Our Collective Responsibility

Source: “Doomsday Clock”/Ryanicus Girraficus

A critical moment has arrived. Last week, the Bulletin of the Atomic Scientists moved the hands of their “Doomsday Clock” closer to midnight. The clock is now as close to the symbolic hour of apocalypse as in 1953, the height of the Cold War. The reasons that the Bulletin president Rachel Bronson gives are curious: “reckless language in the nuclear realm [heating] up already dangerous situations,… minimizing evidence-based assessments regarding climate” (Mecklin, 2018, p. 1). They point not only to an inevitable condition or a natural evolution, but to behavior that arises from a mental state, which could change tomorrow. “This is a dangerous time,” the Bulletin’s statement notes, “but the danger is of our own making” (Mecklin, 2018, p. 6).

Never has the role of psychiatry in world affairs—indeed, the world’s survival—been more important. We have been living with the technology for a while, but can we contain our own impulses? Hardly a week goes by without the relevance resurfacing—and intensifying. Yet rather than responding to the call or taking on any leadership, the field’s main professional organization has gone to great lengths to try to silence the profession. In an unprecedented move, the American Psychiatric Association (APA) expanded the Goldwater rule (the ethical guideline prohibiting the diagnosis of public figures without a personal interview) into a “gag rule,” as many have called it, two months into the current administration. It serves effectively to block any input by psychiatrists on any matter affecting the administration.

The decree appeared on March 16, 2017, in a three-page reinterpretation of a two-line rule, now prohibiting not just diagnosing but making any comment on any aspect of a public figure’s observable affect, speech, or behavior, even in an emergency. It did not seem to matter if the expansion ran afoul of the ethical principle the rule fell under (that psychiatrists contribute to public health) or the primary principle of medical ethics (that we have a duty first and foremost to human health and safety). There was no scientific or philosophical justification for this expansion, and scholarship rather ran counter to this trend (Lilienfeld, Miller, and Lynam, 2018) on January 9, 2018, when the APA again reasserted its very broad interpretation of the Goldwater rule.

Surely it is problematic to change norms and standards under political pressure. An extreme situation may call for a commensurate description, and it does not help the public or the integrity of the profession to compromise medical neutrality, or the principle of applying the same medical standards to all persons, regardless of political affiliation. Modifying standards and even ethical guidelines to make the abnormal appear normal may even be harmful. Above all, like the rest of medicine, mental health has at its core the mission to prevent deaths and to save lives, and to improve the lives it saves. Like the rest of medicine, it has a duty to individual patients as well as to society, to extend care as well as to improve conditions in ways that prevent suffering.

Psychiatry has traditionally been highly focused on the individual, and person-centered care and the intimate meeting of humans are unique strengths worth preserving. However, knowledge gained about human beings in these areas could contribute greatly to a larger social, cultural, and society-level conversation. Global health and global psychiatry have demonstrated this importance. For example, core mental disorders remain consistent throughout a wide range of societies, but attempting to describe them through the lens of white, middle-class North American and European study subjects leaves 80 percent of the world’s population presenting “atypically”. We have also seen the isolation that comes with dubbing posttraumatic stress disorder an individual problem in the context of wars, conflict, and migration, instead of a social problem that needs collective addressing and healing. Cultural knowledge and interchange among different societies have helped to bring a broader awareness, especially as mental disorders are now the world’s leading cause of disability.

Violence prevention, another area of mental health professionals’ growing involvement, has shown that a strict separation between individual and environment is not always possible. The social, economic, and cultural influences are so stark, even in individual violence, that the World Health Organization (WHO) has adopted an ecological model for it. Doing so has made a condition that was once “untreatable” entirely predictable and preventable. Regarding societal trends that produce epidemics of violence, individual characteristics tell us very little, while social conditions tell us a lot. The WHO and other United Nations (UN) bodies documented, for example, how 133 countries changed nationwide policies and instituted laws to reduce global homicide rates by 16 percent in 12 years (WHO, UN Office on Drugs and Crime, and UN Development Programme, 2014).

Now the time has come for the greatest challenge of violence prevention we have faced. At this critical juncture, psychiatry would do well to find its place in the larger community of human efforts. Nothing about psychiatry makes it exclusive or exclusionary. Mental impairment is neither so exceptional as never to be spoken of, nor is it so trivial as to allow us to pretend it does not exist. Mental afflictions are just as real, just as debilitating, and just as widely varying as physical ailments, and we should educate about them without secrecy or shaming.

A high-power position is not immune to mental instability, but rather when it occurs, it can have wide-ranging consequences for public health and needs to be discussed—even if the solution is not ultimately psychiatric. The absence of psychiatry in societal discussions will not be neutral, as history has shown. Mental health has a humanitarian obligation that extends not just to individual patients but also to society, an obligation that is shared with public health, social work, sociology, anthropology, religion, law, political science, economics, and journalism, just to name a few. Restoring the human community to wholeness should be a collective effort, and psychiatry cannot be absent in that conversation, much less in a moment of crisis: at stake may be the capability to end civilization with a single stroke.