COMMENTARY

The Return of the Alienist

James L. Knoll IV, MD

Disclosures

May 10, 2013

In This Article

The "Problem of the Dangerous Mentally Ill"

Despite the popular idea that persons are "railroaded" to asylums for various ulterior purposes, I know of but a few such cases.
-- Allan McLane Hamilton, Recollections of an Alienist, 1916 [1]

Have we made sufficient progress in psychiatry to withstand the current "national dialogues" and politicians' concerns about "the problem of the dangerous mentally ill"? Or have we somehow managed to slip backward, to a time when mental illness was seen as strange and alien? In those times, the persons responsible for treating individuals estranged from society were known as "alienists."[2,3]

We do not find ourselves in the 21st century with progressively liberated circumstances for persons suffering from serious mental illness. More than 10 years after "the decade of the brain," rather than removing the chains that Pinel only dreamed of, we have confined more people with severe mental illness in penal institutions than ever before. Simultaneously, society has managed to cultivate more fearful and negative beliefs about mental illness.

This article will explore the notion that attitudes and beliefs about mental healthcare have taken a regressive turn, such that we require greater social distance from, and alienation of, those suffering from mental illness, and have recasted the psychiatrist in the role of alienist.

Pure Fiction: The Contented Coercive Psychiatrist

Movies that portray psychiatrists in even a vaguely realistic manner are hard to find. Most portray us as power-hungry, twisted "Mesmers" who must be caught and punished. To an extent, this has been reflected in the way that society has decided to let us do our jobs: It is best that our hands be tied, and our judgment curtailed. But fear not -- the reality is that we are far too bogged down with the pretraumatic stress of diagnostic codes and Medicaid hassles to concoct any worthwhile mind-controlling schemes.

As deinstitutionalization was beginning to pick up steam, the US Supreme Court declared involuntary commitment to a psychiatric hospital a "massive curtailment of liberty" that required the protection of a due process hearing.[4] Of course, a physician in any field is able to enact an emergency detention (typically lasting no longer than 48-72 hours) when he or she believes that the patient represents an immediate danger to himself or others.

It is only after this initial emergency detention that formal civil commitment is considered. Here I would add that no psychiatrist I have ever known has derived the slightest degree of enjoyment from this process. To the contrary, it pains and agonizes us like no other duty we undertake. We abhor the idea of disrupting a patient's life, having a judge take away (even briefly) a patient's liberty, and testifying in court about a patient's private struggles. This route -- psychiatric treatment by court order -- is seen by psychiatrists as plodding, painful, and bereft of most of the art that makes the profession enjoyable. Nevertheless, we do it out of our obligation to a panoply of duties -- clinical, ethical and legal. But do we enjoy or look forward to it? One does not need a survey of psychiatrists to discover that we consider it one of the more loathsome clinical duties of our chosen field.

Most psychiatrists are familiar with the clinical aphorism that one of the highest therapeutic achievements is to assist and guide a patient to that unquantifiable and transcendent point at which they arrive at their own insights, their own relief from suffering, and their own lessening of incapacitation. Indeed, our supreme achievement would be to make ourselves -- eventually -- unnecessary. Fostering a dependent or otherwise interminable therapeutic relationship is acknowledged among competent psychiatrists as fundamentally problematic: It is unhelpful to the patient, as well as a signal that the psychiatrist must reevaluate his or her approach. This is because in such situations, it is likely that the patient's subjective experience has not been meaningfully appreciated and the psychiatrist has not adequately understood his or her own emotional reaction to the patient.[5]

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