You Should Check Out Daniel Bergner's Interview with Bari Weiss
Hey friends, ordinarily I would not fill your inbox simply to post a link, but here I think it’s appropriate. Awhile back, I did a podcast appearance on Honestly with Bari Weiss. Out of dozens of podcast appearances, it’s one of my favorites, as it was an expansive conversation about a topic of great importance to me, mental illness. That appearance was, among other things, a response to a New York Times piece by Daniel Bergner on a movement within the mental health world regarding psychotic disorders and their delusions. I was, and remain, quite critical of Bergner’s position, even while I am moved by his story of his brother’s struggles. Recently Bergner appeared on Honestly himself, in part to respond to my criticism of him on that show. The episode is embedded above.
I’m not going to respond to his response, as I think that kind of back and forth can get tiring for everyone, especially the audience, and my feelings about all of this have been spelled out in numerous newsletter posts, especially here. Bergner deserves his opportunity to stick up for himself and his essay, and if you have followed my writings on this topic, I encourage you to listen to the podcast. All I will say is that my writings on mental illness have never been, in any sense, about what is or is not “woke.” That abstraction means nothing to me when it comes to this issue, and my specific observations and complaints are not part of some counter-politics of mine but are instead what I simply believe to be true.
I listened to this, and to your earlier conversation with Bari. Taken together, they offer a very thoughtful and balanced perspective on a difficult issue. Really appreciate your promotion of his critique, it's very much in character, and is one of the reasons I subscribe to your newsletter.
I have been a psychiatrist for almost 30 years. I found Daniel Bergner’s statements and attitude typical of people who think they know about a field but have not actually experienced working in that field.
Daniel bases his expertise on talking with a lot of people who have mental illness and having a family member with mental illness. But, there is a big difference between talking with people who have mental illness or having a family member with mental illness and being RESPONSIBLE for the safety of a hundred or more people with mental illness, and the safety of the people they associate with. When I have a suicidal patient, I am personally responsible for the safety of that patient, just as a surgeon is personally responsible for the safety of the person they are operating upon. The difference is that the surgeon has far more control over the situation than I do. I don’t hospitalize most patients who tell me they are having suicidal thoughts. I spend time and energy evaluating other factors that increase their risk or mitigate it. So, most of the time we can work with the suicidal thoughts and the underlying issues without resorting to hospitalization. I have also had patients expressing thoughts about wanting to harm their family, or at times myself. Again, I don’t reflexively put them in a hospital. I look for other factors, but I must take my responsibility very seriously because if I make a mistake someone is going to die. While Daniel is trying to address the problem of medication overuse, without the experience of being responsible for the safety of others I do not think he appreciates how self-absorbed and condescending his statements can come across as.
Second, individualizing treatment takes TIME. We have a tremendous shortage of psychiatrists, especially in rural areas. While there are psychiatrists who just do cookie-cutter medicine, a lot of us want to spend time with patients to give that individualized care. But there are not enough of us to do that. If your schedule is full and someone is suicidal then you can’t just make an hour or two available to individualize the care for that patient. They have to access emergency psychiatric services. Those services are overwhelmed, if they even exist. If they exist and the person gets emergency psychiatric care then those providers will tend to err on the side of extreme caution because that is what our society demands of its medical institutions. If the emergency psychiatric services don’t exist, then the person will be treated by healthcare professionals who are well-meaning but unlikely to have the expertise to make the helpful connections with a severely mentally ill person. Its not that they don’t want to; they don’t have the expertise, the staff or the time to do so.
Third, Americans in general do not want to pay higher taxes or higher insurance premiums for helping mentally ill people. Or at least Americans with political power do not. Today many of the patients with symptoms of severe and chronic mental illness are housed in jails or are homeless. There is a lot of handwringing over that, but no political will to fund the necessary changes. As an aside, we may have had a chance to do that back in the 80’s but the Regan budget cutting spirit led to the closure of the public mental hospitals and discharged the patients to the streets. The excuse was that the mental hospitals were just warehousing patients, and drugging them, but that was not always the case and with continued funding and research things might have been different. See the book “The Great Pretender” by Susan Callahan.
Fourth, it is true that nothing on any brain scan consistently distinguishes someone with a mental illness from someone without. But concluding that there are no changes in the brain is not valid. Multiple sclerosis was thought to be malingering because there were no physical findings associated with the disease. Until our tests became more sensitive. So, concluding that a negative scan means that the symptoms are not caused by a physical change is a false conclusion, especially when the symptoms cause such a profound deficit in the ability to function.
Fifth, Bari made the good point that often people with mental illness are medicated against their will because they are perceived as dangerous. Daniel equated treating people with mental illness preventatively with medication as the same as incarcerating minorities or young men because those groups have a greater percentage of people who commit violent crimes. This is a strawman argument (and Bari missed that). No one is talking about blanket involuntary treatment of people who have mental illness. We are talking about involuntary treatment of people who are having symptoms of a mental disorder indicating that they are at significant risk of IMMINENT danger to themselves or others because of that mental illness.
Sixth, when Bari brought up the examples of someone swinging a machete or defecating in the street he stated that since those are crimes then we should just treat them as crimes. Seriously!!! I couldn’t believe my ears. Calling law enforcement to handle the mentally ill in crisis. I am NOT suggesting that the police would necessarily use force. I know that police often handle mental health crises with high levels of expertise, but where do they bring the person? To the jail? I know that is often done because there is nowhere else for them to go, but that is his answer??? They are committing crimes so put them in jail? Sounds pretty fascist. Certainly not what I would consider compassionate.
These are some of the points I could make. Overall I found the conversation difficult to listen to. Daniel had nothing to offer that has any chance of actually coming into being for the general population, largely because you would need years of massively increased funding to train enough people to perform the tasks that he wants done. He comes across as a know-it-all who thinks that without any experience working in the trenches he knows enough about the field to make sweeping statements about what is needed. He bases his conclusions on a completely unrepresentative sample of cases and when given observations that disprove his conclusions, he uses illogical analogies to dismiss those observations or simply ignores them. His final suggestion was that we avoid involuntary treatment of the mentally by allowing the criminal justice system to handle them.