Rama Rao Gogineni, MD

“We usually think of what hate does for the individual hated or the individuals hated or the groups hated. But it is even more tragic; it is even more ruinous and injurious to the individual who hates.” -Martin Luther King, Jr.

On Saturday, January 15, 2022, according to the January 16th 

I am grateful to be alive,’ says Colleyville rabbi Charlie Cytron-Walker,

” and consistent with the core principle of Judaism to welcome the stranger, a man was let into Congregation Beth Israel synagogue by the Rabbi when he knocked and asked if the synagogue was a shelter.

 As Shabbat prayer continued, the man clicked a gun, and then held the Rabbi and 3 other Jewish individuals hostage, even as he praised the Rabbi on the live-streamed audio of the service, saying “I bonded with him. I really like him.” The man also said that he himself was going to die, and he did. The additional terrible irony is that Rabbi Charlie Cytron-Walker and his wife are pillars in the area for interfaith dialogue.

As the crisis continued, the suspect was identified as a Muslim. He is a British citizen who immigrated to the United States not long ago. During the hostage situation, he was described as “extremely distressed” and making “political” demands. As information emerges after the event, it seems that he might have chosen this Jewish organization because it was close to a federal prison where he wanted a prisoner freed. This prisoner was convicted of trying to kill US Army officers in 

 and conveyed anti-Semitic sentiment during the ensuing stand-off. The standoff lasted almost 12 hours, and with the active-threat training that the hostages had for such a situation, their maneuvers to flee, and the patience of law enforcement, the hostages fortunately escaped. Given our concern with 

, how the suspect got his gun needs clarification.

The Council on the American Islamic Relations (CAIR), the largest Muslim advocacy group in the United States, condemned the incident as an act of hate: “This latest Anti-Semitic attack at a house of worship is an unacceptable act of evil. We stand in solidarity with the Jewish community. No cause can justify or excuse this crime.”

Omar Suleiman, PhD, a highly respected Dallas-based Imam, also strongly condemned the attack: “…we will be there for our Jewish neighbors as they recover. The perpetrator cannot claim to have acted for any noble cause. He held a beloved faith leader to our community and his congregants hostage with no regard. And those that will use this to stoke the flames of hatred and division will fail as he did, God willing.”

Internationally, similar attacks on houses of worship targeting Muslims, like what happened at the Al Noor and Linwood mosques in Christchurch, New Zealand, on Friday, March 15, 2019; or Christians, like on the International Pentecostal Holiness Church headquarters in Zuurbekom, South Africa on Saturday, July 11, 2020; or the gurdwara Sikh Temple in Oak Creek, Wisconsin, on Sunday, August 5, 2012—all are acts whose apparent aim is to foment social and individual hate, but may also be acts committed by persons who need psychiatric care.

Connected religiously and psychologically to this event, the Jewish Tree of Life synagogue in Pittsburgh also had disastrous loss of member lives on October 27, 2018. This current incident is also liable to be a trigger for that past trauma. So said their Rabbi, Jeffrey Myers, who, in various media interviews after the hostage crisis, also maintained getting mentally stronger through vision of purpose over millennia, combined with ripples of support.

In the United States, as well as the United Kingdom, we are in a time of great conflict and divisiveness that compromises the safety of citizens. Due to projected scapegoating, those who are different usually bear the highest risk of harm.

, an international alliance of social psychiatrists and other mental health professionals of various faiths who have previously written about other conflicts in the Middle East and Afghanistan for 

. Some of the members of this alliance have also edited and written chapters for 3 books published by Springer International over the last 2 years: 

Islamophobia and Psychiatry: Recognition, Prevention, and Treatment

Anti-Semitism and Psychiatry: Recognition, Prevention, and Interventions

. SPIRIT welcomes new members interested in helping our cause.

In our mission, we have a moral, ethical, and clinical responsibility to support the survivors and tend to their visible and invisible wounds, as well as to address the ripple repercussions of the traumas as they spread out from the epicenter into society. Although there is interfaith progress, there is still entrenched cross-cultural hate. We try to research the root causes of these harmful and all too common phenomena. Though it is unlikely that psychiatry can often predict something like this by a given individual, we still might find ways to be proactive rather than reactive, try prevention rather than intervention, and instigate systemic change of the adverse social determinants of such mental problems. Psychological autopsies of perpetrators can provide valuable clues to their personal backgrounds, 

, psychological conflicts, and motives. In the case of the Congregation Beth Israel hostage situation, the perpetrator’s brother has already said he had “mental health issues.”

 and mental illness are often a volatile mix. Similarly, security reviews of what happened will hopefully provide increasingly safer guidelines for the future.

We must also reinforce the psychologically beneficial messages embedded in our current holidays. In an unusual confluence, January 17 this year includes the annual Martin Luther King Jr. Day, the Jewish Tu B’Shivat celebration of environmental sustainability, and the inaugural Muhammed Ali’s Day in Illinois celebrating peace. Together, they point the way to social and environmental justice. In the meanwhile, safety and security must be paramount at vulnerable social and political targets, including the current possibility of copy-cat attacks of faith-based communities.

But first and foremost, we must be part of the solution by refusing to be taken hostage to hate.

is a practicing psychiatrist, Providence Healthcare System, Portland,

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

serves as Kathleen & John Bricker Chair, Department of Psychiatry, LSUHSC. He also is chairman of the Board of Trustees of the Cobb Research Institute and is the 113th present of the National Medical Association. 

 is an associate professor of psychiatry at Harvard Medical School and a fellowship site director for Brigham and Women's Hospital. 

 is a doctor working in frontline psychiatry for the National Health Service at South London and Maudsley NHS Foundation Trust in the United Kingdom.

is a professor of psychiatry at Cooper Medical School of Rowan University. He is active in several national and regional organizations and published and presented on international medical graduates, culture, religion, family psychiatry, gender issues, etc. 

 is assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mt Sinai, New York, NY.

 is clinical professor and chair of psychiatry and behavioral science at the University of North Dakota School of Medicine and Health Sciences.

 is professor emerita, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada. 

 is a psychiatrist, the author of more than 300 peer reviewed papers, founder of Critica, and board member of the Social venture Fund for Arab Jewish Equality in Israel. 

 is professor emeritus in psychiatry at the University of California at San Diego, as well as the author of more than 100 professional articles and 6 books.

 is interested in exploring the intersection between childhood political trauma with immigration stress. She has been recently offered a fulltime research appointment as a visiting researcher at Harvard University in Cambridge, Boston.

 is medical director of the Child and Adolescent Psychiatry Clinic and Multidisciplinary Autism Program at ChristianaCare, Delaware.

1. 'I am grateful to be alive,' says Colleyville rabbi Charlie Cytron-Walker. 

. January 16, 2022. Accessed January 17, 2022. 

https://www.jpost.com/diaspora/article-692639

2. Council on the American Islamic Relations. CAIR condemns hostage-taking at Texas synagogue, working with local community leaders to learn more and provide assistance. January 15, 2022. Accessed January 17, 2022. 

https://www.cair.com/press_releases/breaking-cair-condemns-hostage-taking-at-texas-synagogue-working-with-local-community-leaders-to-learn-more-and-provide-assistance/

3. Omar Suleiman page. January 15, 2022. Accessed January 17, 2022. 

https://www.facebook.com/imamomarsuleiman

4. Gill D. Synagogue hostage-taker had ‘mental health issues,’ brother says. Daily Beast. January 16, 2022. Accessed January 17, 2022. 

https://www.thedailybeast.com/fbi-identifies-synagogue-hostage-taker-as-british-national-malik-faisal-akram

Articles

The recent hostage situation at a synagogue in Texas in indicative of a larger underlying problem. 

We Refuse to Hate

Our national attention has turned to Afghanistan, as the media shares disturbing pictures as news unfolds. Meanwhile, we in psychiatry hear related testimony from patients and colleagues, and are concerned that the withdrawal of US troops may lead to escalating mental health problems locally as well as internationally.

A recent encounter with an Afghan patient embodied the concern and brought the issue to the forefront of consciousness. The patient, who came to America years ago on a special visa based on his work with the US Army, presented with severe symptoms of posttraumatic stress disorder (PTSD). The PTSD was reactivated because of the unfortunate developments in Afghanistan.

I joined the war to act like a buffer. I wanted to protect my people, and also to serve America, the country I love and now call home. That backfired. Despite my best efforts, many people died because of wrong intelligence. Information I gave was ignored or misused. I am now left with the memories, the flashbacks, and the nightmares. How can I undo the damage I caused? I wanted to build schools, so the Afghan children might have a better future. But would God forgive me for taking part in killing?

The patient, wrestling with existential issues and navigating through many layers of shame, guilt, and taboo, was comforted by having a Muslim psychiatrist who shared his religion and aspects of culture. In turn, the cultural and religious understanding helped to create a safe therapeutic space and a sounding board for this patient in his search of meaning and healing.

We have also heard from a Jewish psychiatrist colleague, who entered the US Army as a psychiatrist in 1975, just as the Vietnam war was ending. He saw soldiers who developed unexpected symptoms after serving in Vietnam. Although PTSD as a formal diagnosis was relatively unknown at the time, Vietnam was an impetus to its deeper understanding. Upon arriving at his base in Alabama, a General told him and his physician colleagues that they needed to learn about soldiers because there would be another war in our lifetime.

Nobody could have known that the war in Afghanistan would be the longest war in American history, or that we would again abandon our allies when we left the country. However, despite all the comparisons being made with Vietnam, there is at least 1 big difference: The public has seemed relatively unconcerned with this war compared with the Vietnam war. Nevertheless, this clinician predicted a disaster when a specific Afghanistan withdrawal date was made public, (since it gave the Taliban a clear timetable to prepare for) and now is troubled by the escalating deaths, trauma, and losses, especially among families, women, and children.

Another colleague is a Muslim psychiatrist who wears a hijab. She took care of military veterans during her psychiatric residency training. Almost all of the veterans were being treated for PTSD stemming from the trauma they witnessed in the Iraq and Afghanistan wars(Operation Iraqi Freedom (OIF) and Operations Enduring Freedom (OEF)). [Often her presence, even as a care provider, was a trigger for them. Frequently the veterans would refuse to see her at the outset of their hospitalization because, as one patient put it, “24 hours before I came back home, I killed a woman who looks like you . . . how am I expected to flip the switch and work with you?”

In time, these reactions changed. In fact, over the course of the treatment program, many veterans reported that being treated by someone who looked like the individuals they were trained to fear and distrust was an important part of their healing. There were even some who, by the end of the treatment program, refused to work with anyone but her, reporting that it changed their views of Muslim and Middle Eastern individuals.

This experience reflects many layers of complexity. Veterans following orders experienced trauma and came home with severe PTSD, making it very difficult to return to a multicultural society. Clinicians have an ethical duty to do no harm, yet many Muslim clinicians understandably feel complex emotions when treating those who took the lives of their brethren. Most importantly, the moderate Muslims may be battling for their safety on 2 fronts: there may be forces from within as well as forces thrust upon them, both ultimately contributing to their ongoing intergenerational trauma.

The current trauma can only add to the intergenerational trauma in Afghanistan. Whether or not pulling the armed forces from Afghanistan is the right decision, it seems like better plans could have been made to protect those at risk. It is reminiscent of our ethical principle of not abandoning patients. If a transfer is needed, we cannot drop a patient until a new psychiatrist is involved. Moreover, when we terminate our therapeutic alliance with a patient, we try to do that slowly, reassessing how well that is going along the way. It would be flaunting medical ethics to arbitrarily pick a date just around the corner and abruptly leave.

Psychiatrists must decide whether or not to stand up and speak out against injustice. It may be a professional obligation, in line with the ethical principles of the American Medical Association, American Psychiatric Association, and World Psychiatric Association. These principles put patient needs first, but also include the ethical needs of society.

“A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health,” the APA’s adaptation adds “Psychiatrists may interpret and share with the public their expertise in the various psychosocial issues that may affect mental health and illness.”

This annotation covers our potential obligations to those at risk in Afghanistan. What can we say or, more importantly, what can we do to help them? As far as patient care goes, our troops will need special attention. How those who served feel about the sudden withdrawal may be crucial for how they process the trauma they encountered, especially from a moral injury point of view. Will they feel that their time and participation was wasted? Likewise, will this withdrawal be a trigger for troops who served in Vietnam and were traumatized and criticized for their participation?

In addition, potential patients are likely to come from those in Afghanistan who worked with the United States. If they stay alive and stay there, or become refugees, they are at risk for the repercussions of trauma, betrayal, and loss. Women and children seem to be a target of potential repression and abuse.

The World Psychiatric Association approved their first Code of Ethics for Psychiatry in October 2020, after 10 years of deliberation. That must reflect how difficult it is to come to a consensus on health and mental health values and virtues of various countries and cultures. Yet it has principles that seems relevant to Afghanistan

Psychiatrists advocate in particular for support for mental health programs, especially in but not limited to developing countries and in areas where care for persons with psychiatric disorders is non-existent or rudimentary…

Psychiatrists are aware of the deleterious consequences of family violence, emotional and sexual abuse on mental health and well-being, especially for women and children . . .

There is also another relevant professional ethical set of principles for physicians, those of bioethics, which focus on 4 main principles in individual patient care: beneficence, nonmaleficence, justice, and autonomy. However, when we speak of population health, we must insert 

 before beneficence, nonmaleficence, and justice. Social justice is population health. Social justice movements may come from outside the traditional lines of institutional power, such as Dorothy Day and the Catholic Worker Movement. Thus, although psychiatrists have their own institutional ethics, they must attend to outsiders’ voices, which may offer special guidance.

We must look inward. Have we, as the United States, had an arrogant attitude in our dealings with the rest of the world? Have we acted like we had the power to bend anyone, anywhere to our will? America is not alone in its hubris. Other nations such as the United Kingdom, for instance, played a significant role in military operations in Afghanistan and must accept some responsibility for the chaos that is rapidly unfolding.

This is not a new issue for our country and, therefore, not a specific criticism of any political administration. Instead, perhaps it is a reflection of a deeper psychological problem. This episode is reminiscent both of our withdrawal from Vietnam and our disengagement from Iraq in 2011. It is as if after we are humiliated by not winning a war, we have something to prove, and so we end up doing the same thing again.

This is very similar to a strategy that traumatized individuals often use: recreating the same traumatizing situation over and over in order to master it. Just as a traumatized individual might tend to do, sometimes impulsively and sometimes intentionally, the United States has jumped into situations we did not fully understand, leading to armed civil conflicts around the globe. Although we continue to be a world power, trust in us and our reputation may be deteriorating. Of course, in Afghanistan, we also cannot ignore that continuous wars, conflicts, and humanitarian crises have been ongoing since the Soviet invasion in 1979.

Some could argue that our intentions have always been good, that we intended to help the oppressed, to prevent bloodshed, and to democratize the world. But much of the world does not want to be democratized. Starting with Vietnam and ending with Iraq and Afghanistan (not to mention the many countries left in shambles in the aftermath of the Arab Spring and similar movements), we seem to leave behind wreckage and chaos, lots of civilian casualties, unfinished business, and collateral damage.

Reflecting on the speed with which Afghanistan has fallen, we feel overwhelmed by unfathomable human suffering and the amount of hurt we inflict on each other. Yet we can also choose to be part of the solution through healing activities. Just as our country is trying to reckon with the meaning of the death of George Floyd, we must search for actionable social justice in the midst of this tragedy.

What can be done? Individual mental health professionals can write to politicians and the public. They can raise awareness about the far-reaching effects of trauma and inform the public about the gravity of the situation in Afghanistan, which seems to be heading toward a humanitarian and refugee crisis. They can advocate for as many urgent evacuations of Americans, Coalition Forces, Afghan allies, and vulnerable women and children, as is practically possible. We can also collectively act in ways that engage, rather than shy away from, the silent pandemic of human cruelty. Perhaps the World Psychiatric Association can develop a rapid response team, a United Psychiatrists like the United Nations, to employ when international mental health is at risk. Similarly, perhaps a whole-world approach can bring in NATO and other countries, including China, Russia, and other Muslim countries.

Those who work in the military and the VA should be prepared for the troops’ reactions and be ready to provide education and care. We might anticipate and prepare for a rise in Islamophobia as the country goes through a restless stage of uncertainty and searches for someone to blame. All of these measures would be enhanced by harnessing the power of storytelling and social media to raise awareness about how important psychiatric care really is.

Besides these opportunities, the United States needs some longer-term psychological soul-searching, perhaps via a special Task Force called Operation Mental Freedom (OMF), to break the cycle of these failed invasions. Psychiatrists knowledgeable about intergenerational trauma and cross-cultural relationships are available to help.

Although the US government decides to withdraw from an issue by simply pulling our forces out of a country, it is not an easy task for mental health care professionals to withdraw emotionally and ethically. We are healers, and human suffering touches our very deep core. Thus, we must act accordingly.

–SPIRIT (Social Psychiatrists Interested in Recovery from International Trauma)

The multicultural group SPIRIT was assembled in May 2021 to publish the article “

An Interfaith Psychiatrist Prescription for Middle East Peace

. SPIRIT’s first piece was inspired by the collective concern about the escalating Palestinian-Israeli conflict.

is a practicing psychiatrist for Providence Healthcare System, Portland, Oregon. 

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of 

is Professor Emeritus in Psychiatry at the University of California at San Diego, as well as the author of more than 100 professional articles and 6 books. 

is Professor Emerita, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.

 serves as Kathleen & John Bricker Chair, Department of Psychiatry, LSUHSC. He also is Chairman of the Board of Trustees of the Cobb Research Institute and is the 113th Present of the National Medical Association. 

is Medical Director of Child and Adolescent Psychiatry Clinic and Multidisciplinary Autism Program at ChristianaCare, Delaware. 

is Assistant Professor of Clinical Psychiatry, Columbia University; and Research Psychiatrist, New York State Psychiatric Institute, New York, NY. 

is a Clinical Associate Professor of psychiatry at the Stanford University School of Medicine where she is the Director of the Stanford Muslim Mental Health & Islamic Psychology Lab, and the Director of its community organization: Maristan.org. She also serves as the Associate Division Chief for Public Mental Health and Population Sciences as well as the Section Chief of Diversity and Cultural Mental Health in the Department of Psychiatry and Stanford. 

is Clinical Professor and Chair of Psychiatry and Behavioral Science at the University of North Dakota School of Medicine and Health Sciences. 

is a Professor of Psychiatry at Cooper Medical School of Rowan University. He is active in several national and regional organizations and published and presented on International Medical graduates, culture, religion, family psychiatry, gender issues, etc.

is an associate professor of psychiatry at Harvard Medical School and a Fellowship Site Director for Brigham and Women's Hospital. 

is a doctor working in frontline psychiatry for the National Health Service at South London and Maudsley NHS Foundation Trust in the UK.

The Principles of Medical Ethics, With Annotations Especially Applicable to Psychiatry. 

American Psychiatric Association. The American Psychiatric Association Press; 2013.

2. Code of ethics for psychiatry. World Psychiatric Association. October 2020. Accessed August 17, 2021. 

What can psychiatrists do to help veterans, Muslims, immigrants, refugees, and all those affected by the US withdrawal?

Psychiatrists Concerned With the Afghanistan Situation: Ethical and Practical Issues

FIRST MAN: We should defend ourselves. An eye for an eye, a tooth for a tooth.

TEVYE: Very good. And that way, the whole world will be blind and toothless.

- From 1970 script of the play “Fiddler on the Roof” and often attributed to Mohandas Gandhi

“The three ingredients for healing relational wounds are safety, truth, and reconciliation, and in that order.” - Alisha Moreland-Capuia, MD

Achieving peace in the Middle East is a monumental task that seems to be ever evasive, daunting, and out of reach. A cease fire is welcome, but a far cry from what we want to achieve—lasting Middle East peace. The violence is also spilling over into increased conflict between groups in the United States. Muslims and Jews are subject to worrisome degrees of Islamophobia and Anti-Semitism. The Palestinian-Israeli conflict is an extremely complex tangle of issues to resolve, but a solution is possible, and imperative.

Both sides and their supporters need to abandon ultimately futile and self-defeating acts of violence and retaliation. Instead, they must embrace a more comprehensive and humble vision that takes into consideration the historical, geographic, religious, and cultural context of two cousin tribes that have wounded each other over generations. It is like a longstanding family conflict in which family members stop talking to one another and replace talking with hatred, necessitating therapeutic family interventions. Despite the reservations that some psychiatrists have on entering the social conflict sphere, these are, in fact, areas of psychiatric expertise.

As psychiatrists we know group dynamics. We know our tendency to scapegoat “the other”. We know how the powerful can divide and conquer less powerful groups. We know how to analyze leaders. We know the temporary but necessary pain of revealing and processing the truth. We know from Abraham Maslow, PhD’s pyramid of psychological needs that safety and security must be fulfilled before higher levels needs can be completed. We know that often deeper levels of traumatic causation need to be processed and dealt with before healing can meaningfully occur.

This is not a naive proposal by any means, though it may seem so to some. Inevitably, many will disagree with any Middle East analysis. Rather, it is a plea for change because doing the same thing over and over again, expecting different results, is the very definition of insanity. Constantly suspecting each other’s motives has not moved this protracted struggle even an inch out of square zero. As good as prior endeavors were—that is, things could have gotten even worse—they have not been nearly enough.

There are many intricate political and psychosocial dynamics that come into play to make this mission look impossible; however, fighting parties in other parts of the world have managed, for the sake of their children, to reach some kind of compromise that benefits all involved. Children in the blessed land should not continue to pay the price of our ignorance, false pride, and generational bigotry.

As Muslim, Jewish, Christian, Hindu, and Sikh psychiatrists, in a bio-psycho-social-spiritual model we sense this is a moral and spiritual crisis. We support peace among nations, safe and secure homelands, and opportunities for all. This is not at its essence a fight between Muslims and Jews, or between Arabs and Israelis. This is an ideological and practical war that often intentionally feeds cultish misinformation, especially via the internet, which artificially arouses emotions, leading to relieving emotional tension by ever-increasing violence. Peace-loving civilians lose their lives, while extremist groups and fear mongers run rampant.

Unfortunately, the media usually chooses to focus on the negative events occurring in the Palestinian-Israeli conflict, and ignores equally dispiriting, yet equally important, inter-ethnic tragedies taking place in places like Kashmir, Myanmar, China, Syria, Yemen, Iraq, and elsewhere around the globe. This disproportionate attention to one particular locale in the Middle East only enflames matters more. It leads the public to believe that this is a unique situation, when it is a tendency of human nature that needs to be overcome everywhere. Despite our paradoxically doing so in this paper, we include other examples and intend to address them more in the future.

Perhaps we can learn and apply a few lessons from countries like South Africa, Rwanda, and Bosnia, where warring tribes have seemingly learned to live together. The Truth and Reconciliation Commission was especially effective in helping to bring South Africa out of apartheid without a bloodbath. 

Big problems get resolved only when broken down into small pieces. The use of dialogue can—and should—start in our households, small intra- and inter-faith circles, and cultural communities. A group of international and interfaith psychiatric caregivers have come together to create a community of care and have produced two requested, well-reviewed books that can be used as tools towards healing: 

From these sources, here are some ideal prescriptions to start with:

- Dignity for all, established by working together respectfully for a common end

- Humiliation for none, which means hearing each other out

- Apologies by all, as saying “I’m sorry” and meaning it begins the healing of many wounds

- Gifts to the others, such as sharing assets and promoting each other’s strengths

- Neutral peace-maker(s), or the calling in of trusted third parties, which may ideally need to include mental health experts

- Teaching tolerance to children, both by parents and educators

- Addressing intergenerational trauma, which includes that affecting political decision-makers

Also, as psychiatrists, we know very well that an illness cannot be cured unless we address its root causes, and similarly we have the moral obligation to call for the immediate dismantling of bigoted and violent ideologies, dictatorships, and all structures and systems that support them. They are so damaging to the body, mind, heart, soul, and spirit of so many of the people.

These are simple, though not simplistic, aspirational goals. They are meant as an antidote to the common lament about how complex these situations are, so often leading to excuses about what cannot be done and what cannot be tried. Prayer and mourning must be supplemented with action.

We need a few small steps in addition to this manifesto. Some that could be taken by SPIRIT and like-minded groups include: joint business projects, a student exchange, common textbooks (especially in the early grades), shared vacation spots, media consultation, and joint research. We must look towards innovative and out-of-the-box solutions.

Members of SPIRIT are available for consultation and discussion. We welcome other like- hearted psychiatrists of any religious background, as well as those who are agnostic or atheist, to join our SPIRIT.

is practicing psychiatrist in Providence Healthcare System, Portland, OR. He has provided psychiatric and humanistic care to trauma survivors around the world.

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. He has recently been leading Tikkun Olam advocacy movements on climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

is Clinical Professor and Chair of Psychiatry and Behavioral Science at the University of North Dakota School of Medicine and Health Sciences.

is an associate professor of psychiatry at Harvard Medical School and a Fellowship Site Director for Brigham and Women's Hospital.

serves as Assistant Dean of Clinical Education at Charles R. Drew University and Chief Medical Officer of Kedren Health Systems Inc.

is Medical Director of Child and Adolescent Psychiatry Clinic and Multidisciplinary Autism Program at ChristianaCare, Delaware.

is an assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai, New York, NY.

is a psychiatrist, the author of more than 300 peer reviewed papers, founder of Critica, and board member of the Social venture Fund for Arab Jewish Equality in Israel.

is Professor Emeritus in Psychiatry at the University of California at San Diego, as well as the author of more than 100 professional articles and 6 books.

interested in exploring the intersection between childhood political trauma with immigration stress. She has been recently offered a full-time research appointment as a Visiting Researcher at Harvard University, in Cambridge, Boston.

is a Clinical Associate Professor of psychiatry at the Stanford University School of Medicine where she is the Director of the Stanford Muslim Mental Health & Islamic Psychology Lab, and the Director of its community organization: Maristan.org. She also serves as the Associate Division Chief for Public Mental Health and Population Sciences as well as the Section Chief of Diversity and Cultural Mental Health in the Department of Psychiatry and Stanford.

1. Moffic HS, Peteet J, Hankir A, Awaad R. 

https://www.springer.com/gp/book/9783030005115

2. Moffic HS, Peteet J, Hankir A, Seeman, M. 

https://www.springer.com/gp/book/9783030377441

A cease fire is welcome, but a far cry from what we want to achieve—lasting Middle East peace.

We are at a crossroads in our understanding and approach to psychosis. Biological paradigms and treatments are narrow in their understanding of psychoses and limited in their ability to promote recovery. There is evidence that some psychotic experiences are “normal,” some are traumatogenic, and many are self-limiting and growth-promoting.

Psychiatrists who treat patients with psychosis in institutional, community, and crisis settings provide evaluations and medication management but rarely consider psychotherapeutic interventions.

 However, such interventions can be critical in recovery. Current guidelines recommend cognitive behavioral therapy (CBT) as evidence-based psychotherapy for schizophrenia.

CBT for psychosis (CBTp) follows the general principles and approach of therapy for depression and anxiety with some modifications to address positive psychotic symptoms, cognitive deficits, and stigma associated with psychosis. The stages of therapy include building a therapeutic alliance, developing a formulation, specific interventions to build skills to address symptoms and improve functioning, relapse prevention to enhance resilience, and specific interventions to address stigma.

Ideally CBTp consists of at least 10 sessions over a 6-month period with specially trained therapists. Although CBTp is not widely available, a variety of CBTp-based interventions can be used widely. These components, which take 5 to 20 minutes, are clinically effective.

 The mnemonic CUT-PAR (connect, understand, teach, practice, ask, review) denotes the basic framework of these interventions (

). A deeper connection with a psychotic patient is possible when the psychiatrist has a compassionate attitude, mental state of mindfulness, and uses a variety of strategies as detailed in the Table. Understanding the problem includes turning the existing problems into an actionable plan and enhancing motivation to take action. The take-home work is tailored to the patients’ cognitive and motivational capacities and can be as simple as reading given material or rating mood in different situations.

Asking for feedback reduces the power differential and allows the psychiatrist to change his or her intervention or style. The importance of feedback is even more important when a patient is from a different cultural background.

 The patient reviews the session, and the psychiatrist adds to it. The psychiatrist may want to provide index cards or a notebook for the patient to write down what was learned in the session as well as any take-home assignments.

The CBT approach to delusions is based on the principle of collaborative empiricism. The psychiatrist approaches the delusional belief with an open mind and in a spirit of discovering the truth-akin to the method of a true scientist. There are 8 targets for interventions in delusions.

The first is addressing distress associated with delusions through empathic exploration. 

Mary, a 32-year-old woman, believes that men are entering her house at night and talking about rape. The psychiatrist might say, “It must be very scary for you at night when you are hearing this talk about rape.” Such a response helps the individual lower her defensive stance and discuss her distress. The follow-up would be to bring up any existing coping mechanisms with a question such as “Can you tell me what helped you to deal with this situation for the past 3 weeks?” Psychiatrists often find useful information about the unique coping strategies of their patient. In the above scenario, Mary found prayer to be helpful in protecting her.

Sometimes a lack of real-world information can contribute to the development of delusions, and an intervention to explain how things work in the real world can sow a patient’s doubt of the delusion or change how a patient responds to a delusional belief.

 Annie, a 35-year-old woman, stopped taking her antipsychotic medication because she believed that the pharmacy had given her a different-colored pill to poison her. In this instance, the psychiatrist educated Annie about generic medications and about the FDA, which monitors every aspect of medication manufacturing, distribution, and dispensing. Once Annie learned about the oversight of pharmacies, she agreed to go back on the medication as a trial.

A third area in which one can intervene is by narrowing the sphere of delusional thinking with specific questions. 

Peter, a 40-year-old man, came into the office anxious and mildly agitated because of a persecutory delusion that people were trying to run him off the road on his walk to the clinic. The psychiatrist asked him whether he felt safe sitting in the office. Peter responded that he did feel safe. With subsequent questions, he reported feeling safe in waiting areas, parking lots, and even the side street-the delusions were activated when he was alone on a busy street. Peter was able to recognize the reason for his distress. He acknowledged that by avoiding busy streets he would be less distressed. He left the session with a sense of better control over his situation.

A fourth area is to evaluate the evidence for and against a particular delusion by asking the patient to think of himself as a prosecutor and present evidence for the delusion; 

the psychiatrist is the defense attorney who looks for gaps in the evidence. Then the roles can be reversed. After the discussion, the psychiatrist asks the patient for his perspective on his delusional ideas.

A fifth area of intervention is to ascertain the origin of the delusion. 

The patient is asked to describe the origin and the progression of the delusional ideas. The onset of delusions is usually fraught with doubt about the delusion itself. Once these doubts are unearthed, they can be strengthened.

A sixth intervention is to address the utility of the delusion for the individual. 

An interesting example of this intervention was given by Dr. Aaron T. Beck.

 He described a patient with a grandiose delusion of being Jesus Christ. Dr. Beck asked his patient to come up with a list of the benefits of being Christ and then asked him to think about the downsides. The patient realized that it meant he would be crucified. The outcome of the intervention was that a doubt was sown in the mind of the patient about the utility of this belief.

A seventh area of intervention is judicious self-disclosure.

 Jason, a 50-year-old man, refused to take showers because of a belief bordering on delusion that he would get pneumonia from taking a shower. The origin for the belief was his childhood experience of getting wet in the rain and contracting pneumonia. This delusion was activated by the boarding home operator who insisted that Jason take showers frequently. The psychiatrist used self-disclosure to inform Jason that he had been taking showers every day for decades and never developed pneumonia. The patient’s homework was to take showers twice a week for 2 weeks, to which he agreed.

The final intervention is to address the theme underlying the delusional belief

-in persecutory delusions it is safety, and in grandiose delusions it is trying to overcome a perceived personal weakness. The outcome for any intervention varies and includes that the client feels he is being listened to, feelings of relief, a stronger therapeutic relationship, weakening of delusional belief, a change in dysfunctional behavior, and facilitation of adaptive behavior.

The first step in dealing with hallucinations is a detailed evaluation that includes the triggers, content, beliefs about hallucinations, stigma associated with hallucinations, and behaviors of acting out or resisting command hallucinations (

). If the hallucinations have positive content and the patient is not distressed by them, no intervention is necessary. For stigma and demoralization, referring patients to websites such as a hearing-voices network can provide access to stories of individuals with voices and encourage them to join a local hearing-voices group.

 Command hallucinations can be addressed by finding alternative behaviors that are more adaptive. For example, a patient called her mother several times at night to scream at her because of derogatory voices. A substitute behavior was found: disconnecting the phone at night and talking into it when upset.

The outcome of interventions for voices can include learning more about triggers to avoid, enhanced ability to control the voices, being able to ignore the commands, or learning to accept them without letting them interfere with functioning.

Disorganized thinking interferes with communication, and anxiety worsens disorganization. Addressing anxiety is one way to reduce disorganized thinking. The psychiatrist takes on the role of a coach and employs strategies such as changing the topic, enhancing support, narrowing the focus of conversation, and using breathing meditation techniques or progressive relaxation. When disorganization is present without anxiety, the intervention is to bring it to the patient’s attention by using an “I” statement, such as “I am having difficulty understanding what you are saying. Can you limit what you say to 3 or 4 sentences and wait for me to respond or clarify.” The psychiatrist also keeps his talk to 3 or 4 sentences. If the patient is open to feedback, the psychiatrist lets the patient know when the conversation is clear and when it is not.

Medication nonadherence rates are as high as 47% to 95% among patients with schizophrenia, and optimal utilization of medication is an important part of the recovery process.

The task of the psychiatrist is to identify, acknowledge, validate the medication, and empower patients to make medication decisions in a shared decision-making model. Subjective adverse effects described by the patient are given as much importance as the objective ones observed by the psychiatrist, and medication is framed as a tool to reduce distress and improve functioning-and not as an end in itself. Some of the more specific techniques used to facilitate medication decisions are an evaluation of cost-to-benefit of medication, linking medication decisions to life goals, and complementing information from the patient with objective information from peers or other support systems following the patient’s preferences wherever possible.

When added to medication management visits, CBT interventions improve the therapeutic alliance, reduce stigma associated with psychosis, build skills to self-monitor and manage symptoms, reduce reliance on medication, and promote recovery. Moreover, these interventions reinforce skills learned by patients who undergo formal CBTp. Psychiatrists will find the extra few minutes spent with the patient to be personally enriching and professionally satisfying while improving outcomes and satisfaction for patients and their families.

Dr. Pinninti is Professor of Psychiatry, School of Osteopathic Medicine of Rowan University, Stratford, NJ; Dr. Gogineni is Professor of Psychiatry, Cooper Medical School of Rowan University. The authors report no conflicts of interest concerning the subject matter of this article.

 Longden E, Madill A, Waterman MG. Dissociation, trauma, and the role of lived experience: toward a new conceptualization of voice hearing. 

 Pilling S, Bebbington P, Kuipers E, et al. Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behavior therapy. 

 National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. NICE Guidelines. 2014. 

http://www.nice.org.uk/guidance/cg178/chapter/1-recommendations

The Center Cannot Hold: My Journey Through Madness.

 Pinninti NR, Stolar N, Scott T. A 5-minute first aid for psychosis: defuse crises, help patients solve problems with brief cognitive therapy. 

 Rathod S, Kingdon D, Pinninti NR, et al. 

Cultural Adaptation of CBT for Serious Mental Illness: A Guide for Training and Practice

. West Sussex, UK: Wiley Blackwell; 2015.

 Aaron T. Beck Psychopathology Research Center. 

 Sendt KV, Tracy DK, Bhattacharyya S. A systematic review of factors influencing adherence to antipsychotic medication in schizophrenia-spectrum disorders. 

 Bressington D, White J. Recovery from psychosis: physical health, antipsychotic medication and the daily dilemmas for mental health nurses. 

 Deegan PE, Drake RE. Shared decision making and medication management in the recovery process. 

Psychiatrists who treat patients with psychosis in institutional, community, and crisis settings provide evaluations and medication management, but rarely consider psychotherapeutic interventions. However, such interventions can be critical in recovery. 

Rama Rao Gogineni, MD

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