had our country been attacked in this way – and certainly never before in the continental U.S. One feels totally helpless in response to this provocation. The average citizen does not have the tools to go after the perpetrators. We have a binary choice: submit to this helplessness and despair vs. take action. Scores of people descended on the World Trade Center site in a remarkable effort to find survivors, and ultimately to find the victims’ bodies, without necessarily using the best possible precautions to avoid lung damage and other hazards. The emphasis for all of us was on immediate action. Read more

Attention Surplus? Re-examining a Disorder

Posted on March 7, 2006
Filed Under mental health | 278 Comments

Note: this essay appeared in The New York Times Op/Ed Section on March 7, 2006

The recent recommendation that Ritalin and other medications for attention-deficit disorder carry the most serious allowable warning will certainly slow the explosive growth in the use of those drugs.

That was the intention of some members of the Food and Drug Administration advisory committee that called for the packaging alert, known as a black-box warning.

But the recommendation and concerns about growth in the use of these drugs may force us to think about the disorder, known as A.D.H.D., in new and different ways, from an evolutionary and contextual standpoint.

Every generation likes to believe that it is witnessing the most dramatic epoch in history. In the case of the current Western world, that belief may indeed be accurate, particularly in light of the striking changes of the last 30 years.

As the business writer and consultant Peter Drucker pointed out, most people in the United States, Japan and parts of Europe are “knowledge workers.” We live in an information age, in a knowledge-based economy.

For those of us who have “attention-surplus disorder” — a term coined by Dr. Ned Hallowell, a psychiatrist in Boston who has A.D.H.D. — this knowledge-based economy has been a godsend. We thrive. Read more

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