Johan Verhulst, MD

Dr Verhulst (1938 -2019) was Associate Professor Emeritus of Psychiatry, University of Washington, Seattle, WA. Dr Beahrs is Professor Emeritus of Psychiatry, Oregon Health & Science University, Portland, OR. 

Many human dilemmas are undecidable in principle.

Should an individual marry or choose a career path? Should society favor the hidden hand of free enterprise or rely on the protective beneficence of an elite? Such choices share four defining features: 1. importance, 2. the social domain, 3. conflict, with valid arguments pulling in different directions, and 4. undecidability by either data or logical argument (ie, uncertainty).

The parties to such dilemmas often share a common ambivalence about the issue but gravitate to opposite poles; then they come into conflict and become increasingly polarized-at each other’s throats over what they actually share. For example, a patient shared with the senior author (Verhulst) that he and his girlfriend had come to a crossroads: should they formalize their relationship into a marriage commitment or ward off vulnerability by preserving autonomy? They were mutually attracted, common-valued, and heavily invested in one another, but each had suffered relationship traumas in the past. Verhulst simply noted and reflected on their shared ambivalence and suggested an experiment-whether they could successfully switch roles and argue each other’s side. They could. And after doing so, their polarization lost its power and they got married. In retrospect, their biggest problem had been to disqualify the other’s fears.

Some of the most polarized large-scale social conflicts share similar features. Here are three examples:

 All parties recognized the horror of child abuse and acknowledged the value of psychotherapy for its victims; they recognize the frailty of memory, the role of family integrity, and the presumption of innocence.

 In a Gallup poll of Muslims from the Middle East and liberals from the West, both sides admired the West’s freedoms and Islam’s strength of values; they also both abhorred the West’s regressive excesses and violent Islamic extremism.

 But in each case, despite these commonalities, the parties gravitated to opposite poles and ended up at odds.

 The horrific carnage of World War I erupted within a Western domain that had largely common interests and shared values.

Logically, we humans think in binary terms-either A 

not-A. In fact, it is more often everything in between. Two factors feed into this dichotomy:

 Human cooperation probably evolved through conflict with hostile groups of other hominins.

 If so, survival often turned on deciding between “us” and “them,” idealizing one and devaluing the other. If we do not already have an enemy, we will create one.

 That is the human tragedy, especially because ambivalence and polarization are sure to follow.

Parties to dilemmas often share a common ambivalence about the issue but gravitate to opposite poles; then they come into conflict and become increasingly polarized-at each other’s throats over what they actually share.

. Computability requires digitizing the continuum into discrete bits that are either zero or one in order to avoid wandering and to provide for error correction.

 Information processing is metabolically costly, and costs can be contained by further excluding most of the “in-betweens.”

 Thus, binary thinking most likely co-evolved from many directions and became built into brain function.

Our brains give meaning to sensory input and propose action plans.

 They enter consciousness as subjective emotional preferences, not factual truths-as truth is often undefinable. Many preferences are pre-programmed-eg, “us” versus “them,” empathy versus defense, reciprocity, seeking love and friendship, child care, sense of fairness, ambivalence about authority, and motives to reward or punish.

Brains are evolved to make assessments along all of these dimensions. But they offer clean interpretations only in emergent and unambiguous situations, eg, if someone is trying to grab my purse. In other situations, one might expect brains to present a range or series of possible options. But this does not happen. Instead, our brains respond to social complexity by bringing opposing interpretations and responses into awareness. The resulting either/or choices are usually undecidable, laying foundation for the shared ambivalence and unnecessary polarizations that so often ensue.

How does one choose among many options, where none is any more “true” or “correct” than the alternatives? Facing a difficult decision, one must first assess whether it can be determined reliably by factual data and logical reasoning, as sometimes occurs in math or physics. This is rarely possible within the social domain. As in law, causation is attributive here-serving not to explain facts, but to regulate behavior.

 Most problems are undecidable in this domain.

In psychiatric practice, it is often helpful to translate what appear to be individual psychodynamics into the “social brain” framework where most undecidable choices actually arise

Rational strategies fail in any of at least three different ways. One, unresolved ambivalence can paralyze constructive action. Two, defending a polarized position unnecessarily fuels discord and excludes the often shared data that are needed for optimum problem-solving. And three, attempting logical analysis where it does not and cannot apply results in simply spinning wheels and going around in circles.

What else, then? Human experience shows that people solve social problems primarily by relying on subjective factors such as personal beliefs, preferences, values, and priorities in order to find a solution that feels right. Deciding the undecidable always remains a leap of faith, or, a matter of intuition. There are neither any logical shortcuts nor any one single correct decision. Any decision or non-decision will have unanticipated side effects and complications. Most cases that are decided by the US Supreme Court are probably undecidable, which partly explains why the selection process for justices is so heavily value-driven and affect-laden.

In psychiatric practice, it is often helpful to translate what appear to be individual psychodynamics into the “social brain” framework where most undecidable choices actually arise-ie, an interactional perspective.

 So translated, more issues come to be considered as being widely shared. For example, most people begin intimate relationships with an assortative mating process of selecting for common beliefs, preferences, values, and priorities-and to this extent, shared ambivalences. But unique differences also tend toward a polarizing process, as an easier answer. And when such a pattern becomes established, this polarizing is apt to become self-sustaining and escalate the discord-at the expense of problem-solving.

We suggest a threefold path toward resolving such frequently occurring but intrinsically unnecessary conflicts.

1. Recognize and label the underlying shared ambivalence, thereby widening the domain of perceived common interest.

2. Validate opposing parties’ choices and their rationales, further expanding this domain.

3. Search for alternative ways to frame the situation in search of compromises and other ways to compartmentalize along different axes or binary dimensions. Such reframing lies at the core of psychotherapy-ie, how one party can help to change another party’s brain function without medically or surgically invading it.

The potential to extend such intervention to large-scale social conflict is yet untapped. Decisive legal intervention helped to mitigate the recovered memory controversy.

 The abortion debate was tempered through compromise with face-saving in continental Europe, though it is still intractable in contemporary America.

 Competitive victim narratives are still lethal in the Near East, eg, those that rationalize the intractable conflict between Israel and Palestine,

and the Great War eluded all diplomatic resolution.

More reassuringly, reframing is being tested as a potentially viable way to address intractable conflict where sacred values are at issue.

 In all such cases, the parties had possessed common interest with shared ambivalence, selectively swung to opposite poles through binary thinking, and came into unnecessary but increasingly intractable conflict. Perhaps validating the nature of undecidable choices and shared ambivalence can offer more hope for human reconciliation.

This article is in memory of Johan Verhulst, MD.

There are no conflicts of interest concerning the subject matter of this article.

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Articles

Reframing is being tested as a potentially viable way to address intractable conflict where sacred values are at issue. In memory of Johan Verhulst, MD.

Undecidable Choices and the Polarization of Shared Ambivalence: What Can Psychiatry Add to Dispute Resolution?

[[{"type":"media","view_mode":"media_crop","fid":"14162","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_7379309827402","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"692","media_crop_rotate":"0","media_crop_scale_h":"165","media_crop_scale_w":"160","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"margin: 2px; float: right;","title":" ","typeof":"foaf:Image"}}]]We grieve Sandy Hook as we continue to grieve Aurora, and shudder because we know there will be a “next time.”

During the 23 years I practiced psychiatry in Wisconsin, I (DK) saw many patients in the emergency department whom I judged to be more psychotic and more dangerous than either Adam Lanza or James Holmes appears to have been before the horrors for which we now know their names. Not once was I able to prevail on Crisis Intervention for the county to approve admission of any of those patients to the excellent state mental hospital less than 9 miles away. Instead, outpatient treatment at Community Mental Health Center (CMHC) was mandated. This was because of limited funding and the limited number of inpatient beds available for seriously mentally ill patients-even ones who displayed definite signs of dangerousness.

Politicians are discussing bans on the sale of certain types of guns, magazines, and ammunition. President Obama has focused on the expansion of background checks for certain types of gun sales. There is discussion of infringing on the basic relationship between psychiatrist and patient and relaxing the privacy of mental health records with respect to interested government agencies. Even the US Supreme Court [

] understood the chilling effect this would have on mental health treatment: “For this reason, the mere possibility of disclosure may impede development of the confidential relationship necessary for successful treatment.”

These proposed initiatives are mostly desperate efforts to find a patch to replace a mental health system we dismantled

-most importantly, the system of state mental hospitals.

As of this writing, more than 150 days have elapsed since a young man with likely significant psychiatric illness did something all of us consider unthinkable. More than 150 days since he walked into an elementary school and murdered 20 children and 6 staff members after killing his mother. In public discourse, the problem has been defined in 2 terms: “gun violence,” and “serious mental illness.” Most proposed solutions in the medical literature focus almost exclusively on the first component.

There is a long tradition in the US of operating institutions for the care of persons with serious mental illness.

 The Society of Friends began admitting patients to the Pennsylvania Hospital in 1752. The Commonwealth of Virginia established the Public Hospital for Persons of Insane and Disordered Minds in 1768. The Government Hospital for the Insane, now known as St Elizabeth’s Hospital, opened in 1855. Virtually every state had one or more state mental hospitals by the mid-20th century.

Is it possible that we as a society care less for the plight of the seriously mentally ill than we did 100 or more years ago? Is homelessness an answer for these suffering individuals? Is incarceration with minimal mental health treatment an ethical solution? When the jails in our most populous counties become our largest public mental health facilities, we definitely have a problem-a problem we created-in how we respond to serious mental illness.

, “If you build it, they will come,” we may simply need to build it, and build it, and build it, until a public mental hospital system exists where the seriously mentally ill may come for treatment. Good treatment for serious mental illness must be hospital-based and of sufficient duration to be effective. Outpatient treatment is for people of sufficiently sound mind to make decisions regarding their own health and treatment.

, I (JV) observed that long-term psychiatric hospitalization may lead to paternalism and abuse of power. Our current appreciation of the importance of 

 and patient empowerment can not only help avoid such dangers but also inspire a truly humane and therapeutic hospital environment.

In addition to the 28 killed and 2 injured in the 

, other recent mass shootings include 33 dead, 23 wounded at Virginia Tech; 6 dead, 14 injured in Tucson; and 12 killed, 58 injured in Aurora. In each of these cases, it appears that the shooter was seriously mentally ill. CDC statistics for firearm deaths in 2010 show 19,390 suicides, 11,062 homicides, and 950 unintentional and law enforcement deaths.

Every firearm death is tragic. For the approximately 20,000 suicides by firearms annually, the CDC estimates that 45% are primarily the result of “mental health” problems, and 31% are the result of “intimate partner” problems. This means that at least 76% of suicides are broadly mental health–related.

 With respect to violence toward others, 13% of people with a serious mental illness reported having committed assaultive acts during the previous year.

The majority of homicides, including those involving firearms, are not committed by persons who are psychotic or suffering from a severe psychiatric disorder. Nevertheless, a statistical analysis based on the Swedish national registers for all hospitalizations and all criminal convictions indicated that in a 5-year period, about 1 in 20 violent crimes were committed by patients with severe mental illness.

 Many more offenders are in a temporary state of rage or despair.

 are committed by people in the midst of an episode of serious psychiatric disorder. This cannot be known for certain in every instance because perpetrators of mass violence often do not survive the event, and many have not previously seen a psychiatrist. These tragedies involve many factors: an untreated seriously mentally ill person; in unimaginable distress; with relatively easy access to military style weapons; and illegal psychoactive drugs; living in a society with substandard treatment of the seriously mentally ill; largely due to society’s unwillingness to adequately fund public mental health; in a culture increasingly lacking in cohesive societal responsiveness.

Until the final third of the 20th century, the states operated mental hospitals where psychiatric care was provided for people with severe mental illness. In 1955, the nation’s capacity for mental health care in public institutions exceeded 558,000 beds, equivalent to 1,060,000 beds today. By 1994, this capacity had dropped to 72,000 beds.

1. Beginning in 1954, more effective treatment became available, primarily medication for severe psychiatric illnesses such as schizophrenia and bipolar disorder. Medication allowed many patients to be discharged from state mental hospitals.

2. Many persons with severe mental illnesses are now found in correctional facilities. A recent estimate was 321,000.

3. Another large group of seriously mentally ill persons is found among the 3.5 million Americans who experience homelessness annually.

4. The CMHC program was never able to provide the intensity of care available in the state mental hospitals. Federal funding for CMHCs evaporated and more patients entered the world of corrections and homelessness since there were no public hospitals to which to return.

Current status of the seriously mentally ill 

Without the availability of public mental health beds, seriously mentally ill patients often enter a downward spiral of despair, social isolation, unemployment, poverty, homelessness, malnutrition, disease, substance abuse, and victimization by violence.

Thomas Insel, Director of the NIMH, testified in January 2013 that the delay from the start of an episode of serious mental illness to contact with a professional is 5 years on average.

 It is possible that episodes of violence like those cited at the beginning of this essay were committed by young men in the early stages of schizophrenia or bipolar disorder-which would have increased the likelihood that they would not have yet come to the attention of the mental health system. Five years of deterioration; suffering; access to alcohol and illegal drugs; going without humane care and treatment; deterioration of family, social, and community relationships; potential access to firearms; and increased risk of violent behavior. Five years on average in the United States of America!

1. Revitalize the state mental hospital system to readily provide safety, evaluation, and treatment before an act of violence has occurred

2. Lower the threshold for legal commitment, with appropriate civil safeguards to protect patients and potential victims

3. Develop a transitional system of “partial hospitalization” to facilitate a carefully managed return to the community

Dr Kramer is Emeritus Clinical Professor at the University of Wisconsin School of Medicine and Public Health in Madison. Dr Verhulst is Emeritus Associate Professor of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine in Seattle, and Senior Advisor, The Kinsey Institute for Research in Sex, Gender, and Reproduction at Indiana University in Bloomington. The authors are with the Research Committee, Group for the Advancement of Psychiatry.

Members of the Research Committee, Group for the Advancement of Psychiatry also include Dr John Beahrs, Emeritus Professor of Psychiatry, Oregon Health and Science University, Portland; Dr Barbara Hale-Richlen, the Hale-Richlen Center for Psychiatry, Milwaukee; Dr David Keith, Professor of Psychiatry and Behavioral Sciences, Upstate Medical Center, SUNY, Syracuse, NY; Dr Patrick Malone, Psychology Associates, Chapel Hill, NC; and Dr Alan Swann, Professor and Vice Chair for Research, department of psychiatry and behavioral sciences, The University of Texas Health Science Center, Houston.

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When our jails become our largest public mental health facilities, we definitely have a problem-a problem we created-in how we respond to serious mental illness.

Author | Johan Verhulst, MD

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