Tuesday, November 10, 2009

A Psychiatrist's Reflections on Dr. Hasan

I'm not going to speculate publicly about Dr. Hasan's psychological state, about which, of course, I know nothing. The American Psychiatric Association Principles of Medical Ethics very clearly - and in my view correctly - prohibit armchair psychoanalysis:
On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.
Today's New York Times reported that Dr. Hasan was in contact with a jihad-supporting cleric in Yemen many months ago (see here) and that he bought the gun that was allegedly used in the crime at Fort Hood shortly after arriving in Texas. Those public reports lead me to these thoughts about psychiatric education and the ethical responsibility for self scrutiny.

A central component of clinical education in psychiatry is that we clinicians need to observe ourselves as carefully as we observe our patients. Our thoughts and feelings are important sources of "data" - they can give information about our patients. In my residency the training director told us that "no human being is truly boring. If you feel bored while you're with a patient it's either because the patient is talking to hide what's important, which makes what he's saying an empty shell, or what he's saying threatens you, and your boredom is a defense."

In more than 40 years of practice since hearing that precept it has served me (and fellow residents) well. Whenever I felt bored I went into action - which of the two alternatives was going on?

The news reports suggest that the idea of criminal action entered Dr. Hassan's mind long before he carried it out. Honest human beings acknowledge that all manner of things come into their minds. The most notorious failing on the part of psychiatrists is sex with patients. The proper professional response to sexual thoughts about a patient is "differential diagnosis." Why is this reaction occurring? Is it telling me the patient is lonely, or making an erotic appeal? If so, that's the proper focus of therapeutic attention. But if the reaction is more about me, then the professional should ask - what is it telling me about myself? What do I need to do? The proper professional response is to ask for consultation when the answers aren't clear.

Psychiatric ethics are unambiguous about sexual involvement with patients - whether it is a current or former patient, sexual involvement is always unethical. If a psychiatrist found himself beginning to rationalize why the ethical principles do not apply to him it is as much of a danger signal as hearing about suicidal plans from a patient. Immediate consultation is required.

Similarly, it wouldn't be a sign of "pathology" if a thought of harming others were to enter a clinician's mind. The same training director told a story to make the point that aggressive thoughts were not in themselves unhealthy, and might even be constructive: "It was the minister's 50th anniversary of what looked like a very happy marriage. A mischievous parishioner asked 'Minsiter - tell the truth - in 50 years of marriage did you ever think of divorce?' After a moment of thought the minister responded - 'divorce, never....murder, often...'"

But if a fantasy about harming patients, colleagues or others took on a life of its own it would call for immediate consultation with a colleague and some form of corrective action. It's when aggressive and erotic fantasies are kept secret that they fester and turn dangerous.

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