Boris Vatel, MD

In Russian, the word “friend” has a more intimate meaning than other words used for people we know personally. There are acquaintances, there are comrades, and then there are 

. Of the latter it is said, “A friend is someone with whom you have eaten a pound of salt,” meaning that it is a person who has been with you through thick and thin. I often think of this meaning of the word “friend” when someone mentions that so-and-so is his “friend on Facebook.”

The social media phenomenon has become very popular in the past decade, and it has brought about a new way of relating to others. Social media services such as Facebook and Twitter allow simultaneous communication with multiple people, a kind of communication that is rarely possible in physical circumstances-after all, it is not every day one finds himself a speaker in front of a crowd of listeners.

[[{"type":"media","view_mode":"media_crop","fid":"27774","attributes":{"alt":"Friends on social media","class":"media-image","id":"media_crop_6083887428017","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2745","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"width: 200px; height: 203px; float : right","title":" Â©JSlavy/Shutterstock","typeof":"foaf:Image"}}]]It has been suggested that psychiatrists should embrace social media as a “

new and exponentially growing form of communication

 However, rather than encouraging social media use, a closer look at this form of communication suggests that there are many good reasons to stay away from social networking, both personally and professionally.

For most of our history, contact and relationships between human beings have involved physical proximity. Although remote communication such as letter writing has existed for thousands of years, it was understood to have a secondary role to that of communicating in person. Under conditions of physical proximity, communicating with others has necessarily involved the use of special senses: sight, hearing, touch, and smell.

Indeed, the degree of intimacy between people may be said to reflect how many special senses they use when they are together. How close people feel to one another may determine the physical distance between them when they get together, how loudly or softly they speak, whether they make physical contact, etc. In how we consciously or unconsciously manipulate these aspects of communication, we necessarily discriminate between people, establish degrees of specialness, and declare how private or public the relationship is.

Letter writing was traditionally a form of communication that existed in parallel to-but not as a replacement for-a physical relationship. In addition to conveying informa-tion for its own sake, a handwritten letter necessarily bore a unique imprint of the individual writing it. As a physical object with some permanence, it could be made particularly personal or unique in any number of ways. Letters took on scents; bore the stains of tears or spilled ink; and often contained other physical mementos, such as a lock of hair.

In the early 20th century, communication by telephone became possible, and by the middle of the century, most households in developed countries possessed a telephone. Technical matters and cost considerations meant that for at least the first 50 years or so after the invention of the telephone, this device was used to communicate with those who were not a great distance away and for short periods of time.

Even though several households may have shared the same “party line,” telephone conversations were generally understood to take place between two individuals and were, in principle, if not always in practice, a private matter for them. Private telephones were to be found in private spaces, such as homes, whereas public telephones in the community were protected by the confines of a booth that ensured privacy from within and shelter from the noise without.

Individual advice, counseling, or treatment needs to take place in the framework of a face-to-face clinical encounter. In turn, physicians who have a need to make a public statement can do so in any number of ways that do not involve social media.

As telephone communication became less expensive, more accessible, and finally available in the portable form of cellular phones, people started spending more time using it. A curious phenomenon began to take place. Although the two-way nature of conversation continued, the portable nature of cellular telephones has resulted in a merging of a space that was previously considered private with a space that was clearly public.

Where once people separated themselves from others to speak on the telephone, they now began taking phone calls while surrounded by others. The person who chose to use the cell phone in the public space became a de facto public speaker who violated all rules of social conduct in that he addressed himself to no one who was actually present. In fact, an observation has been made that those who have cellular phone conversations in public resemble psychotic individuals responding to auditory hallucinations.

Whereas public cell phone behavior involves talking to one remote person while in the physical proximity of many, social media behavior involves communicating with many remote persons even when one may be physically alone. Both types of behavior occur in apparent ignorance of social rules in the physical world and rely on technology that makes such communication appear normal.

A social media relationship is different from a physical one in several important ways.

The virtual relationship requires that those who participate in it be consumers of a service that makes virtual relationships possible. One is a Facebook subscriber first and a person with “Facebook friends” second. It is those who design and maintain social networking sites who are ultimately in charge of such relationships; they set up parameters in which communication between users takes place and they are the long-term keepers of whatever information users choose to share on their sites. Virtual relationships are literally the property of someone who otherwise would have no part in them if such relationships were to happen in physical space. Moreover, while physical communication has always been a need common to all humans, one can be certain that social networking first and foremost fills the financial needs of its creators.

Because virtual relationships have no physical dimension, they are conditional and dependent on a number of factors that point out their artificial and fragile nature. Try having a Facebook relationship if you have no computer access, if the Internet service is down or unusually slow, if the power goes out, if your backup battery dies, or if one day Facebook is outlawed. The central question here: who is ultimately in control of such a relationship? Does it arise organically between individuals who are free to structure it the way they see fit? Or does it depend on a complex system whose contingencies are ultimately maintained by and for the benefit of others?

Social media relationships take place on display, with the specific purpose of being seen by others. As a result of its intentional transparency, it lacks depth or character. In explaining why he does not use social media, someone recently said, “There is nothing I would want to say to anybody that I would wish to say to everybody.”

Because social media postings are meant for multiple persons, they lose the individual character that face-to-face communication inherently possesses. In real-life situations that are bound by time and space, people cannot help but have unique and unrepeatable encounters with others. In contrast, communication structured along the lines of computer logic is inorganic and infinitely reproducible. This reproducibility applies also to the number of “friends” one may have on Facebook. No wonder a new lingo has to be invented for these things, such as “friending” someone or the awkward “like us.”

Social media relationships foster narcissism in ordinary individuals and encourage narcissistic hypertrophy in those who already possess cluster B traits. What better outlet for people obsessed with themselves than to talk about themselves, often in the most trivial ways imaginable, to as many people as possible? Having many “friends,” being accepted as a “friend” or contact, being mentioned in posts by others-all these appeal to the need to appear important before ourselves and others. Being liked or well regarded is a natural human tendency. However, while in the physical world an exaggeration of this tendency becomes highly visible and irritating to others, thereby providing a limiting influence, in the virtual world, it is encouraged and rewarded.

When people who find it difficult to negotiate human relationships enter a world of pseudo-relationships offered by social networking, they become even more prone to developing grandiosity as well as narcissistic injury. It is not a rarity to see patients whose psychiatric symptoms are exacerbated by reading something negative that someone posted about them on a social media site. How many disagreements, disputes, and misunderstandings have occurred as a result of these completely artificial and superficial communications via a computer monitor? Again, because virtual relationships do not involve physical proximity, people feel free to post comments on social media sites that they would never dare say to someone’s face.

The cure-if only a partial one-is to get out of social media and to start living a real life.

Social media relationships are intentionally public. It is difficult to see how such communication would be useful in the arena of psychiatric care, where what is communicated within the treatment is meant to be as confidential as possible. We communicate best with our patients on a face-to-face, individual basis. This allows for the appreciation of the patient’s unique circumstances as well as of nuances of communication on both sides of the treatment equation. If telephone interactions are not a substitute for direct communication with our patients, social media interactions are even less appropriate.

In terms of providing public education in very broad strokes, the Internet already contains numerous resources for those suffering from mental illness. Individual advice, counseling, or treatment needs to take place in the framework of a face-to-face clinical encounter. In turn, physicians who have a need to make a public statement can do so in any number of ways that do not involve social media, such as speaking in their local community, writing articles, and participating in educational campaigns.

Social media is not a habit we should encourage in our patients or embrace for ourselves without a good understanding of its many limitations. We could better spend our time developing good face-to-face communication skills, learning how to negotiate private as well as public space, and ultimately having genuine relationships with others. In the real world, we all need friends who are true to the meaning of that word, salt and all.

This article was originally posted on 7/29/2014 and has since been updated.

Dr Vatel is staff psychiatrist, Evansville State Hospital, Evansville, Indiana.

 Peek H. Social media: an opportunity for psychiatrists. Psychiatric Times. July 9, 2014. 

http://www.psychiatrictimes.com/blogs/couch-crisis/social-media-opportunity-psychiatrists

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People feel free to post comments on social media sites that they would never dare say to someone’s face. The cure, if only a partial one, is to get out of social media and to start living a real life. What is your opinion on this issue?

Social Media Use: A Closer Look at the Real Meaning of Friends

At a recent medical staff meeting, my colleagues and I had a lively discussion about a new dress code adopted by the agency we work for. In an effort to foster the professional appearance of the employees, several changes to the dress code were announced. Among these was prohibition of jeans, T-shirts, flip-flops, revealing clothing, and the like. One of our colleagues voiced a concern that the new dress code policies went against the spirit of “stigma reduction” in the sense that to make ourselves more approachable to our patients, we should avoid the sort of dress that might make us appear somehow superior to them. Indeed, as part of orientation training at our hospital, we were told that patients felt most at ease with staff members who dressed in the same style as they did. This idea has been implemented so well at our hospital that it is often very difficult to tell staff members from patients, hospital badges on the former and parkinsonism in the latter being at times the only distinguishing characteristics.

That approachability has something to do with familiarity is obvious. Opposites may attract, but people tend to gravitate to those who resemble them most. There is no great leap of logic in assuming that someone dressed in jeans, flip-flops, and a T-shirt may feel more comfortable around those similarly dressed than around a person wearing pressed khakis, oxfords, and a button-down shirt. However, is our “dressing down” therapeutic for our patients? And, to what extent is our dress an accurate and honest reflection of our position?

In psychiatry circles, much has been said over the years about physicians’ paternalism and the stigmatization of mental illness and the mentally ill. From an insider’s point of view, it has been interesting to notice that many practitioners of a specialty that has struggled to be recognized as possessing legitimate medical expertise have also felt very uncomfortable with the authority implied by the possession of such expertise. Somehow there is a subtle reluctance to admit that, at least in the field of medicine, the doctor knows more than the patient and is the expert in the area in which the patient is having trouble. I have wondered whether this phenomenon is not more pronounced in psychiatry than in other medical fields, such as surgery, where the difference between the knife wielding doctor and the unconscious patient is rather harder to ignore. That there are doctors and there are patients implies that somewhere there is a line between health and illness. That those who are ill want to get rid of what is bothering them also implies that what ails them is not a desirable thing to have. Although it seems self-evident that people do not like to be ill, the notion that illness is not desirable and that some illnesses are less desirable than others has come to be known as stigma against those conditions. At the same time, there exists the notion that we ought to spare the feelings of those suffering from undesirable conditions. Since even in an effort at feeling-sparing no one could sensibly argue that such undesirable conditions are actually desirable, it has been argued instead that people with undesirable conditions are just like people without those conditions, or putting it only slightly differently, that the line dividing patients from doctors is illusory. Dressing down, it turns out, is one way of blurring the distinction between patients and those who treat them.

The relationship between the doctor and the patient is inherently unequal. Although in psychiatry this inequality is most pronounced in settings in which the patient undergoes involuntary treatment, it exists in the most voluntary of arrangements. After all, the doctor is assumed to possess some skill or expertise that the patient lacks and is in need of. The doctor is in need of getting paid, but outside private practice settings, the reimbursement comes from a source other than the patient and this reduces the doctor’s need for a particular patient. The patient’s needs, expectations, and hopes are directed toward the physician to a much greater extent and for reasons quite different from those running in the other direction. The relationship is unequal from the start and by its very nature. This fact can hardly be disputed, but there has been no shortage of attempts to minimize it or at least to pretend to do so. Before we deny or minimize the obvious, it would behoove us to ask whom this benefits and whether we can do so while maintaining integrity and honesty toward the very patients whom we are trying to help.

Since the inequality in this type of relationship results from there being a particular kind of expertise on one side and not the other, there are only so many ways of changing the situation. One is to pretend that the patient possesses medical expertise and the other is to pretend that the doctor does not possess it. Neither works very well in practice. The former approach amounts to nonsense because it is always the patient, regardless of how well educated he may be, who comes to and pays the doctor and not the other way around. The latter approach may work in a round-about way when we place the initiative for seeking care and the responsibility for following medical advice on the patient’s shoulders. It is one way of saying that it is the patient who ultimately determines what happens in the treatment. However, this approach does not work in the many involuntary settings in psychiatry in which the patient has little choice in the treatment ordered by the doctor. Since attempts at equalizing expertise do not work, there remains only one approach at leveling the field: to minimize the difference in how things look on the surface of the treatment dyad or, to get back to the original topic of dress codes, for the doctor to dress down.

Assuming that it is not the doctor’s expressed preference to wear jeans to work, whom do we fool when we don them in order to make things appear more equal on the two sides of the treatment relationship? Are we really fooling our patients to whom we give prescriptions and administer injections and whom we lock behind the doors to which we and not they have the keys? Is the jeans-wearing physician really perceived as less authoritarian when he gives testimony that convinces a judge to commit the patient to involuntary treatment? When we try to act as if we do not possess the authority that we in fact possess not only by virtue of expertise but also by law, I am afraid we do so only to soothe ourselves. The patient who may think we are “cool” for dressing as he does will see us for who we really are the moment we use our expertise and authority to contradict him or to insist that he must follow this or that treatment regimen.

Dressing down does nothing for the so-called stigma against mental illness if by that term we mean the notion that it is not desirable to be mentally ill. We can dress as casually as possible and act like pals with our patients, but that will not change the fact that we would not want to trade places with them. And until we feel ready to trade places with our patients we cannot in all honesty deny that an illness, and mental illness particularly, engenders a certain attitude toward those who have it from those who do not. We can pretend by using superficial means that there is no difference between our patients and ourselves, but this pretense will only take us and them so far.

I would argue that ignoring or disavowing the inequality in the relationship with our patients is neither honest nor therapeutic. Our patients, at least those who want the treatment, come to us precisely for the sake of the very thing that lies at the heart of the inequality, that is for the knowledge and expertise that we are supposed to possess. Patients interested in getting better want physicians who are experts in their fields and they accept the authority issuing from a doctor as acting in the interests of their own good. Any idea can be distorted to such extremes that it becomes untenable, and I am not advocating extending one’s authority so as to bully one’s patients or to condescend to them. All doctors sooner or later themselves become patients. Thus, we must never forget that “there, but for the grace of God, go I." This attitude ought to give rise to humility as regards our own fragility and to compassion toward our patients. However, the spirit of this attitude is distorted greatly when we try to pretend to our patients and to ourselves that there is equality in the relationship because we dress alike. This is a false notion that confuses the most superficial aspect of the relationship between the doctor and the patient with what is lying at the very core of the issue. If we act with authority appropriate to our expertise and rooted in compassion and humility, our patients will benefit from the relationship and we will remain honest with them and with ourselves. If we do not, wearing jeans will not help.

Dr Vatel is a Staff Psychiatrist at Evansville State Hospital and Lecturer in the department of psychology at the University of Evansville, in Evansville, Ind.

There is a subtle reluctance to admit that, at least in the field of medicine, the doctor knows more than the patient and is the expert in the area in which the patient is having trouble.

On the Pretense of Dressing Down

I found out about the death of Dr Thomas Szasz from a former student of mine whom I introduced to Dr Szasz’s writings during her college seminar with me last spring. I thought it ironic but appropriate that a student should be bringing this news to her teacher, rather than the other way around. That at least one young person from that small class of 15 learned enough about Dr Szasz to take notice of his death means that he will be remembered for a while longer. With most of us destined for oblivion within a generation, this may be something.

It would not be overstating matters to say that during his long career, Dr Szasz has been one of the most controversial figures in the psychiatric profession. Since the original publication of his book, 

 he has aroused a great deal of passionate debate within and outside the profession, along the way gathering many more critics than sympathizers. As someone with rather categorical and uncompromising views, he provoked similar responses in his audience. Hardly anyone familiar with Dr Szasz-and the number of those who are is likely dwindling-carries a dispassionate view of his beliefs. To the end Dr Szasz defended his ideas with an unbending will, but with the passing of the years, his message has appealed to fewer and fewer psychiatric practitioners. In a way he outlived his own teachings and died a person of apparently little relevance to most contemporary psychiatrists.

Even to those who cared to listen to him, Dr Szasz was an enigma. He called himself a psychiatrist and yet stated explicitly and unyieldingly that he believed neither in psychiatric illness nor in the legitimacy of psychiatry as a medical specialty. In his own books, Dr Szasz compared himself with “a theologian who does not believe in God.” As a hired psychiatric expert witness at the trial of Darlin June Cromer, he refused to examine the defendant on the grounds that a psychiatric examination could yield no useful information because no such thing as mental illness existed. He challenged all of us who practice psychiatry as MD’s not to practice better, or more cautiously, or more humbly; he challenged us to surrender our very identities as medical practitioners-ironically, without giving up his own public persona as a psychiatrist.

Dr Szasz hit many psychiatrists where they were most vulnerable. Having spent years proving that one was no less a physician than an internist or a surgeon, hearing Dr Szasz deny one’s professional identity was insulting, to say the least. At a time when much psychiatric practice consisted of psychoanalysis or analytic psychotherapy, Dr Szasz’s beliefs may not have aroused such a strong reaction. However, as the field changed into one built on a medical model and standing on an avowed biological basis, Dr Szasz’s claims that psychiatry was not a legitimate medical specialty became especially charged. Still as time passed, Dr Szasz’s voice appeared to be of one crying in the wilderness, eventually drowned out amidst the loud campaigns for public awareness of mental illness and the successful marketing of medications that became the most widely consumed in the history of pharmaceuticals.

And yet, if we put away the sense of being betrayed by one of our own, if we look past his transparent polemics, if we avoid mirroring the rigidity of his views, can we find something of value in what Dr Szasz had to say? A related question is whether we can put aside the sense of being always right long enough to examine the possibility of being sometimes wrong? I suggest that despite his many weaknesses, Dr Szasz asked the kind of questions that should be borne in mind not only by practicing psychiatrists but also by anyone in a position to help those with mental discomfort. What are our definitions of mental illness and mental health? How do we distinguish ordinary human suffering from pathological mental phenomena? What is the legitimacy of coercive treatment? To what extent is the patient responsible for his predicament? Who benefits when problems in living begin to be seen as illnesses requiring treatment?

In addition, Dr Szasz reminds us that to date psychiatry has not been able to escape the subject-object predicament. Whereas non-psychiatric specialties focus on observable lesions of the body, the object of psychiatric inquiry is the internal experience of the patient, something for which no reliable and patient-specific biological correlate has been found. Like it or not, that we deal primarily with the internal experience of human beings makes psychiatry more related to philosophy than to neurology. This is a far cry from Dr Szasz’s conclusion that the internal experience, by virtue of being subjective, cannot be diseased. However, it also makes patently false the claim that current psychiatric diagnosis stands on the same footing with diagnosis in other medical specialties. One important difference is that a medical diagnosis can be made in an asymptomatic patient or in one who is dead. Dementias and other organic illness aside, no “functional” psychiatric illness such as bipolar disorder, major depression, or schizophrenia was ever diagnosed on autopsy. Although there are some medical disorders such as epilepsy that can only be diagnosed in a living person, such examples are exceptions in non-psychiatric medicine but the rule in psychiatry.

We do not have to agree with all of Dr Szasz’s conclusions to profit from his inquiry into our field. After all, he, too, was only human-sometimes right, and sometimes wrong. His lasting legacy and value to the field lie in examining the very foundation of what we believe as psychiatrists. Without placing these philosophical building blocks on more or less firm ground and without noticing where cracks between them still remain, the structure we erect will crumble easily. Whereas Dr Szasz concluded that there was no emperor, we may insist that one exists while admitting that he may sometimes be found without his clothes. This will, at least, be an honest start to clothing him appropriately at all times. Rest in peace, Dr Szasz.

The Myth of Mental Illness: Foundations of a Theory of Personal Conduct.

It would not be overstating matters to say that during his long career, Dr Thomas Szasz has been one of the most controversial figures in the psychiatric profession.

Author | Boris Vatel, MD

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