What are the scariest themes from a 50-year career in psychiatry?
PSYCHIATRIC VIEWS ON THE DAILY NEWS
Today is Halloween, an annual day devoted to being scared. Children and adults dress up in sometimes scary costumes, knock on doors yelling out “trick or treat,” and hope for getting treats. It seems like the editors of Psychiatric Times™, in asking what we psychiatrists think the scariest topics in psychiatry are, realize that there are lots of scary things in the house of psychiatry.
When I started to brainstorm what I thought was scariest in psychiatry over my 50-year career, I got scared because there were so many scary topics. In fact, I have come to think that my whole career could be described as a really scary one.
It seems like what I chose to do was almost always somewhat frightening and my reaction was our inborn tendency for “fight or flight” from these perceived risks or danger. Here are some of those scary topics.
Psychiatrists may be fortunate in the sense of not having many patients die in comparison to some other medical specialties, but when one does, usually by suicide (other than physician assisted deaths), it can be particularly devastating. It was for me as a second-year resident in 1973. After seeing an elderly married man with depression for an evaluation, he walked into Lake Michigan and drowned.
Fortunately, instead of being kicked out of the residency, I found the treat of support and sharing of responsibility from faculty. I decided to focus on such high-risk patients and never did have another suicide, in part because I learned to watch for the paradox of someone looking better for no obvious reason right before they tried suicide, having become relieved by their decision.
There is a Jewish saying that to save a life is to save the world. Perhaps that is why suicide is still such a scary topic in psychiatry to me.
When I was being recruited to the Medical College of Wisconsin in 1989, I was asked if I would start up an academic managed care program, the first in the country. That sounded scary because organized psychiatry was beginning to become very critical of it after participating in its early development. I asked my mentors and respected elder colleagues what to do and they were split.
I decided to take the job in order to be a participant/observer from the inside. It was a challenge, first not to lose money with captivated contracts. Then, at a Wisconsin Psychiatric Association conference, the President of the American Psychiatric Association at the time publicly called me “evil,” later to apologize to me privately.
Those mixed reactions led to my agreeing to do the first book on the ethical challenges, a book that also received mixed responses—including 2 separate major reviews over time—but is still relevant.1
There have been critics of psychiatry ever since its emergence as a field, but that escalated after a journalist put out a book concerned with what he felt was insufficient recognition of the problems of psychopharmacology.2 Meeting this author at a Group for the Advancement of Psychiatry meeting, I was asked to write for the new online publication MadInAmerica. I did so, but felt tricked as my first blog, on the value of psychiatrists, got blasted. So did some following columns.
These blogs allowed for comments and one was that “all psychiatrists should be thrown under the bus.” My wife saw that, got scared, and I stopped writing for them.
For better or worse, there is still much conflict, lately being about the relevance and use of the serotonin hypothesis in depression, which I think can be either a trick or treat!
Late in my academic career at the Medical College of Wisconsin, the Chair asked if I would work part-time at a men’s medium security prison. It was about the only kind of psychiatric setting and system I had not worked in or led.
Not wanting to be tricked, I again asked colleagues for their opinion and one who worked there said that “the scariest aspect was driving there and not hitting a deer.” Yet, I still hesitated after the chief state prison psychiatrist gave me 3 instructions: do not wear a tie, do not shake hands, and put your chair closer to the door.
With some trepidation, I tried it out. The facility looked like a Holocaust concentration camp when I first came. I was yelled at by a guard when I ran in the rain.
Nevertheless, it proved to be an invaluable experience and I won a health care journalism award for writing about it. I learned much about sociopathy, including that its presence is much higher outside of prison, especially in corporations. I also learned that most of the overrepresented young Black males had posttraumatic stress disorder and not sociopathy. I encountered “evil” once again, but this time, for the first time, I thought in a patient who might be evil because I could not find any other explanation for his thinking and behavior.
Mostly, when something felt scary in psychiatry, I tended to react with fight, at least for a time. However, for one unrecognized challenge, I decided on “flight.” As for-profit managed care escalated, time with patients decreased at my medical school to the point where psychiatrists were forced to schedule patients mainly for 10-minute medication checks.
After I decided that was not ethically competent patient care, I retired in 2012, only to find out from a retired emergency medicine physician that I had burned out. To try to prevent that trick for colleagues, reducing burnout has become a focus over the past decade.3
Sorro to the Rescue
There certainly have been other scary psychiatric moments: collegial wokeness, finding a staff member dead in his bed from a gun suicide, climate instability, careless psychedelic use once again, and mental health family challenges, among them. Along the way, I tried to find a model or alter ego to support my fights. For one Halloween party for psychiatrists many years ago, I picked a Zorro costume, the legendary fighter for social justice, but instead of physical process, I would use psychiatric wisdom.
To personalize Zorro, I used the name Sorry, the S being for Steve. My motto was: “You’ll be sorry.”
Personally though, despite all the frightening aspects of psychiatry that I have encountered, I have not been sorry to have done so; however, I have come now to the time to look for—and find—more of the joy and awe of psychiatry and society.
Dr Moffic 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 related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of Psychiatric Times™.
1. Moffic HS. The Ethical Way: Challenges & Solutions for Managed Behavioral Healthcare. Jossey-Bass; 1997.
2. Whitaker R. Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. Crown; 2010.
3. LoboPrabhu S, Summers R, and Moffic HS, eds. Combating Physician Burnout: A Guide for Psychiatrists. American Psychiatric Association Press; 2019.