James L. Knoll IV, MD

interview with James L. Knoll IV, MD. In the first half of the conversation, Knoll discussed the challenges of treating patients with traits like psychopathy or 

Forensic psychiatrists have emotionally taxing jobs: They spend countless hours studying acts of violence and the individuals who commit them. How could anyone endure this job for more than a few years?

James L. Knoll IV, MD, has survived decades in the field. In this edition of 

, Knoll talks about how he maintains his mental well-being. He also reveals the childhood obsession that set him on his career path, reflects on how forensic psychiatry has changed over time, and looks forward to how it might change for the better in the future.

His childhood fascination with the Jonestown murder-suicide.

How he got interested in forensic psychiatry.

The risk of burnout in forensic psychiatry (or any other psychiatric specialty).

How the arts and other creative endeavors can help psychiatrists stay mentally and physically well.

The tension at the heart of the forensic psychiatrist’s identity: are they primarily treaters of mental illnesses, or expert witnesses?

The new importance of social media for forensic investigations.

Why it’s important not to judge patients—no matter how difficult they may be.

is professor of psychiatry and director of forensic psychiatry at SUNY Upstate Medical University in Syracuse, New York, and clinical director of Central New York Psychiatric Center in Marcy, New York. He is Emeritus Editor-in-Chief of the 

 and President-elect of the American Academy of Psychiatry and the Law (2022-23).

Podcasts

Forensic psychiatry is not for everyone, but looking back on his life and illustrious career, James L. Knoll IV, MD, realizes that he was destined to study crime. 

A Forensic Psychiatrist Takes the Stand

Psychiatrists are not strangers to difficult and even potentially dangerous patients, but James L. Knoll IV, MD, has made these populations one of his specialties. With decades of experience in forensic psychiatry, Knoll takes listeners deep into the US criminal justice system, where he treats both inmates suffering from detention-related psychiatric disorders and an especially challenging group that he has dubbed 

How prisons’ strict social hierarchies can contribute to psychiatric illnesses.

The high prevalence of bipolar disorder and schizophrenia in corrections—and their potential causes.

The different challenges of treating patients in prisons vs jails.

Why inmates with psychiatric illnesses end up in the correctional system for longer than those without psychiatric illnesses.

The role of mental health courts in improving psychiatric care in the correctional system.

The challenges of treating patients who are high in psychopathy or have anti-social personality disorders.

, in which Knoll talks about how he first became interested in forensic psychiatry (at age 10). 

James L. Knoll IV, MD, shares insights from his decades in forensic psychiatry, where he has treated some of the criminal justice system’s most difficult and dangerous patients. 

Treating ‘Morally Objectionable’ Patients

, I find my thoughts returning to the topics of death, terror, and the absurd.

 Now this anniversary must be considered alongside the pandemic. As the pandemic began to unfold, I became curious about 

, particularly as viewed through the lens of Terror Management Theory (TMT).

 Briefly, TMT posits that our awareness of death’s inevitability creates an existential crisis and desperate need for self-preservation. TMT has shown that affirming one’s worldview, self-esteem, and close relationships may help maintain psychological well-being by buffering death-related thoughts and providing outlets for symbolic immortality.

One of the most unsettling aspects of the pandemic has been the amount of uncertainty surrounding it. The pandemic has surprised and confused us because we are watching it all unfold in real time: Variants arise, and medical decision-making requires continuous flexibility and updating.

It seems intuitive that the COVID-19 pandemic would significantly affect global mental health.

 However, since all this is developing contemporaneously, it is difficult to be certain. We are left to infer that children and adolescents are probably more likely to be vulnerable to depression and anxiety during and after isolation ends.

 Yet a recent review and meta-analysis found that the“psychological impact of COVID-19 lockdowns is small in magnitude and highly heterogeneous.”

 How can this be? Any amount of time spent watching news media assures us that social unrest, ideological division, and urban violence have been escalating. Frequency and magnitude aside, there can be no denying such remarkable events as the 

, economic damages, and multiple protests across the country. We have witnessed a cooccurrence of pandemic and social upheaval that has produced a continuous outpouring of terrifying messages. If TMT has informed us of anything, it is that when death terror increases, society reaches out for the familiar, the safe, and the protective.

A reasonable estimation at the current time is that there are “widely varying ways in which people have responded to the COVID-19 pandemic.”

 But it is the general commonalities of response I would like to address, and for which TMT has relevant explanations. For 35 years, TMT research has suggested that individuals employ both 

defenses in response to death terror. Proximal defenses are used for death thoughts that are the conscious subject of current attention. Such defenses include suppression, denial, and behaviors designed to reduce vulnerability. Current-day examples might include trivializing the impact of the virus, or even denying its existence. Proximal behaviors of greater utility might include employing social distancing, hand-washing, and mask-wearing. In contrast, the distal defenses are unconscious and/or on the periphery of consciousness. Distal defenses are focused on maintaining faith in one’s worldview, enhancing self-esteem, and finding outlets for symbolic immortality. A present-day example might include adopting a strikingly polarized, ideological narrative about the virus—as can be currently seen in the absurd, almost comical, political polarization of the pandemic.

A common challenge in the face of tragedy and death terror is the tension between these proximal and distal defenses. Post 9/11, the tension was between securing air travel and national security (proximal defenses) and our ability to freely travel and visit loved ones (distal defense interruption). During COVID-19, the 

tension has been between masking and vaccination

 (proximal defenses) and social distancing (distal defense interruption). Thus, the tension between fears of a deadly virus and the desire to reopen the economy and have a normal life produces a situation in which “[p]roximally, we want to forestall death and feel safe from it in the short term… [and] distally, we want to maintain the view that life is meaningful and that we are valuable contributors to that meaningful life.”

 In the case of strong and persisting death terror, efforts to keep safe in the moment may interfere with efforts to find meaning and significance in the future.

This death terror tension places us in a precarious situation. Consider the aftermath of the 9/11 response: For the first time in history, all nonemergency airflight in the United States was immediately grounded, leaving virtually all citizens without freedom of travel to see family. Further, the 9/11 attacks precipitated the invasion of Afghanistan, which in turn became the United States’ longest and most expensive war. To say that 9/11 and its aftermath impacted civil liberties, privacy, and freedom would be an understatement. A similar death terror tension can be seen during the COVID-19 pandemic, where large social gatherings (concerts, protests, political rallies, etc) have directly put large numbers of individuals in danger of disease. In such situations, the need for meaningful social interaction and/or symbolic immortality has the paradoxical effect of increasing risk of death. When faced with a conflict of extremes, finding a middle path or compromise is often a reasonable option.

Whenever tragedy strikes and produces a no-win situation, as it often does, I am always reminded of the masterpiece play written by Nobel laureate Samuel Beckett titled 

. It is an existentialist-absurdist play about the will to survive in the face of deep despair and meaninglessness. The play, which premiered in 1957 at London’s Royal Court Theatre, “portrays a universe which is nearing its end but which could continue repeating itself; the end which all seem to be moving toward is both certain and elusive.”

 The setting is suggestive of a post- apocalyptic scenario in which the characters “pass the time mortifying each other and toying with fears and illusions of a possible change, all along sensing the inevitability of their end.”8 The entire play takes place in a partially underground room for the 4 characters: Hamm (the master), Clov (the servant), and Nagg and Nell (Hamm’s father and mother). Hamm is in a wheelchair and orders Clov around the room and to look out the window for signs of life. But outside, there appears to be no such signs—nothing, in fact, but gray skies.

 and both 9/11 and recent circumstances. To start, the characters stay in a single, bleak room and are left to face “isolation, claustrophobia, loss, nostalgia, and an extremely tight and structured repetitive form.”

 Much of Beckett’s work contains similar themes (eg, 

). This was because Beckett, who was deeply affected by WWII, developed the belief that “life itself is absurd, and this incurs reactions of both black mirth and profound despair.”

, the character Hamm states, “You’re on Earth, there’s no cure for that!” Beckett does not attempt to deny or soften his message that “human existence is characterized by suffering, decay, and isolation as we crawl towards death.”

 Yet despite the pain, monotony, and absurdity, it can be argued that Endgame’s overarching message is positive. The play’s existential slow burn ultimately leaves us with compassion for the human condition. Despite the characters’ awareness of the absurdity and meaninglessness of human life, they persevere with attempts to construct meaning through language and imagination. One interpretation of Beckett’s message is: 

In the midst of negation, I revolt – and I do this by creating meaning. I laugh when I can, accept what I must, and persevere to the best of my ability.

 This is the same sentiment Camus demonstrates when he wrote the 

 and imagined him happy: “The struggle itself… is enough to fill a man’s heart.”

In a sense, death-denying cognitions are a form of a wish. Held up to the light of day, this wish is for nothing other than a compensatory sense of triumph over reality. But of course, reality cannot be overcome, and to maintain such a stance toward life is to increase one’s suffering. The fact that we spend so much energy denying this truth must ultimately lead us down the road of compassion. It is perhaps one of our biggest challenges as a species and has been so for most of recorded history. The ancient Japanese described the challenge wisely and poetically: “There is a saying of the elders that goes, ‘Step from under the eaves and you’re a dead man. Leave the gate and the enemy is waiting.’ This is not a matter of being careful. It is to consider oneself as dead beforehand.”

 In other words, the end was built in as soon as we entered consciousness. Surrendering to and accepting the 

 means freedom, and a corresponding diminution of excessive ego. In contrast, too strong a denial of death results in a pervasive unawareness, particularly with one’s connectedness with others and the whole of life.

What lessons might incomprehensible tragedies like 9/11 or pandemics have for us when our death-denying maneuvers have exhausted themselves and our defenses have been rendered ineffective? The lessons of psychology, philosophy and human nature suggest we might consider these 3 antidotes: compassion, compromise, and creativity.

Compassion is not weakness, nor is it passive. Rather, it is emotionally challenging, daring, and life-altering. Certainly, when we practice compassion, we can expect to experience fear and pain. Our conscious existence is a series of plays put on by characters and voices in our heads, and this is the same for everyone until the end. This alone is cause for compassion. Compassion for the human condition teaches us to relax and move gently toward our fears. The benefits accrue when we slowly relinquish our hardened aversion to mortality and allow our fear to increase our flexibility.

Compromise should be familiar to psychiatrists and psychoanalysts. Life requires continuous compromise, as the pandemic has taught us. The compromises may be practical and concrete, such as using telemedicine or wearing masks in public. Or the compromises may be less discernable—such as intrapsychic or existential compromises. For example, we may know that we have only so many years left (if lucky) to spend time with elderly relatives. Not wanting to risk harm to them and/or others, we compromise by seeing them virtually and feeling more gratitude for the fewer in-person visits we might have left with them. Regardless, note that to achieve successful compromise, it is critical that we do not ask more of the world than it can possibly deliver. Since the pandemic is still unfolding and narratives remain unfinished, there will be plenty of opportunity for compromise.

As writer Melissa Fay Greene noted in a 2021 article in 

, “Sometimes you just have to come to terms with the world as it is, and to human beings as they are, rather than how we wish the world and people were.”

 Greene observes that the pandemic has given rise to a theme: “…[I]n the worst of times, even as many people surprised us with their indifference,” some have “managed to cross barriers and offer us kindness, compassion, alliance, and strength.”

This finally brings us to creativity, which requires imagination and leads to innovation. Analysts who understood drive theory might relate creativity to libido or life force. Creativity is freeing and motivating. When a society has become paralyzed with fear, it is at risk of losing touch with its creativity, resulting in less freedom, diminished perspectives, and stagnated innovation. Even when afraid, we should cultivate human creativity because it is among our greatest and most reliable strengths. Our capacity for creativity gives birth to meaning and, thus, direction and purpose.

 that leads to successful compromise is no simple feat. To even move in the direction of compassion and compromise, 2 mental processes must first take place: 1) disengage from current mental drama, and 2) let go of all mental chatter to become more present in the moment. Meditation is helpful to practice these skills, but they can be learned in whatever way best suits the individual. For example, one can simply notice throughout the day when compassion comes more easily, or just as importantly, when it is difficult. Take note of when it is resisted and become curious as to why. If having self-compassion is a problem, attend to this early in order to generate compassion for others. Another helpful practice is to consider the common humanity and efforts required for routine things we take for granted (eg, numerous people contributed to any simple meal you eat, from the farmers to the local grocery store staff). Explore and consider whether this is more mentally helpful than watching the evening news and becoming perturbed by one’s own inner monologue.

The Buddhist tradition teaches that sitting meditation is a practice to carry into one’s daily life. When the current of the mind whisks us away, we notice this, and then return to the present. This pattern is an eternal recurrence throughout our lives. Repeatedly, we are hit by both small waves and devastating tsunamis. The practice of bringing ourselves back to reality trains the mind to return to a state of equanimity. We are reborn into the present—over and over. By being continually reborn, we may yet transcend the uncertainty, absurdity, and fear that limit us.

is professor of psychiatry and director of forensic psychiatry at SUNY Upstate Medical University in Syracuse, New York, and clinical director of Central New York Psychiatric Center in Marcy, New York. He is Emeritus Editor-in-Chief of the 

 and President-elect of the American Academy of Psychiatry and the Law (2022-23).

Acknowledgments: The author would like to acknowledge the help and insights of Ron Pies, MD, and the inspiration of David Keith, MD.

1. Knoll JL IV. 9/11 10th Anniversary: a mortality salience reminder. 

 September 9, 2011. Accessed August 9, 2021. 

https://www.psychiatrictimes.com/view/911-10th-anniversary-mortality-salience-reminder

2. Knoll JL IV. Panic and pandemics: the return of the absurd. 

 March 30, 2020. Accessed August 9, 2021. 

https://www.psychiatrictimes.com/coronavirus/panic-and-pandemics-return-absurd

3. Pyszczynski T, Lockett M, Greenberg J, Solomon, S. 

Terror management theory and the COVID-19 pandemic.

4. Alzueta E, Perrin P, Baker FC, et al. 

How the COVID‐19 pandemic has changed our lives: a study of psychological correlates across 59 countries.

5. Loades ME, Chatburn E, Higson-Sweeney N, et al. 

Rapid systematic review: the impact of social isolation and loneliness on the mental health of children and adolescents in the context of COVID-19.

The psychological impact of COVID-19 pandemic lockdowns: a review and meta-analysis of longitudinal studies and natural experiments.

http://fajardo-acosta.com/worldlit/beckett/endgame.htm

8. An analysis of Beckett’s Endgame—the human condition. 

https://www.sciencesnail.com/philosophy/an-analysis-of-becketts-endgame-the-human-condition

9. Wenaus A. “Zero, zero, and zero”: Beckett’s 

 2017;4:74-103. Accessed August 9, 2021. 

https://westernchiasma.files.wordpress.com/2017/08/chiasma-4-materialism_wenaus.pdf

12. Greene MF. You won’t remember the pandemic the way you think you will. 

. Published online April 6, 2021. Accessed August 9, 2021. 

https://www.theatlantic.com/magazine/archive/2021/05/how-will-we-remember-covid-19-pandemic/618397/

Articles

How has human behavior been affected by the tragedy of 9/11 and the recent trauma of the COVID-19 pandemic? 

9/11 20th Anniversary: COVID-19 Endgame

In late March 2020, the United States was in full panic mode. What I observed compelled me to write about 

, the absurd, and whether there were any reasons for optimism or perhaps some positive growth opportunities.

 It was my hope that we might tap into our creativity to manage the overwhelming death fears, regression, and unhelpful acting out. I wished for our “better angels” to shine forth, leading us away from despair and irrationality and toward hope and gratitude.

Sometimes, life’s lessons appear unexpectedly. Several weeks ago, a forensic psychiatry fellow who graduated from my program—now a friend and colleague—called to tell me that he had almost died from COVID-19. He explained that he now had a completely altered view of life. Of course, I was awestruck and grateful that he reached out to share his story with me. I suggested that 

® readers might find his story inspirational and asked if he would feel comfortable sharing it. Consistent with his reenergized sense of humanity and gratitude, he agreed and penned the essay here: what I found to be a beautiful, moving, and inspirational story. Thank you, Dr Tirado: This is medicine we all desperately need at this point in time.

Surviving Coronavirus: A Psychiatrist’s Personal Journey

is director of forensic psychiatry and professor of psychiatry at SUNY Upstate Medical University in Syracuse, NY. He is editor in chief emeritus of 

1. Knoll JL IV. Panic and pandemics: the return of the absurd. Psychiatric Times®. March 30, 2020. Accessed July 30, 2020. 

Sometimes, life’s lessons appear unexpectedly. 

A Dose of Much-Needed Medicine

The scientific race to develop a vaccine is in full swing, but when will we begin to develop a more rational, healthy 

response to pandemics? Camus understood that “pestilences” recurred over time, yet always seemed to take us by surprise. In his classic, The Plague (

1947), he writes about a virus that destroys half the population of an ordinary town.

 It is considered one of the greatest novels of the postwar period. Camus lays out our stages of psychological response to a plague, writing: “At the beginning of a pestilence and when it ends, there's always a propensity for rhetoric. In the first case, habits have not yet been lost; in the second, they're returning.” Here, the master of the existential and absurd would have us recognize that inescapable death transforms a habit-constrained life into an exercise in absurdity.

Camus’ Plague may also be viewed as our vulnerability to random extermination by any means. Or as philosopher Alain De Botton

 writes: “Plague or no plague, there is always, as it were, the plague, if what we mean by that is a susceptibility to sudden death, an event that can render our lives instantaneously meaningless.” Camus and similar philosophers believed the Absurd arises out of the conflict between our search for meaning and the apparent random nature and meaninglessness of the universe. What is produced by the conflict will depend on the individual, but may include various forms of denial, dissociation, and sublimation.

And so, it is the Absurd to which we now turn. Indeed, we cannot turn away as we are in the midst of a storm of absurdity. Grocery stores with empty shelves. Hoarding of food and supplies. A 

 Historians of real-life pandemics understand that they unfold as social dramas.

 If this is the case, might this most recent pandemic supply us with some truths about human nature? A relatively clear response pattern has been described by epidemiologists throughout history. The recurring pattern is as follows: 1) deny and ignore, 2) recognize and attempt to explain as the drama unfolds, and 3) the resolution. Epidemiologists are perpetually aghast at our ability to forget this pattern and be caught off guard. Camus understood this conundrum exceptionally well, writing: “So all a man could win in the conflict between plague and life was knowledge and memories.”

Beyond the basic stages of denial, recognition, and recovery, are we able to discern any other psychological themes based on a social and psychological analysis of our behavior? Let us approach this in the manner of a psycho-dynamic anthropologist sent from another planet to observe our species at this moment in time. This investigator would first note our extreme “contamination” fears that go well beyond social distancing, handwashing, and so on.

Our observer would note our curious scramble to obtain and hoard toilet paper. Next, our hoarding of provisions and sudden rush to purchase more weapons would be of interest. The observer could easily discern that the stress humans are currently experiencing has created visible fault lines in our socio-cultural structures. All of these findings would be viewed as our reflexive response to sudden and acute death fears-or what is called “mortality salience” in the terror management literature.

 Our alien observer may well conclude that our species has not yet achieved a rational response to our own mortality-impending or otherwise. Finally, it might be recorded for posterity that humans appear to “forget” the social drama pattern, preferring to bury it back into the unconscious not long after the resolution of a pandemic.

Even a brief review of our past concerning responses to intense reminders of death is both enlightening and disturbing. They include such startling responses as scapegoating, “othering,” and a variety of risky death denying behaviors. Anti-Semitism and blaming of Jewish people were rampant when the Bubonic Plague swept across Europe in the 14th century. The Great Flu Pandemic (1918) is more commonly known as the “Spanish Flu,” despite the fact that the virus did not originate in Spain. Other countries were fearful of reporting their own afflicted status, while Spain transparently reported the problem to the press. It would appear that in the recognition stage of an epidemic, the need to explain is so powerful that if uncertainty remains, identification of a scapegoat becomes the default position. And have we seen such responses recently? Indeed, we have. Early anti-Chinese sentiment spread much more rapidly across the globe than actual virus itself. 

 As the pandemic has progressed over the past few weeks, we have seen all manner of panic-inducing reports in the media.

Morbid statistics that rise daily. Breaking news about the latest celebrity to have contracted the virus. One cannot but have sympathy and understanding for the general public who are relentlessly bombarded with confusing, and often divergent, messages. A scientist, who underscores the impact of his op-ed article by noting he is “an MIT-trained physicist and complexity scientist who studies pandemics,” urgently recommends a five-week “national lockdown.”

 Almost simultaneously, a Nobel laureate and Stanford biophysicist, who has analyzed 

 cases worldwide, writes that the data don’t support such a dire scenario, and that “

Without a consistent, calm, level-headed message, how can we expect the public 

to resort to well-worn habits that result from confusion and reminders of death? Certainly, they will-and absurdity will, temporarily, ensue. We will divide and “other” just as surely as viruses will mutate and infect us again in the future. Besides reports of hate crimes against Asians rising, the absurd can be seen in recent generational tensions. Millennials have been 

to the virus as the “#BoomerRemover,” while the older generation responds by shaming the younger for their “#CoronaParty” during spring break.

Virtually every culture engages in rituals to both forestall and ease death anxiety. It was not until the late 80s that researchers began formally studying death anxiety and how it is a “driving force behind the human motives for self-esteem and meaning in life, and thus plays an important role in diverse aspects of human behavior.”

 (TMT), our innate biological instinct for survival, combined with our capacity for self-consciousness, sets the stage for painful awareness of our mortality and its attendant terror.

 TMT research, derived from the Pulitzer Prize winning work of cultural anthropologist Ernest Becker, suggests that increased death terror motivates us towards the familiar (e.g., tradition, in-group worldviews, and cultural orientations.

 TMT research has progressed over the past several decades, finding that “death primes,” or reminders of mortality, are associated with:

• Hardening of traditions and fundamentalist beliefs

• Enhanced efforts to achieve attachment security

• Aggression against others who threaten one’s culture or traditions

Given the continuous media reports of death primes (the pandemic, the precarious nature of our environment, economic and political instability, etc.), one may wonder if the resultant death terror will be more intense than usual.

 Even if this turns out to be accurate, is there any reason for optimism? There is reason to believe so. For example, resilience-a proven strength of humans, is often seen in the midst of crisis and disaster.

What we learn in times of pestilence: that there are more things to admire in men than to despise.

At the heart of every tragedy is the finality of “the end” (e.g., loss) -the ultimate expression of which is death. To reckon with the end and death is to struggle with finding meaning in the face of the absurd. This can be seen in Samuel Beckett’s modernist works dealing with loss, suffering and death.

 Facing the absurd and death terror need not always result in morbid outcomes. TMT research has begun to suggest that resilience, when under the strain of death terror, may lead to positive progress, flexibility and new meanings. Of course, resilience in general is capable of producing personal growth and improved functioning in the face of stress and adversity.

My colleague, Dr Lloyd Sederer, who has led mental health disaster responses in New York, notes that there are always lessons to be learned and optimistic actions we can take.

 In addition to providing calming guidance in the form of organizational mandates and coordinated responses, we can begin with ourselves. In line with TMT research, Dr Sederer suggests turning to our sustaining, meaningful relationships; adequate self-care; exercise and various mindfulness exercises. TMT research from a positive psychology standpoint has found that death anxiety may also result in the following positive opportunities and growth-oriented goals:

• Valuing creativity and creative achievement

• Prioritizing growth-oriented goals and positive standards

Within times of chaos may lie the seeds of opportunity leading to new strategies, novel solutions and expanded meaning. Yet this will depend largely on our ability to sit with uncertainty and avoid the pressure to regress to unhelpful habits. In this way, death fear may serve as a cognitive reorganizer to develop a stronger “existential self-consciousness that sustains a process of self-overcoming.”

 A balance must be achieved, however, between healthy death terror buffers and outright panic driven denial. The influence of death awareness is truly profound, and may generate negative outcomes, as well as impel us along “more positive trajectories and contribute to the good life.”

Around 1637, the classical French painter Nicolas Poussin completed a masterpiece titled 

, also referred to as The Arcadian Shepherds. The beautiful painting shows an idyllic pastoral scene in which shepherds are gathered around a tomb. The title can be translated roughly to “Even in Arcadia, there I am,” or “Even in Arcadia, death is there.” Since the time of ancient Greece, Arcadia has been a metaphor for a Utopia, as it was far from the complexities and troubles associated with urban city life. As with all great art, it contains multiple meanings. One message is for us to never forget the fragility and brevity of life. Another message, more subtle but equally important, is that we have a duty to do our best to calm and sublimate our death fears. Recognizing this duty now seems to be an important task-one that we cannot allow ourselves to continue repressing.

Camus would likely have endorsed this approach, as his solution to the Absurd was to fully accept it – while continuing to live on – thereby achieving a transcendent form of freedom and personal meaning. Perhaps we might let this pandemic serve as our creative stimulus to begin to develop and test a set of go-to responses to mitigate panic in the face of a pandemic? We will surely have more opportunities to implement them. This would be a human triumph – to better understand and respond to those in the throes of overwhelming death terror, and develop “robust international responses to affected patients and communities.”

 and adopt a Camus-type philosophy which leads us away from fear and despair, and towards “a softening of the heart, a turning away from judgment and moralizing to joy and gratitude.”

is Director of Forensic Psychiatry and Professor of Psychiatry at SUNY Upstate Medical University in Syracuse, NY. He is Editor in Chief Emeritus of 

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We often push thoughts of death far out of our awareness, but at the present time they unavoidably re-emerge. Can we learn something helpful from this?

Panic and Pandemics: The Return of the Absurd

Despite advances in addiction research, substance use disorders continue to tighten their grip on society. Forensic psychiatrist and Editor in Chief Emeritus of 

 James L. Knoll IV, MD, weighs in on a case report.

A Rock and A Hard Place, by Eduardo Constantino, MD

Dr Constantino has our gratitude and sincere respect for submitting his case which is both real world and timely. Upon consulting with many respected addiction psychiatrists to formulate my response, all of them added that they were grateful that these difficult issues were being raised for discussion. I must imagine that such cases will be seen with greater frequency, particularly as the specialty of addiction psychiatry advances and substance use disorders tighten their grip on society.

In my view, Dr Constantino’s case is not so much a case about malpractice, but an extremely rich case highlighting the ethical and legal duties of a practicing addiction psychiatrist. There do not appear to be any clear deviations from the standard of care, nor are we made aware of any damages-effectively removing two of the 

that a plaintiff must prove in a malpractice case.

 Nevertheless, the learning value from this case is substantial. Dr Constantino’s “awkward quandary” involved the frustrating dilemma between preserving a patient’s right to confidentiality-and an ethical/clinical duty to act beneficently and preserve life. Yet as with many clinical dilemmas, the resolution often lies along the path of engagement and dialogue with the patient.

All physicians are presumed to have some awareness of confidentiality, given that it is required by professional ethics, hospital policy, and federal and state law. The exceptions to confidentiality are relatively small in number and include: medical emergencies, statutory reporting requirements (suspected child or elder abuse) and an individual state’s legal requirements regarding patients’ credible threats to third parties (Tarasoff statutes). From a legal standpoint, actions for breaching confidentiality may include: breach of contract, breach of statutory duty and professional misconduct. Confidentiality and privacy of psychiatric records is especially important in the field of addiction psychiatry. In fact, this issue is stressed by federal law, which requires that documentation in addiction treatment be held to even higher standards of confidentiality than general psychiatric and medical encounters.

 (AAAP), a “basic principle of confidentiality of personal health information is that, to the greatest extent possible, control of personal medical information should be in the hands of the patient. Nonetheless, when patients receive . . . substance use disorder services, their agreement to begin treatment should include their written consent that certain identifiable health information will be shared with other health professionals.”

A major concern of patients and addiction psychiatrists is that failure to maintain strict confidentiality in the setting of substance use treatment can potentially result in a cascade of highly adverse consequences.

 For example, it is not uncommon for disclosure of substance use treatment to result in: loss of employment, loss of child custody, discrimination by insurers and other health care professionals. Of course, the possibilities of arrest and incarceration are ever-present. Unsurprisingly, such concerns may lead individuals in need of treatment to avoid seeking the help they need-often until it is too late. Keeping this in mind, let us turn to Dr Constantino’s first question: “

Even though his probation officer was allowed to speak to any and all medical staff, could we legally call the probation officer against the patient’s specific instructions?”

Based on the case description, the treatment team’s decision to not call the probation officer seems appropriate, as doing otherwise would be a violation of consent and breach of confidentiality. It is recommended that psychiatrists obtain specific signed consents “for release of any personal health information to entities outside of the health-care delivery system, such as . . . judges, prosecutors, police or other legal investigators, or institutional or community corrections officials, even in response to subpoenas, as stipulated in 42 CFR Part 2.”

 Absent patient consent, requests for information from law enforcement or other government agencies seeking information without patient consent should be denied. One exception to this may be a specific court order (per 42 CFR Part 2). However, such court orders are typically reserved for patients who have been involved in serious crimes.

Addiction specialists know that parole and probation officers play a critical role in the lives of their patients. A positive relationship with a parole officer can mean the difference between recidivism-and continued wellness in the community.

 Because of their central role, it is important to have a clear understanding, from the beginning of treatment, about the precise conditions of probation that were ordered by the court. A meeting with the probation officer may be helpful to establish rapport, ground rules, limits of confidentiality and to review any legal documentation from the court. A reliable understanding of the probation officers’ “marching orders” will put the treatment team in a better position to understand any concerns the probation officer may have, as well as what information may be communicated between parties.

Turning to Dr Constantino’s second and third questions regarding notifying the patient’s IOP, and concerns about providing appropriate care-it is noted that the patient refused to give consent to speak to his IOP substance use treatment center. From a clinical standpoint, effective coordination of care is assumed to be in the best interests of the patient. Yet in this case, it can be argued that the same legal restrictions apply to informing the patient’s IOP. This is highly unfortunate, but there appear to be at least two barriers. First, the patient refused to give consent. Second, there is no mention that consent was legally applied by the court to the patient’s original terms of probation, which would allow for communication of health information with the IOP and vice versa.

There are several important points to consider regarding this impasse. The AAAP notes that when patients opt to not allow health information to be shared among other providers, they “should be educated about the implications for the quality of the health care services they may receive, and thus the potential detriments to their own health care outcomes and health status, when they decline to sign the consent.”

 Therefore, an open and serious discussion with the patient regarding the potentially life-threatening consequences of refusing to allow communication between mental health and substance use treatment providers should be undertaken and documented. However, the patient is noted to have poor insight into his dilemma and so we proceed to other options for now, while recognizing that improving insight will remain a continuing goal.

James L. Knoll IV, MD, analyzes the ethical and legal duties of psychiatrists treating substance use disorders.