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Friday, July 16, 2021

Book Review: Not to People Like Us by Susan Weitzman



"If you think I support domestic abuse-- if you think my not explicitly writing, ad nauseum, "NO TOLERANCE" or "IT'S NOT THE VICTIM'S FAULT" is evidence that I think "sometimes the bitch deserves it "then I can tell you without error that [this year] is going to be way too complicated a year for you to endure, and you are seeing a psychiatrist, and it isn't helping. Stop being you. The world does not have to validate your prejudices." ~ The Last Psychiatrist.

 

Warning: Since I am writing about domestic abuse, I quote the Last Psychiatrist before people start accusing me of “victim blaming” or “excusing the abuser.” Obviously, people who injure other people are committing a crime and deserve to be in jail. But that doesn’t mean the victims have no responsibility for any self destructive behavior (which BTW is NOT a crime) they exhibit – like returning to their abusers again and again and protecting them by keeping the abuse secret. 

As Michael Kerr once said, when it comes to relationships: “It’s all my fault” and “I had nothing to do with it” are both irrational ideas. The sad part about this is that absolving the victim of any and all responsibility for their predicament often has the effect of making them feel more helpless, useless, and resigned to their fate. The people who do this to them are without a doubt harming the very people they claim to be helping.

The book being reviewed here is about upper class, affluent couples in which the men physically and mentally abuse their wives. The author believes the couple dynamics in this population are different than in those in poorer communities. Strangely, most of the women she discusses are highly-educated professionals or have high paying jobs, and some of them even earned more than their husbands.

The most interesting thing about this book for me is the author. As I read it, I kept wondering if she thinks these women are as stupid as they act, although she is clearly questioning that proposition. She spends half the book wondering about how such bright, educated woman can believe their bullcrap excuses for staying in these relationships, and blame themselves for the abuse (although some of them did admit to provoking it, to supposedly make the beatings more predictable), and the other half buying into their rationalizations.

I wondered why the author didn’t question some of her own assumptions. For instance, she says most of these women she has interviewed did not come from families of origins in which there was significant spousal abuse. Well, maybe, but how can she know she is being told the truth about that? 

These women often lied about the abuse from their husbands to everyone for years, and even to other therapists, before coming clean. Some of them told their mothers about it, and the author admits that their mothers essentially blamed them for the abuse and told them to go back to their husbands. And in her chapter on the children from these relationships, she says, “…they too feel that they must hide the family secret.” If the abuse victim grew up in such a family, wouldn’t that characterization apply to her? So what on earth makes the author believe these women would suddenly become paragons of honesty about their parents when they come to see her?

Some of the women also claimed to think that they would be left penniless if they were to leave their successful husbands, even though many have or had successful careers themselves, and that their husbands will be able to manipulate the courts so they would never get alimony or child support. Well, rich successful men sometimes are able to do that, but in what alternate universe are there no attorneys capable of forcing otherwise reluctant men to fork over the cash? Maybe these cases where the rich men prevail are won partly because their wives hired lawyers who secretly believe that she really did deserve what she got. 

Why are they hiring such terrible lawyers? Weitzman brings up the O.J. Simpson case as an example, but apparently does not know how badly the prosecutors botched the case. (This is brilliantly described in the book Perfect Pitch by Jon Steel).

Then there is the book’s title. These women allegedly hide the abuse because they sort of think it isn’t supposed to be happening in their social circles, and they are ashamed. But if someone is beating the crap out of you, why would you care whether or not it was happening to anyone else? It’s clearly happening to you, and it’s clearly evil. If fact, if you really thought your situation was that unusual, that would highlight how unacceptable it ought to be.

And another implicit premise here seems to be that being embarrassed is worse than having your jaw broken! Really???

The stories the author relates literally reek of gender role conflicts in both the husbands and wives, but gender roles barely rate a mention. Despite the author’s psychodynamic training, the concept of intrapsychic conflict seems foreign to her, let alone her having an understanding of family systems issues and the power of groupthink and kin selection. 

For example, despite being successful career women, many of these women expected, and were expected by their husbands, to do all of the domestic chores and child rearing. One father wouldn’t even get up to feed the baby when mommy was violently ill. A lot of the couples also stopped having sex while the man was off having multiple affairs – the old Victorian whore/Madonna conflict in the flesh.

The author correctly points out that most of these men have narcissistic personality disorder, but she does not understand the family dynamics of it. (As my readers know, my views of that are different than the prevailing wisdom). She does make the accurate point that one of the DSM criteria for this disorder, lack of empathy, is incorrect. These men have very good empathy. The problem is they use it in order to more successfully manipulate other people to get what they want. Not having something is obviously not the same thing as using something one has in the service of bad intentions.

The author does acknowledge that these women did seem to ignore red flags when they first meet their husbands, but seems to downplay the significance of this, and offers no convincing explanations of why they would do this. In fact, as I like to say, there are often more red flags than at a meeting of Chinese communists.

Oh well.

Tuesday, June 22, 2021

Substance Abuse: Self-Destructive Behavior






 "The surest way to humility is humiliation” ~ commonly heard saying at Catholic 12-Step meetings in Ireland

 

It seems like the debate over whether or not substance abuse is a “disease” is never ending, as described recently by fellow blogger George Dawson. I really don’t want to get into the particulars of that, because the debate is almost always a waste a time due to the multiple definitions of the word disease that get employed and continually conflated in such debates.

 

I’d rather focus on one main issue: How much control do most addicts have over their drug use? My opinion is that the question can best be answered by re-classifying most, though maybe not all, substance addiction behavior as self-destructive behavior. Voluntary. If it were not voluntary, addicts would have next to no control over when and under which circumstances they chose to not indulge, no matter the consequences. Almost no addict is using 24/7 unless they are actively suicidal.

 

Now, some people might argue that substance abuse might be a form of obsessive-compulsive disorder. When people with OCD who have compulsions do not engage in their compulsion, their anxiety level skyrockets. This may be due to clearly abnormal firing of some nuclei in their brain. While they can certainly choose to let their anxiety skyrocket, this choice is indeed very difficult.

 

However, skyrocketing anxiety can have another cause besides the clearly pathological firing of brain nuclei. It can also be caused by panic over anticipated consequences of engaging or not engaging in a particular behavior. If doing so might lead to massive invalidation by everyone a person knows and cares about, then doing so becomes very difficult because of kin selection and tribalism, two subjects I have previously blogged about extensively.

 

Although, due to our current state of knowledge about the brain – literally the most complicated object in the known universe – there is no way of knowing for certain if most substance abusers indulge because of feared consequences of not indulging, or because of abnormal brain firing of some sort. And of course there may be two different types of addicts, so either or even both possibilities may be true depending on which addict one is dealing with.

 

Based on my clinical experience with all sorts of self-destructive and self-defeating behavior in my psychotherapy patients, I’m going to come down on the side of feared consequences for most of them. So am I saying an addict’s family system needs them to continue to be addicts in some way? Well yes, that’s exactly what I am saying.

 

If this is the situation, it does not make sense to ask the question of whether or not the addict wants to be an addict, because in fact they would be ambivalent about it (intrapsychic conflict, the primary concept in psychoanalysis – what a novel idea!). While some substance use in moderation in some contexts is indeed pleasurable, the life of an addict is anything but. They hate what the drug does to them. Many no longer even get high from cocaine after extended use, for example. And if getting high really made them feel so good, then why aren’t addicts the happiest people around instead of some of the most miserable? The problem is that the feeling of existential terror due to kin group invalidation feels even worse. So they indulge. Self-destructively.

 

Now, the family groupthink issue which triggers any given family’s need to have an addict in their mist to remain stable is not always the same, so each family has to be evaluated individually on its own terms. But let me discuss the most common example of such an issue: Puritanism.

 

Puritans on the whole believe, to put it bluntly, that we are nothing but sinful piles of crap in God’s eyes, and that we have to be sinners because, well, all people are sinners who must therefore ask for God’s forgiveness. So, as clearly stated in the 12 steps, which are based on Protestant conversion techniques, our will must be a problem. If we are willful, we simply must come to a bad end. The only way out is to renounce our will and turn it over to a “higher power” - which is actually the group to which we belong. And do what they want us to.

Did someone mention willfulness there?

I’ve heard docs from 12-Step programs give talks at medical meetings during which they would tell the most humiliating stories about their own crazy behavior when they were using – a public version of what they do in meetings. Essentially, these folks are substituting a less harmful form of self-abasement for a more harmful one. Just like the Irish slogan at the top of this post says rather overtly. I suppose that’s the better of the two options, but it’s still self-destructive. But it makes their conflicted parents feel better about not acting on their own forbidden impulses. While having already received vicarious satisfaction of these very impulses watching their children indulge. Heaven forbid anyone might feel good about doing something selfish.

Friday, May 28, 2021

Why Fat Shaming is Counterproductive

 


"If you are overweight and your parents are overweight, the inclination is to blame genetics...did fatness genes get passed on, or was it overeating behavior? After all, fat people tend to have fat pets." ~ Tim Ferriss


As most of my readers probably have noticed, there has been in the media a lot of talk about “acceptance” of obesity and “body positivity.” People who dare to criticize the obese for leading what is clearly a highly unhealthy life style which both shortens their average life expectancy and leaves them more vulnerable to a whole host of rather unpleasant diseases like serious COVID complications are torn apart for being “fat-shaming” monstrous, offensive people who are trying to shame people for how they look. TV talk show hosts Bill Maher and James Cordon got into a public tiff about this.

We now have plus sized Barbie dolls as well as celebrities like Lizzo sing the praises of having a large body. How dare anyone “fat-shame” anyone?

Actually I agree that fat shaming is a waste of time and is in fact counterproductive, but maybe not for the reasons most people think. On the other hand, turning unhealthfulness into a virtue is not exactly a smart thing to do either.

Now of course some people put on weight much more easily than others. Some people have diseases like hypothyroidism which cause obesity, although they are treatable in the majority of cases. But significant obesity (and I am NOT talking about just being somewhat overweight) is due to serious over-eating and avoiding exercise which is, like I will say about substance abuse in an upcoming post, self-destructive behavior.

It is certainly not genetic, as there has been a huge uptick in the number of obese individuals in many countries over the last thirty years or so, and to my knowledge there have been no selective breeding programs for obesity. There were very few kids with weight issues when I was in school in the fifties and sixties – unlike today.

In my model, self-destructive behavior is a form of self debasement designed to keep the person from self-actualizing in a way that might seem to threaten family homeostasis. In this model, obese people do not need to be shamed, because they are already feeling ashamed of themselves. In fact, they are frequently doing what they do in order to generate shame! They are, in a sense, trying to feel bad about themselves. Therefore, if you shame them, you are in fact reinforcing this tendency, and they get worse rather than better. The shaming serves as a “reward” (in the behaviorist sense, although certainly not in the usual sense) for the behavior that leads to the obesity!

Of course, if other people don’t say anything about the problem, the self-destructive behavior still continues. Truly a damned-if-you-do, damned-if-you-don’t situation for anyone who is truly concerned about the health and safety of an obese individual.

The key to solving this issue is understanding of and empathy with the collective forces that have led to this unfortunate behavior, and honestly taking responsibility for one’s own behavior. A tall order for those enmeshed in this kind of groupthink.


Friday, May 14, 2021

Healthy versus Unhealthy Love




It's best to be able to take care of your spouse's needs while still being true to yourself and taking care of your own as well.

 https://www.relationsarea.com/what-is-the-difference-between-healthy-and-unhealthy-love/

Thursday, April 29, 2021

Book Review: The Quick Fix by Jesse Singal



 

As someone who has been a critic of many of the excesses and science fiction currently present in clinical psychology, psychiatry, and psychotherapy, I have often been frustrated by how little attention has been paid in these professions to the problems that I bring up. Yeah, I know, awwww, poor me, people won’t listen to me. But aside from my narcissistic injury, a lot of patients are receiving substandard care due to the alignment of the forces described in the masthead of my blog.

This excellent and entertaining book by Singal tackles similar issues that have recently been plaguing experimental and social psychology. For those who don’t know, the field of academic psychology is actually two separate fields: clinical psychology, which deals with psychotherapy and other treatments for people with psychological problems, and experiment psychology, which studies both normal and abnormal psychology from an academic perspective. Interestingly, these two branches of the academic discipline are often very critical of each other, and members often refuse to communicate with one another.

Singal’s focus is on what he clearly shows is an explosion of overly-simplified ideas about how to change widespread social behavior, which have been widely taken up by politicians, corporations and the media and praised in TED talks, but which are often backed by very weak and inconsistent evidence that was obtained by highly suspect means and invalid experimental designs. 

Unfortunately, quick fixes have a strong appeal to human beings who are often averse to complicated formulations that look at the wide variety of different influences on human beings that results in their overall behavioral tendencies.

He tackles such widely-believed ideas as the importance of self esteem, fear of so-called “super-predators,” and the belief that societal forces like sexism and racism can be defeated by victims who act as if they were powerful, have grit, or think positively. He looks at notions of “implicit bias” that corporations have been using to train their employees to make themselves feel better about decreasing racism and sexism in their midst—without actually doing anything about the explicit biases which are really at the heart of the problem. Let’s focus on repairing individuals without any reference to the collective forces with which they are faced! Gee, sounds a lot like my criticism of the current treatment of patients with personality disorders.

He brings up, often in very humorous ways,  frequently ignored issues that are widespread in psychological research such as self-report bias, third variables that aren’t even considered, the fundamental attribution error (familiar to my readers), the file drawer effect (studies which come out negative are not reported so that the number of positive studies is misleading), the questionable use of p values, overgeneralizing by ignoring the context in which a research project was done, range restriction in statistics, the “jangle” fallacy (calling the same phenomenon by different names),  social desirability considerations in subject self-report, hypothesizing after results are known to explain away seemingly contradictory results (“HARKing”), the lack of replication in findings, and “bullet point” bias (oversimplification of complex situations).

Wow! Highly recommended.

Friday, April 9, 2021

Creativity and Self-Actualization




One of the themes of this blog concerns the forces that interfere with the ability of people to self-actualize, or express themselves and their opinions, and act on their own personal desires, even when their kin or social group may not always be supportive. Self-actualized people do not always follow in groupthink patterns during which they will go along to get along, agreeing with the family or ethnic groups ideas and philosophies while remaining willfully blind to any information that contradicts the group mythology.

 

Although she did not put it in those terms exactly, the question of whether the ability to do this is an important contribution to creativity in the arts and sciences was addressed by Nancy C. Andreasen, a well known psychiatry professor at the University of Iowa College of Medicine and the former editor in chief of The American Journal of Psychiatry, in an article entitled Secrets of the Creative Brain in the July/August 2014 issue of the Atlantic magazine. 

 

She describes a study she has been doing with a lot of creative people, many of whom are celebrities. In the article, she first discusses the often purported relationship between genius and madness, and found that there is indeed some truth to the idea that there is some. The incidence of mental illnesses in her subjects and their family members is indeed higher than expected. Although some of it may involve heredity, as evidenced by the incidence of schizophrenia, most of the psychiatric disorders found in her sample were those that primarily involve interpersonal dysfunction: certain mood and anxiety disorders and alcoholism.

 

Why might that be? Her answer speaks to my speculation about the role of self-actualization in creative people:  

 

“One possible contributory factor is a personality style shared by many of my creative subjects. These subjects are adventuresome and exploratory. They take risks. Particularly in science, the best work tends to occur in new frontiers. (As a popular saying among scientists goes: “When you work at the cutting edge, you are likely to bleed.”) They have to confront doubt and rejection. And yet they have to persist in spite of that, because they believe strongly in the value of what they do. This can lead to psychic pain, which may manifest itself as depression or anxiety, or lead people to attempt to reduce their discomfort by turning to pain relievers such as alcohol.”



To be innovative in one’s field involves the ability to persist in letting one’s mind work in the face of scorn and rejection from one’s peers. Even though it does hurt, innovators didn’t let rejection of publications or grant application stop them from continuing. They also had the wherewithal to be proven wrong at times and yet not be discouraged from continuing to search widely for better answers to technical questions.

 

Creative genius also involved the willingness to teach oneself about a wide variety of subjects rather than be spoon fed by teachers only in one’s chosen field of endeavor. Andreasen noted that many of her subjects were what she referred to as autodidacts – basically self-taught. Many had gotten in trouble with their school teachers for pointing out times when the teacher said something that was not true. She also found that many of her subjects were “polymaths” – people who read widely not only in their chosen area of expertise but in many subjects, both in the sciences and the humanities.


This sounds like self-actualization to me.


 


Tuesday, March 16, 2021

Loose Associations Between Various Clinical Attributes of Patients Sharing a Diagnosis




Doctors are being pressured more and more to make quicker and quicker clinical decisions using information from studies that show correlations between certain symptoms and certain genes and other patient attributes, both psychological and physical. They are at risk of becoming sucked into a Lake Wobegon effect - the fictional town where it was said everyone’s intelligence is above average. Clinicians should still  assess each individual separately in order to avoid conclusions based on the ecological fallacy (thinking all patients with a particular disorder react exactly the same as the average patient with the disorder). In fact, most people with a certain characteristic fall outside of the average value when looking at another characteristic that seems to correlate with it.

Some people object to personality disorder diagnosis for a similar reason: each person with these disorders presents somewhat differently than the “average” person with the disorder.

However, this whole problem does not mean that we should completely avoid making diagnoses or looking for other correlating characteristics which are likely to be found in the average person in a group. This information can provide a clinician with clues as to where to start an investigation. The diagnosis of borderline personality disorder, for instance, correlates strongly with the spoiler role developed in families in which the parents have conflicts over the role of being a parent. This knowledge is useful in telling a physician or therapist what questions to ask the patient when exploration of the relevant factors begins. 

It does not, however, mean that an initial inquiry is guaranteed to be fruitful, only that in many cases it will be, so starting there may save the clinician a lot of time looking at things that will turn out to be irrelevant. For it to be useful, however, the doctor must treat an initial idea as an hypothesis, and be completely open to the possibility that the hypothesis may turn out to be wrong.

Obviously, the strength of any discovered correlation affects how soon one should start looking for it. Much of the personality disorder literature these days is clinically useless because the correlations “discovered” are either too small, too obvious, or too unimportant to mean much of anything in helping the clinician develop some sort of psychotherapeutic strategy. A study by Wildey et. al. in the  August 2020 issue of the Journal of Personality Disorders found correlations between so-called externalizing disorders like antisocial personality disorder or substance abuse and the negative quality of a person’s relationships using multiple assessment methods. Ya think?

Some studies even look for associations between qualities that are actually intrinsic to the definition of a personality disorder and the disorders themselves. A rose is a rose last time I looked. Like people with BPD being very reactive. I kid you not.

Even dumber is looking at so-called “mediating” variables. For example, one study in the Journal of Personality Disorders by Sato et. al, in the April 2020 issue found that “rejection sensitivity” was mediated by attachment anxiety, the need to belong, and self-criticism. You mean if you think negatively about yourself but still want to fit in, that might lead to anxiety? I know academics face the need to publish or perish, but as I am fond of saying, “No Sh*t, Sherlock.”

Tuesday, February 23, 2021

Book Review: The Shattered Oak by Sherry Genga

 


This involving book, based on a true story but with some facts altered, is written as a first person account (although it is not the author's story) from a woman involved in a severely physically and emotionally abusive marriage. The author takes the reader on a fascinating tour inside her mind and thought processes.

The book strongly implies that she made no effort to leave for many years, and says that her parents refused to help her do so, under the rationalization that they were too afraid of her husband. She finally does leave and files for divorce. The narrative does not discuss the husband’s behavior during the divorce, but it appears that it went fairly uneventfully and without any stalking by her ex. She received the house and custody of their three daughters in the settlement, and her ex seems to have made alimony payments regularly.

Three years later she has a “nervous breakdown,” and describes in vivid terms her overwhelming sense of doom due to her depression. She makes three serious suicide attempts, and describes her ambivalence over abandoning her children and leaving her eldest daughter to take care of the other two, while all the while also feeling tremendous guilt over her daughter having had to take care of her in a parent-child role reversal.

She finally gets committed to a horrible mental hospital and given ECT against her will. Although she does not say she was diagnosed with major depressive disorder, her disturbing descriptions of her thoughts and feelings while in the depressed state are impressive, and give the reader a sense of what it might be like to have been in her shoes. It later turns out that she did not have a typical major depressive disorder, but one caused by a medical disorder, Cushing’s disease, which leads to very high level of the stress hormone cortisol, a steroid. A major depressive syndrome is seen in 50%–70% of the cases of Cushing’s syndrome. 

She opines that the high levels of cortisol may have come from high levels of stress, which, she implies, seems to have increased rather than decreased after she got out of the marriage. As it turns out, however, that was not the case at all. Her disorder was caused by a tumor of the pituitary gland.

It does not mean that anyone is “blaming” her for the severe abuse she suffered, but it is extremely important in the mental health field's attempts to prevent others from following in her footsteps, to pose the question of why she stayed with her husband for so long, and why she felt more stressed out after the divorce than during the time she was with her husband. There is no way we can know the answers to this question for certain just from the descriptions in this book, but there are several tantalizing clues.

The usual excuses offered up to justify the behavior of women who repeatedly return to an abusive relationship often do not hold water, but especially so in this case. As per her own description, she was in far more danger of being killed by him over the long run if she stayed than if she left. While they were together, he constantly threatened to kill her and even fired gunshots at her, narrowly missing her head on purpose. There were literally bullet holes in the walls.

She also knew very well that he was violent before they were married, because there were episodes of it back then.

And why would she be more stressed out after she left if, as it seems, her ex was not stalking her? The narrator admits that she still loves her husband even after the divorce despite all the pain he put her through. She offers a very interesting hypothesis about why he abused her: he came from a highly abusive family himself, and was taking his anger out at them on her. The question she keeps asking herself is how she could have helped this man to become less bitter. Presumably, how else. What she had been doing clearly did not work. Her question is consistent with my hypothesis about  this case

Readers of this blog can probably guess what that hypothesis is: the odds are pretty good that she was sacrificing herself so that her husband, whom she loved, could continue to channel his destabilizing anger away from his own parents, and that her doing something like this might have also been her role in her own family of origin. You know, the family that refused to help her leave her husband. At the end of the book we find reasons that this hypothesis would certainly necessitate further exploration. 

She was treated like a servant by her own parents growing up, especially compared to her two siblings, who could seem to do no wrong in her parents' eyes. Her older brother finally tells her that she was the result of an affair that her mother had had with a neighbor, and she was not her father’s biological daughter. Might the father have taken his anger at her mother out on her, with her mother going along with the program in order to keep the family together? You be the judge.

I wonder what her parents' upbringing might have been like.




Tuesday, February 2, 2021

The “Logic” of Researchers in ADHD

 



About 15-20 years ago or so, when I was still Director of Psychiatric Residency Training at the University of Tennessee Medical School, I went to a grand rounds (a teaching conference involving the whole department) to hear a talk by a doctor about adult ADHD. It turned out to be more of a drug commercial for some or other stimulant the sponsor of the talk was selling.

The guy basically said that this pseudo-diagnosis was in fact incredibly common – up to 14% of the adult population – and all of them should be taking significant doses of one of the most dangerous and addictive class of drugs that are available by prescription – classified by the FDA in the same category of abuse potential as opiates like morphine. Wow.

During the Q&A at the end of the talk, the subject of ADHD in children came up. Someone asked him why so many kids diagnosed with the disorder could go to a video game arcade (which had at the time only recently gone the way of the dinosaurs) and concentrate with tremendous focus on the game they were playing despite all sorts of buzzers and bells going off, flashing lights everywhere, and scores of people milling all around talking to each other. The speaker opined that this was “not concentration.” I’ve heard that sentiment many times before and since from Pharma shills. Well if it isn't concentration, I wondered, then WFT is it?

Another skeptic in the audience from child psychiatry asked him about the high incidence of alcoholism in the parents of ADHD patients. His response: “If you had a kid like that, you’d probably drink too!” Oh, I see. Alcoholism is caused by having rambunctious children.

I should have gotten up and cussed the dude out for saying heinous stuff like this, but my boss in the department might have frowned on it.

All this reminds me of another talk I once heard from someone from the National Institute for Drug Abuse during an outside medical meeting. He was going on and on about how cocaine, another stimulant BTW, depletes a chemical in the brain called Dopamine, which makes it nearly impossible for abusers to enjoy anything but the drug. Someone (again, not me) got up and asked, “But aren’t we doing that when we prescribe stimulants to our kids?” The speaker’s answer, “But the drugs work so well.”

So I’m guessing that the answer to the question that was actually asked, which the speaker completely avoided, was, “Yes.”


Friday, January 8, 2021

The Decline of Academic Medicine in the US




In an article called “The precipitous decline of academic medicine in the United States" from the American Academy of Clinical Psychiatrists by Richard Balon, MD and Mary K. Morreale, MD, the authors describe how the profiteering currently infecting medical treatment in this country is also in the process of destroying medical education.

Some of what they wrote:

“Structural problems in academic medicine exist within all parts of its tripartite mission: education, clinical care, and research. With clinical care, there are tedious requirements for documentation in difficult-to-navigate electronic medical record systems, demands on productivity in the form of ever-increasing [office visits], and senseless demands from managed-care organizations. All of these clinical demands reduce the time for teaching, which, ironically, university deans expect us instructors to increase. Similarly, education has been increasingly regulated by what has been referred to as the ‘medical-education industrial complex.’ Regulatory agencies have introduced changes with possibly negative consequences and no evident benefit.

 

“Academic research—at least in psychiatry—has been experiencing an ‘intellectual crisis,’ leading to the conclusion that ‘evidence-based medicine does not appear to provide an adequate scientific background for challenges of clinical practice in psychiatry and needs to be integrated with clinical judgment.’ And despite the glow that research funding brings to investigators and administrators, the sad fact is that, for the institution, research is a money loser.

 

“Due to the pandemic, in anticipation of a loss of $350 million, Johns Hopkins ‘imposed a hiring freeze, canceled all raises, and warned about impending furloughs and layoffs….’…[despite] Johns Hopkins had $10 billion in assets and a $6 billion endowment …Leadership compensation at Johns Hopkins is similar to the business world, with the university’s president earning $1.6 million in salary and an additional $1.1 million in deferred and other types of compensation.

 

“In Michigan... the CEO of the William Beaumont Health system affiliated with Oakland University had a total compensation of $5.9 million in 2018, with a base salary of $1.85 million, a bonus of $1.6 million, deferred compensation of $1.66 million, and $810,000 in other compensation.”

 

And here I thought that this had only happened at the medical school I worked at, the University of Tennessee in Memphis. When I first started there as psychiatry residency training director in 1992, the faculty practice group called UTMG was a delight to work with. The administrators worked for the doctors. We were told that we had to bring in 160% of the UTMG portion of our annual salary in patient care activities. The department was flush with cash, with a million dollar reserve for research and other academic activities. Faculty could earn extra money by seeing extra patients, keeping a percentage of every additional dollar they brought in.

 

The psychiatric emergency room at the public hospital, run by our department, was a model. We also trained police to deal with mental illness through the formation of what was called a Crisis Intervention Team, which was copied by several police departments throughout the rest of the country. Police became experts at de-escalating conflicts and apprehending the seriously mentally ill safely, transporting them to the Psych ER for evaluation. (Does this sound like something that might help the police regain public trust in today’s atmosphere? I think so).

 

Meanwhile pressure was building to install managed care models, especially after Medicaid in Tennessee was changed into Tenncare, which called for the formation of several HMO’s to provide treatment. UTMG decided that they wanted to form one, which they called TLC. Having experienced managed care in California, I warned everybody what might happen, but no one would listen. One child psychiatrist thought managed care was a good idea and advocated for it.

 

Before long, the doctors were working for the administrators instead of the other way around. Top administrators were paid over a million dollars apiece. The department’s reserves suddenly disappeared. UTMG drained the Psych ER of funds until it had to close. The child psychiatrist who advocated for managed care had his own pet project, a day care center for teens, destroyed. Faculty members were told they had to keep working any extra hours that they had been working – but without any of the extra pay they had been getting! Faculty members were also suddenly told they were “losing money” for the organization, even though they were bringing in the same amounts they had been, and even though the state - not UTMG - was paying for the faculty’s office rent and the cost of their phone system!