Rama Rao Gogineni, MD

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.

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

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.

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

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. 

Islamophobia and Psychiatry: Recognition, Prevention, and Treatment

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

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

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

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

Articles

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

An Interfaith Psychiatrist Prescription for 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.

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 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

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 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. 

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 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

Articles

An Interfaith Psychiatrist Prescription for Middle East Peace

Brief Cognitive Behavioral Therapy Interventions for Psychosis