When Patients Become Colleagues

Charles C. Dike

Psychiatric News

Published Online:27 Oct 2022

Dr. Jones, a psychiatrist in private practice, described to me a conundrum she was trying to resolve. A patient she has been treating for eight years with psychotherapy and medication was recently certified as a therapist. The patient intends to terminate treatment with her and set up a private practice in the same district as the psychiatrist. The new therapist is asking for a collaborative relationship with the psychiatrist in which he would refer patients to the psychiatrist for medication management. The psychiatrist is not comfortable with the proposal and worries that her deep knowledge of her ex-patient’s flaws would negatively influence her view of the patient as a therapist. Most importantly, however, she is concerned about the risks of boundary violations and a breach in confidentiality, for example, when patients ask about the relationship between the psychiatrist and their referring therapist, as often happens.

The APA Ethics Committee has received questions about similar situations. One such question involved a patient who had received psychiatric treatment at an institution for years and was now applying to work as a clinician at the same institution a decade later. In this case, the Ethics Committee affirmed the need for psychiatrists “to support the concept that treatment matters and that people can recover and live full lives by addressing the challenges of mental illness. Psychiatrists should model that seeking treatment is a healthful and positive behavior and not a stigmatized act that will forever preclude a person, once a patient, from joining a team of respected mental health professionals. A history of mental health treatment should not be used to ban employment; a history of appropriate qualifications and pursuit of necessary medical treatment should be positive indicators for employment.”

Nonetheless, every such situation requires deep reflection to avoid potential ethics breaches. In some cases, the guidance is clear. For example, it is unethical for a psychiatrist in a solo private practice to employ a former patient because the pre-existing doctor-patient relationship is likely to influence the working relationship on both sides with potential negative consequences. In Dr. Jones’s case, however, the situation has ethics considerations that need to be addressed. Here is the advice that I gave to Dr. Jones: After celebrating her patient’s success, she should schedule a private meeting to discuss the contours of their new professional relationship. She should clarify that it would be a challenge to be his psychiatrist in the future should he suffer a relapse and need care. Further, Dr. Jones should point out that a personal relationship with a former patient could be unethical, especially if intimate, and therefore, all social interactions should be avoided as much as possible. When it is not possible to avoid them, they should carefully manage their interactions, social or professional, making sure boundaries are not breached. Dr. Jones should also discuss possible circumstances that could insinuate to others that she and the therapist had a prior treatment relationship as any such acknowledgment on her part would be a breach of her patient’s confidentiality. The fact that her former patient discloses their relationship to others does not absolve the psychiatrist of this ethical injunction. Such a discussion would prevent future problems and set the stage for the next chapter of their relationship.

The info is here.

The Scientific Study of Consciousness Cannot and Should Not Be Morally Neutral

Mazor, M., Brown, S., Ciaunica, A., et al. (2022)

Perspectives on Psychological Science, 0(0).

Abstract

A target question for the scientific study of consciousness is how dimensions of consciousness, such as the ability to feel pain and pleasure or reflect on one’s own experience, vary in different states and animal species. Considering the tight link between consciousness and moral status, answers to these questions have implications for law and ethics. Here we point out that given this link, the scientific community studying consciousness may face implicit pressure to carry out certain research programs or interpret results in ways that justify current norms rather than challenge them. We show that because consciousness largely determines moral status, the use of nonhuman animals in the scientific study of consciousness introduces a direct conflict between scientific relevance and ethics—the more scientifically valuable an animal model is for studying consciousness, the more difficult it becomes to ethically justify compromises to its well-being for consciousness research. Finally, in light of these considerations, we call for a discussion of the immediate ethical corollaries of the body of knowledge that has accumulated and for a more explicit consideration of the role of ideology and ethics in the scientific study of consciousness.

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The animal-models-of-consciousness paradox

An instance in which the scientific community has failed to acknowledge the intimate link between consciousness and ethics is in the use of animal models of consciousness. Our focus here is on the use of animals that are assumed to be conscious as an opportunity to probe the underlying mechanisms of consciousness in ways that would not be ethically acceptable with human subjects. In such studies, animals are often captive and deprived of basic needs and undergo invasive procedures. At the same time, for these animals to be appropriate models for the study of consciousness, it has to be assumed that they are conscious. Because conscious capacities play a pivotal role in the attribution of moral status to animals, in these experiments, scientific validity and moral justification are in direct conflict. This conflict is particularly acute in the study of consciousness and subjective experience: That an animal is an adequate model for the study of consciousness makes it more likely to be capable of experiencing rich phenomenal states, self-awareness, or suffering and to have its life considered to be deserving of appropriate protection much more than being an appropriate model for the study of the immune system does.

In a recent study of the neural correlates of consciousness, researchers contrasted brain activation in awake, sleeping, and anesthetized macaque monkeys (Redinbaugh et al., 2020). For this study, two monkeys were kept in captivity, implanted with brain electrodes, and immobilized by sticking rods in a head implant during electrophysiological recordings. In another study from 2021, a behavioral measure of conscious awareness was reported in four caged rhesus monkeys (Ben-Haim et al., 2021). Scientists surgically implanted subjects with a metal extension to their skull for the purpose of restraining movement during experimental sessions and restricted subjects’ access to water at testing so that they were motivated to participate in the task for juice droplets. In a study from 2019 on the neural basis of introspection, researchers abolished parts of the prefrontal cortex of six caged macaque monkeys, which were killed at the end of the study (Kwok et al., 2019). In another study published in Science in 2020 (Nieder et al., 2020), a neural correlate of sensory consciousness was demonstrated in the brains of two male crows by implanting electrodes in their brains. These are mere examples of typical research practice in the field of invasive electrophysiology that conform with current ethical guidelines in place at a national level and are commonplace in many fields of study. Yet common to these studies is that their scientific relevance rests on the animal being conscious, whereas their ethical justification rests on the animal not deserving the same protection from suffering as a human subject.

The article is here.

‘What if Yale finds out?’

William Wan

The Washington Post

Originally posted November 11, 2022

Suicidal students are pressured to withdraw from Yale, then have to apply to get back into the university

Here are two excerpt:

‘Getting rid of me’

Five years before the pandemic derailed so many college students’ lives, a 20-year-old math major named Luchang Wang posted this message on Facebook:

“Dear Yale, I loved being here. I only wish I could’ve had some time. I needed time to work things out and to wait for new medication to kick in, but I couldn’t do it in school, and I couldn’t bear the thought of having to leave for a full year, or of leaving and never being readmitted. Love, Luchang.”

Wang had withdrawn from Yale once before and feared that under Yale’s policies, a second readmission could be denied.

Instead, she flew to San Francisco, and, according to authorities, climbed over the railing at the Golden Gate Bridge and jumped to her death.

Her 2015 suicide sparked demands for change at Yale. Administrators convened a committee to evaluate readmission policies, but critics said the reforms they adopted were minor.

They renamed the process “reinstatement” instead of “readmission,” eliminated a $50 reapplication fee and gave students a few more days at the beginning of each semester to take a leave of absence without having to reapply.

Students who withdrew still needed to write an essay, secure letters of recommendation, interview with Yale officials and prove their academic worth by taking two courses at another four-year university. Those who left for mental health reasons also had to demonstrate to Yale that they’d addressed their problems.

In April — nearly 10 months after S. had been pressured to withdraw — Yale officials announced another round of changes to the reinstatement process. 

They eliminated the requirement that students pass two courses at another university and got rid of a mandatory interview with the reinstatement committee.

The reforms have not satisfied student activists at Yale, where the mental health problems playing out on many American campuses has been especially prominent.

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In recent years, Yale has also faced an “explosion” in demand for mental health counseling, university officials said. Last year, roughly 5,000 Yale students sought treatment — a 90 percent increase compared with 2015.

“It’s like nothing we’ve ever seen before,” said Hoffman, the director of Yale Mental Health and Counseling. Roughly 34 percent of the 14,500 students at 

Yale seek mental health help from college counselors, compared with a national average of 11 percent at other universities.

Meeting that need has been challenging, even at a school with a $41.4 billion endowment.

Bluebelle Carroll, 20, a Yale sophomore who sought help in September 2021, said she waited six months to be assigned a therapist. She secured her first appointment only after emailing the counseling staff repeatedly.

“The appointment was 20 minutes long,” she said, “and we spent the last five minutes figuring out when he could see me again.”

Because of staffing constraints, students are often asked to choose between weekly therapy that lasts 30 minutes or 45-minute sessions every two weeks.

The info is here.

Psychiatry wars: the lawsuit that put psychoanalysis on trial

Rachel Aviv

The Guardian

Originally posted 11 OCT 22

Here is an excerpt:

In the lawsuit, the 20th century’s two dominant explanations for mental distress collided. No psychiatric malpractice lawsuit has attracted more prominent expert witnesses than Ray’s, according to Alan Stone, the former president of the APA. The case became “the organising nidus” around which leading biological psychiatrists “pushed their agenda”, he told me.

At a hearing before an arbitration panel, which would determine whether the case could proceed to trial, the Lodge presented Ray’s attempt to medicalise his depression as an abdication of responsibility. In a written report, one of the Lodge’s expert witnesses, Thomas Gutheil, a professor of psychiatry at Harvard, observed that the language of the lawsuit, much of which Ray had drafted himself, exemplified Ray’s struggle with “‘externalisation’ – that is, the tendency to blame one’s problems on others”. Gutheil concluded that Ray’s “insistence on the biological nature of his problem is not only disproportionate but seems to me to be yet another attempt to move the problem away from himself: it is not I, it’s my biology.”

The Lodge’s experts attributed Ray’s recovery at Silver Hill at least in part to his romantic entanglement with a female patient, which gave him a jolt of self-esteem.

“It’s a demeaning comment,” Ray responded when he testified. “And it just speaks to the whole total disbelief in the legitimacy of the symptomatology and the disease.”

The Lodge lawyers tried to chip away at Ray’s description of depression, arguing that he had shown moments of pleasure at the Lodge, such as when he had played piano.

“The sheer mechanical banging of ragtime rhythms on that dilapidated old piano on the ward was almost an act of agitation rather than a creative pleasurable act,” Ray responded. “Just because I played ping-pong, or had a piece of pizza, or smiled, or may have made a joke, or made googly eyes at a good-looking girl, it did not mean that I was capable of truly sustaining pleasurable feelings.” He went on, “I would say to myself: ‘I am living, but I am not alive.’”

Manuel Ross, Ray’s analyst from the Lodge, testified for more than eight hours. He had read a draft of Ray’s memoir and he rejected the possibility that Ray had been cured by antidepressants. He was not a recovered man, because he was still holding on to the past. (“That’s what I call melancholia as used in the 1917 article,” he said, referring to Freud’s essay Mourning and Melancholia.)

Ross said that he had hoped Ray would develop insight at the Lodge. “That’s the true support,” he said, “if one understands what is going on in one’s life.” He wanted Ray to let go of his need to be a star doctor, the richest and most powerful in his field, and to accept a life in which he was one of the “ordinary mortals who labour in the medical vineyard”.

Ray’s lawyer, Philip Hirschkop, one of the most prominent civil rights attorneys in the country, asked Ross: “As an analyst, do you have to sometimes look inside yourself to make sure you’re not reacting to your own feelings about someone?”

“Oh yes,” Ross said. “Oh yes.”

“You who’ve locked yourself into one position for 19 years with no advancement in position other than salary, might you be a little resentful of this man who makes so much more money, and now he’s here as your patient?” Hirschkop asked.

The article is here.

Your Land Acknowledgment Is Not Enough

Joseph Pierce

hyperallergic.com

Originally posted 12 OCT 22

Here is an excerpt:

Museums that once stole Indigenous bones now celebrate Indigenous Peoples’ Day. Organizations that have never hired an Indigenous person now admit the impact of Indigenous genocide through social media. Land-grant universities scramble to draft statements about their historical ties to fraudulent treaties and pilfered graves. Indeed, these are challenging times for institutions trying to do right by Indigenous peoples.

Some institutions will seek the input of an Indigenous scholar or perhaps a community. They will feel contented and “diverse” because of this input. They want a decolonial to-do list. But what we have are questions: What changes when an institution publishes a land acknowledgment? What material, tangible changes are enacted?

Without action, without structural change, acknowledging stolen land is what Eve Tuck and K. Wayne Yang call a “settler move to innocence.” Institutions are not innocent. Settlers are not innocent.

The problem with land acknowledgments is that they are almost never followed by meaningful action. Acknowledgment without action is an empty gesture, exculpatory and self-serving. What is more, such gestures shift the onus of action back onto Indigenous people, who neither asked for an apology nor have the ability to forgive on behalf of the land that has been stolen and desecrated. It is not my place to forgive on behalf of the land.

A land acknowledgment is not enough.

This is what settler institutions do not understand: Land does not require that you confirm it exists, but that you reciprocate the care it has given you. Land is not asking for acknowledgment. It is asking to be returned to itself. It is asking to be heard and cared for and attended to. It is asking to be free.

Land is not an object, not a thing. Land does not require recognition. It requires care. It requires presence.

Land is a gift, a relative, a body that sustains other bodies. And if the land is our relative, then we cannot simply acknowledge it as land. We must understand what our responsibilities are to the land as our kin. We must engage in a reciprocal relationship with the land. Land is — in its animate multiplicities — an ongoing enactment of reciprocity.

A land acknowledgment is not enough.

The info is here.

Cross-cultural variation in cooperation: A meta-analysis

Spadaro, G., Graf, C., et al.

JPSP, 123(5), 1024–1088.

Abstract

Impersonal cooperation among strangers enables societies to create valuable public goods, such as infrastructure, public services, and democracy. Several factors have been proposed to explain variation in impersonal cooperation across societies, referring to institutions (e.g., rule of law), religion (e.g., belief in God as a third-party punisher), cultural beliefs (e.g., trust) and values (e.g., collectivism), and ecology (e.g., relational mobility). We tested 17 preregistered hypotheses in a meta-analysis of 1,506 studies of impersonal cooperation in social dilemmas (e.g., the Public Goods Game) conducted across 70 societies (k = 2,271), where people make costly decisions to cooperate among strangers. After controlling for 10 study characteristics that can affect the outcome of studies, we found very little cross-societal variation in impersonal cooperation. Categorizing societies into cultural groups explained no variance in cooperation. Similarly, cultural, ancestral, and linguistic distance between societies explained little variance in cooperation. None of the cross-societal factors hypothesized to relate to impersonal cooperation explained variance in cooperation across societies. We replicated these conclusions when meta-analyzing 514 studies across 41 states and nine regions in the United States (k = 783). Thus, we observed that impersonal cooperation occurred in all societies-and to a similar degree across societies-suggesting that prior research may have overemphasized the magnitude of differences between modern societies in impersonal cooperation. We discuss the discrepancy between theory, past empirical research and the meta-analysis, address a limitation of experimental research on cooperation to study culture, and raise possible directions for future research. 

Discussion

Humans cooperate within multiple domains in daily life, such as sharing common pool resources and producing large-scale public goods. Cooperation can be expressed in many ways, including strategies to favor kin (Hamilton, 1964), allies and coalitional members (Balliet et al., 2014; Yamagishi et al., 1999), and it can even occur in interactions among strangers with no known future interactions (Delton et al., 2011; Macy & Skvoretz, 1998).  Here, we focused on this later kind of impersonal cooperation, in which people interact for the first time, they have no knowledge of their partner’s reputation, and no known possibilities of future interaction outside the experiment. Impersonal cooperation can enable societies to  develop, expand, and compete, impacting wealth and prosperity. Although impersonal cooperation occurs in all modern, industrialized, market-based societies, prior research has documented cross-societal variation in impersonal cooperation (Henrich, Ensminger, et al., 2010; Hermann et al., 2008; Romano et al., 2021). To date, several perspectives have been advanced to explain why and how impersonal cooperation varies across societies. 

A pdf is here.

Loss aversion, the endowment effect, and gain-loss framing shape preferences for noninstrumental information

Litovsky, Y. Loewenstein, G. et al.

PNAS, Vol. 119 | No. 34

August 23, 2022

Abstract

We often talk about interacting with information as we would with a physical good (e.g., “consuming content”) and describe our attachment to personal beliefs in the same way as our attachment to personal belongings (e.g., “holding on to” or “letting go of” our beliefs). But do we in fact value information the way we do objects? The valuation of money and material goods has been extensively researched, but surprisingly few insights from this literature have been applied to the study of information valuation. This paper demonstrates that two fundamental features of how we value money and material goods embodied in Prospect Theory—loss aversion and different risk preferences for gains versus losses—also hold true for information, even when it has no material value. Study 1 establishes loss aversion for noninstrumental information by showing that people are less likely to choose a gamble when the same outcome is framed as a loss (rather than gain) of information. Study 2 shows that people exhibit the endowment effect for noninstrumental information, and so value information more, simply by virtue of “owning” it. Study 3 provides a conceptual replication of the classic “Asian Disease” gain-loss pattern of risk preferences, but with facts instead of human lives, thereby also documenting a gain-loss framing effect for noninstrumental information. These findings represent a critical step in building a theoretical analogy between information and objects, and provide a useful perspective on why we often resist changing (or losing) our beliefs.

Significance

We build on Abelson and Prentice’s conjecture that beliefs are not merely valued as guides to interacting with the world, but as cherished possessions. Extending this idea to information, we show that three key phenomena which characterize the valuation of money and material goods—loss aversion, the endowment effect, and the gain-loss framing effect—also apply to noninstrumental information. We discuss, more generally, how the analogy between noninstrumental information and material goods can help make sense of the complex ways in which people deal with the huge expansion of available information in the digital age.

From the Discussion

Economists have traditionally treated the value of information as derivative of its consequences for decision-making. While prior research on noninstrumental information has shown that this narrow view of information may be incomplete, only a few accounts have attempted to explain intrinsic preferences for information. One such account argues that people seek (or avoid) information inasmuch as doing so helps them maintain their cherished beliefs. Another proposes that people choose which information to seek or avoid by considering how it will impact their actions, affect, and cognition. Yet, outside of the curiosity literature, no existing account of information valuation considers preferences for information that has neither instrumental nor (concrete) hedonic value. By showing that key features of Prospect Theory’s value function also apply to individuals’ valuation of (even noninstrumental) information, the current paper suggests that we may also value information in some of the same fundamental ways that we value physical goods.

The research is here.

Moral disciplining: The cognitive and evolutionary foundations of puritanical morality

Fitouchi, L., André, J., & Baumard, N. (2022).

Behavioral and Brain Sciences, 1-71.

doi:10.1017/S0140525X22002047

Abstract

Why do many societies moralize apparently harmless pleasures, such as lust, gluttony, alcohol, drugs, and even music and dance? Why do they erect temperance, asceticism, sobriety, modesty, and piety as cardinal moral virtues? According to existing theories, this puritanical morality cannot be reduced to concerns for harm and fairness: it must emerge from cognitive systems that did not evolve for cooperation (e.g., disgust-based “Purity” concerns). Here, we argue that, despite appearances, puritanical morality is no exception to the cooperative function of moral cognition. It emerges in response to a key feature of cooperation, namely that cooperation is (ultimately) a long-term strategy, requiring (proximately) the self-control of appetites for immediate gratification. Puritanical moralizations condemn behaviors which, although inherently harmless, are perceived as indirectly facilitating uncooperative behaviors, by impairing the self-control required to refrain from cheating. Drinking, drugs, immodest clothing, and unruly music and dance, are condemned as stimulating short-term impulses, thus facilitating uncooperative behaviors (e.g., violence, adultery, free-riding). Overindulgence in harmless bodily pleasures (e.g., masturbation, gluttony) is perceived as making people slave to their urges, thus altering abilities to resist future antisocial temptations. Daily self-discipline, ascetic temperance, and pious ritual observance are perceived as cultivating the self-control required to honor prosocial obligations. We review psychological, historical, and ethnographic evidence supporting this account. We use this theory to explain the fall of puritanism in WEIRD societies, and discuss the cultural evolution of puritanical norms. Explaining puritanical norms does not require adding mechanisms unrelated to cooperation in our models of the moral mind.

Conclusion

Many societies develop apparently unnecessarily austere norms, depriving people from the harmless pleasures of life. In face of the apparent disconnect of puritanical values from cooperation, the latter have either been ignored by cooperation-centered theories of morality, or been explained by mechanisms orthogonal to cooperative challenges, such as concerns for the purity of the soul, rooted in disgust intuitions. We have argued for a theoretical reintegration of puritanical morality in the otherwise theoretically grounded and empirically supported perspective of morality as cooperation. For deep evolutionary reasons, cooperation as a long-term strategy requires resisting impulses for immediate pleasures. To protect cooperative interactions from the threat of temptation, many societies develop preemptive moralizations aimed at facilitating moral self-control. This may explain why, aside from values of fairness, reciprocity, solidarity or loyalty, many societies develop hedonically restrictive standards of sobriety, asceticism, temperance, modesty, piety, and self-discipline.

A pdf is here.

Institutional betrayal, institutional courage and the church

Susan Shaw

Baptist News Global

Originally published 26 JUL 22

Betrayal by trusted people, like pastors, teachers, supervisors and coaches can inflict devastating consequences on victims. According to psychologists who study trauma, betrayal trauma affects the brain differently than any other trauma, particularly when the victim depends upon the perpetrator. Betrayal trauma threatens the very sense of self of the victim, who often cannot easily escape because of physical, psychological or spiritual dependence.

Institutional betrayal

When institutions don’t address perpetrators but rather meet survivors with denial, harassment and attack, they engage in institutional betrayal. Institutional betrayal occurs “when an institution causes harm to people who depend on it.”

Betrayal blindness describes ignoring, overlooking, “not-knowing” and forgetting betrayal. People, including victims themselves as well as perpetrators and witnesses, exhibit betrayal blindness to “preserve relationships, institutions and social systems upon which they depend.”

We don’t have to think very long to name a depressing list of instances of institutional betrayal by the church: segregation, clergy sex abuse, conversion therapy, exclusion of women from church leadership and ordained ministry, purity culture, the Magdalene laundries, witch hunts, Indian schools, on and on.

In recent days, we’ve seen institutional betrayal at work in megachurches like Hillsong and Highpoint, where popular pastors engaged in abusive conduct and their churches enabled them. The clergy abuse scandals in the Catholic Church and Southern Baptist Convention are textbook examples of institutional betrayal — institutions that chose to protect themselves rather than address the harm done to members.

Rather than challenging itself to create welcome, repair harm and do justice, the church often has chosen to preserve itself, to overlook harmful behavior by leaders and to demonize and ostracize those who speak out against abuse

Findley Edge, who taught religious education at Southern Baptist Theological Seminary, wrote about the process of institutionalization. Edge explained people developed great and exciting ideas, and these ideas lead to innovations and movements. As time goes along, these innovations and movements develop structure to continue to facilitate their growth. Eventually, the first generation that formed the great and exciting idea dies out, and soon people only know the institution and not the idea that sparked it. Their goal then becomes preservation of the institution, not the idea.

Uncritical dedication to the preservation of an institution can easily lead to institutional betrayal, especially when people depend upon organizations like the church, work or family.

Jennifer Freyd, the psychologist who coined “institutional betrayal,” says people protect institutions by participating in what she calls DARVO — Deny, Attack and Reverse Victim and Offender.

The info is here.