Michael A. Kalm, MD

There’s an old joke about change: How many psychiatrists does it take to change a light bulb? Just one, but the light bulb really has to want to change.

One of my teachers ruefully described working for change as a “sandwich board” concept. Poor people during the 1930s earned money as walking advertisements, wearing sandwich boards with messages on the front and back, like “Eat at Joe’s,” and “Open for Breakfast From 7-11 AM.” My teacher used to say that our patients came to us wearing sandwich boards, with the front saying, “Please help me to change,” and the back, saying, “Over my dead body.”

Our patients do come to us for help. They want to feel better. But they also come to us with fear that makes change difficult. They come to us with psychological defenses, like denial, which stop them from facing what they fear most. They also come with prejudices, beliefs, anecdotal evidence, confirmation bias-all designed for feeling better but perpetuating the same distress.

Our duty as psychiatrists is to build trust, to provide a safe environment where our patients can be open; reveal their darkest thoughts, feelings, and fears; try out new things, and use their new skills out in the world if they so wish. When we do our job right, our patients can return to, or achieve for the first time, a healthy state where they can be in the world confident, thriving, and able to sustain healthy relationships.

But this is not easy. Sometimes fear runs too deep and denial is too great. Many years ago, I had a patient with paranoid schizophrenia. With therapy and medication, she recovered from psychosis and was a full-time student heading towards a full, thriving life. However, before her illness, she had been an accomplished pilot. At the time I was treating her, the Federal Aviation Commission (FAA) had a rule that prohibited renewal of a pilot’s license as long as the person was taking prescribed medications. I appealed to the FAA on her behalf, asserting that I would trust my life flying with this patient, because, with her medication, she was completely stable and competent. But rules are rules. No license.

My patient decided to discontinue her medication. I urged her not to do so, emphasizing the risk of relapsing into psychosis, and that she would risk losing her license anyway and probably much more. But the license was too important to her. She stopped the medication, and, as predicted, relapsed into psychosis. She resisted treatment and ran away. I received a letter from her family some years later that she never finished school, couldn’t hold a job, and had become homeless.

This is the paradox of psychiatry. We are agents of change with a patient population that often fears change. We suffer the “Curse of Cassandra.” Cassandra was the subject of Greek mythology, a princess who was cursed by the gods to always tell the truth but never be believed. It was Cassandra who warned the Trojans that the Greeks were hiding within the wooden horse and that it should be kept out of the city, but she was not believed. In her wonderful book, 

, historian Barbara Tuchman defined political folly as behavior exhibited by leaders of countries who ignore the advice they are given by their “Cassandras,” people whom they have trusted and had hired specifically for their advice. This is not just true of political leaders. It is also true for many of our patients as well as many communities.

This brings us to climate change. Our planet is in the grips of global warming, bringing massive climate disruption, creating mega-storms, floods, droughts, heat waves, and the beginning of climate migration. If unchecked and not reversed, we are headed towards a bleak future of species and habitat extinction, mass migration of people, hundreds-of-millions dead from starvation, and warfare over dwindling resources.

We are now hearing about a “Green New Deal,” a comprehensive restructuring of governmental, environmental, and economic policies, including ambitious technological innovation and massive transformation of the workforce, in order to save the planet and secure the future. While public support for clean energy is nearly 80%, the “Green New Deal” is being seized upon to create fear and suspicion of unacceptable costs, personal sacrifices, and lost jobs. While these proposals are being endorsed enthusiastically by many, they are met with outright derision by others.

As psychiatrists, do we have a role to play here? Some would say no, for a number of reasons. First of all, the population at large is not our patient. We have a rule in psychiatry-a good one-that says, “No therapy without a contract.” Secondly, we ordinarily do not discuss politics or world affairs with our patients. Thirdly, we ordinarily do not tell patients that they have to change.

But there are exceptions-when a patient is caught in a hopeless marriage, we sometimes say to them, “I’m afraid that you will be depressed for the rest of your life if you don’t leave this marriage.” If they are stuck in an addiction-whether it is alcohol, drugs, gambling, or even overspending, we sometimes say to them, “You are suffering from addiction. It is a disease, and it is a disease that will kill you if you don’t find the courage to face it openly.”

Even with psychosis, in which the patient appears to be divorced from reality, we sometimes say, “Your thinking is a delusion, and as difficult as it is, you must fight your way through to reality.”

What does climate change and a Green New Deal have to do with these clinical situations? Everything. Climate change has come about for multiple reasons that scientists and economists will debate for a long time. But the bottom line is-we currently have a global economy that is built on the consumption of fossil fuels. That model no longer works. The longer it continues, the more damage is done, and the harder it is to find a solution.

Sex therapists tell their older patients, “You can’t have sex at 70 the way you had sex at 25. You have to redefine what sex is so that you can not only continue to enjoy it, but even increase your enjoyment!”

And so must we-thus the Green New Deal. We can’t stop burning fossil fuels. We have to replace that part of our economy with something that will not only diminish climate change but will also improve our lives. This means innovation, new ideas, alternate forms of energy, job training, infrastructure repair, wider education, urban planning, water management, and on and on. As I said, the details of what properly constitutes a Green New Deal is a subject to be debated by scientists, economists, sociologists, and ordinary people everywhere. Our job as psychiatrists is to provide the crucial hope in a better future and the necessary courage to take the steps to get there.

Nothing prepares us more for this momentous task than what I call the second paradox of psychiatry: psychiatrist as “happy warriors.”

What is a “happy warrior”? I must share a story about one of my heroes, Jacob Javits. Javits was a long-time Senator from New York, elected to office from both the Republican and Liberal parties. Neither party was particularly happy with Javits running on the other party’s ticket, but Javits believed in the principles of both parties, so he felt no conflict. He was considered one of the Senate’s “happy warriors,” always willing to take on a fight for a cause in which he believed, no matter how unpopular, always in good spirits while doing so. After retiring from the Senate, he continued to fight for the causes he believed in, even after he was virtually incapacitated with amyotrophic lateral sclerosis, and to the end, always of good cheer.

Late in Javits’s life, a reporter asked how he remained in perpetual sanguinity, even when faced with such tremendous adversity. Javits responded that, when immigrating to this country, his family was very poor. To get food on the table, his father, Morris, became a Golden Gloves Boxer. This was in the era before weight classifications in boxing-no flyweight against flyweight or heavyweight against heavyweight. They just drew two names out of a hat, and you got into the ring. So, here was Morris, five foot four inches tall, just over 100 pounds, getting into the ring with a six-foot four 200 pound behemoth. Javits said, “My father had only one rule about that-’Hit ‘em with what you’ve got.’ Fair or unfair-didn’t matter. Win or lose-didn’t matter. Just ‘Hit ‘em with what you’ve got.’ That was my father’s rule and I made it my rule. It’s still my rule-‘Hit ‘em with what I’ve got,’ and I’m still doing it.”

We in psychiatry are happy warriors. We don’t give up on patients. We recognize and accept their fears, their denial, their prejudices, their disbeliefs, and we stick with them as long as they’ll let us in order to find ways to make it easier for them to accept painful truths and make courageous changes that will provide them a better future.

Although the population-at-large are not our patients, they are our fellow citizens. They are part of our community, and, as citizens, we owe it to them to apply our knowledge and skills as much as we can to build a healthy environment in which improvements and innovations can be made for the benefit of all. We must help those who are already striving for a Green New Deal to be happy warriors themselves!

Dr Kalm is Clinical Assistant Professor of Psychiatry, University of Utah. He is past president of the Utah Psychiatric Association. Trained at Duke, Dr Kalm is committed to the welfare of his patients, and by extension, to all people and all species of the earth. 

Dr Kalm reports no conflicts of interest concerning the subject matter of this article.

Author | Michael A. Kalm, MD

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Cassandra or Happy Warrior: How Paradoxes of Psychiatry Can Sustain the Green New Deal