"Reductionism in Medicine and Psychiatry" - Extract from "Psychiatry in Crisis" by V Di Nicola & D Stoyanov

Summer 2023 • Volume 4, Issue 3
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Photo on cover by Joseph Silvio, M.D.
Joe describes the photo:
This holy shrine in Malaysia is magnificent.
It’s hard to get a true sense of scale from
the photograph, but the structure to the
left of the golden statue is a stairway
over a hundred steps high leading to
a sacred cave. The colors and carvings
were spectacular.
Photo on back inside cover by Arsinée
Donoyan.
Arsinée describes the photo:
Lavender Field (Québec, Canada)
Management
Next Wave Group, LLC
Newsletter Design
Betsy Earley / Director of Publications
Email: Betsy@baymed.com
• Letter from the Editor of Capital Psychiatry P6
Gerald P. Perman, M.D.
• Editorial: Q-Anon in Context P7
Michael Delollis, M.D.
• Summer Scenes in Quebec, Canada P10
Photo Spread by Arsinée Donoyan
ARTICLES
• Science Examines American Politics: An Introduction P14
Joseph Silverman, M.D.
• Capital Psychiatry’s Psychoanalytic Clinic: Out-of-Control Control
Cases or When a Low Fee is no Bargain P19
Nathan Szainberg, M.D.
• Reductionism in Medicine and Psychiatry (Extract from Psychiatry in
Crisis: At the Crossroads of Social Science, The Humanities, and
Neuroscience) P24
Vincenzo Di Nicola
ESSAYS
• Mentally Ill on the Streets: An Open Letter to our Mayors P28
David V. Forrest, M.D.
• Woodley House: Providing 65 Years of Dignity and Comfort P34
Sue Breitkopf, Chief Development Officer
• The License Renewal P38
Margaret Roberts, M.D.
• Compassion, A Long-Forgotten Antidote P42
Mariam Elghazzawy, G.W. MS2
BOOK REVIEW
• A Critical Reflection on the Past, the Present, and Possible Futures of the
Psychiatric Field by Vincenzo Di Nicola and Drozdstoj Stoyanov P44
Reviewed by Marcelo Pakman, M.D.
SHORT STORY
• Chain Reactions P46
Rachel Treat, M.D. Candidate, Class of 2025
POETRY
• Cherry Blossoms P59
Antonio Igbokidi, MSIII
• Losing Control and Paradox P61
Ankur Sah Swarnakar PGIII
• Kristallnacht II and Hope En Wing P63
Joan Turkus, M.D.
• Raspberry International: A Villanelle P65
Stephen Rojcewicz, M.D.

4 CAPITAL PSYCHIATRY, THE E-MAGAZINE OF THE WASHINGTON PSYCHIATRIC SOCIETY
Gerald Perman, MD, DLFAPA
Editor
John Clark, John Fatollahi, M.D., William Lawson, M.D., Ph.D., and H. Steven Moffic, M.D.
Editorial Board
Patricia H. Troy, M. Ed., CAE
Project Management
Betsy Earley
Graphic Design
Anne Benjamin
Web Design and Flipbook
Anne Marie Dietrich, MD, FAPA
President
Enrico Suardi, MD, MSc, MA, FAPA
President-Elect
Todd Cox
Secretary
Marilou Tablang-Jimenez, MD, DFAPA
Immediate Past-President
Navneet Sidhu, MD
Treasurer
Yolanda Johnson
Executive Director
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imply endorsement of any content, announcement, or advertisement.
© Copyright 2023 by the Washington Psychiatric Society.

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Margaret Roberts shares her frustration in her efforts
to renew her D.C. medical license after having briefly
retired from psychiatry. This was clearly a case of “no
good deed…” Finally, Mariam Elghazzawy describes
a moral dilemma she faced while walking to class in
medical school and the resolution at which she arrived.
Vincenzo Di Nicola and Drozdstoj Stoyanov’s
important new book, A Critical Reflection on the Past, the
Present, and the Possible Futures of the Psychiatric Field
is reviewed by Marcelo Pakman.
Rachel Treat entertains with a whimsical short story
about her recent experiences as a medical student in the
form of a poem accompanied by her own illustrations.
Finally, our poetry contributions, each with a psychiatric
slant, by Antonio Igbokidi, Ankur Sah Swarnakar,
Joan Turkus, and Steven Rojcewicz are indescribably
beautiful, profound, engaging, thought-provoking,
poignant…and the last, delicious as well!
Capital Psychiatry again thanks Joseph Silvio for his
beautiful cover photo, Arsinée Donoyan for her lovely
photo spread and inside-back-cover photo, Betsy Earley
for her superb selection of graphics and formatting
skills, Patricia Troy for her continued counsel and
guidance, and John Clark, John Fatollahi, William
Lawson, and H. Steven Moffic, our outstanding
Editorial Staff.
We hope that you enjoy this wide-ranging and superb
2023 summer issue of Capital Psychiatry.
PLEASE, dear readers, continue to submit articles,
essays, and poetry to Capital Psychiatry. Our e-magazine
depends on you!!!
Cordially yours,
Gerald P. Perman, M.D.
Editor, Capital Psychiatry
By Gerald P. Perman, M.D., DLFAPA
L E T T E R F R O M T H E E D I T O R
Dear Colleagues,
Welcome to the summer 2023 issue of Capital
Psychiatry: the e-magazine of the Washington Psychiatric
Society and the proud recipient of the 2023 American
Psychiatric Association Best Practices Award that was
presented at the APA Annual Meeting in San Francisco
this past May.
This issue opens with an editorial by Michael Delollis
on the widespread and troubling social phenomena,
Q-Anon.
Canadian photographer Arsinée Donoyan treats us to a
stunning display of her photography with seascapes of
the Canadian maritime coast.
In our regular section of articles, Joseph Silverman
applies his scientific No Free Will determinism
perspective to American politics. In my opinion,
Silverman’s views are extremely important and vastly
underappreciated. Nathan Szainberg describes some
of the pitfalls of low-fee analysis making the case that
you often “get what you pay for.” Vincenzo Di Nicola
and Drozdstoy Stoyanov’s important new book,
Psychiatry in Crisis: At the Crossroads of Social Science,
the Humanities, and Neuroscience, is reviewed by
Marcelo Pakman in his A Critical Reflection on the Past,
the Present, and the Possible Futures of the Psychiatric
Field. In the next section, David V. Forrest has written
an Open Letter to U.S. Mayors in which he provides a
thoughtful, humanitarian, and practical approach to
address the sad plight of the homeless mentally ill. As
a society, we have egregiously failed so many of our
brothers and our sisters.
Sue Breitkopf, Chief Development Officer at Woodley
House in Washington, D.C., describes the tremendous
service that Woodley House has provided for over
65 years to its mentally ill residents. I got to know
Sue when Woodley House invited me to rock out for
10 years with musical entertainment at its annual
Beethoven’s Birthday party before the pandemic.

7
Q-ANON IN CONTEXT
By Michael Delollis, M.D.

I
think that we could all benefit from looking at
Q-Anon from a slightly different perspective. That is,
I think we can understand more by looking at this
phenomenon within our current social context.
Q-Anon is a movement with a large following on social
media and within the political right. It began in the
United States but has now spread internationally. It was
started by an anonymous source on the dark web who
supposedly was privileged to inside information about a
secret international organization for the exploitation of
children.
The source is identified as “Q,” therefore the name
Q-Anon. It has borrowed material from anti-Semitic
sources such as the “blood libel” of the 10th century and
the czarist Russian forgery, the “Protocols of the Elders of
Zion.” The core of this belief system is the existence of an
international organization dedicated to the exploitation,
sexually and otherwise, of young children by powerful
men who are politically protected and are above the law.
It also prophesies a Savior often identified with former
president Trump. The savior is supposed to expose
the perpetrators and their supporters and possibly
exterminate them.
This summary describes what Q-Anon is, but it doesn’t
explain the attraction that this narrative holds for so
many people throughout the world. What is striking
about the Q-Anon narrative is how closely it resembles
the revelation in recent years about the sexual predation
within the Catholic Church, the Boy Scouts, the Southern
Baptist convention, women’s gymnastics, and by many
powerful individuals like Harvey Weinstein and Jeffrey
Epstein.
Within these revelations are networks of powerful
people with direct access to vulnerable children and an
organizational structure to protect the perpetrators and
silence the victims. These revelations make it clear that
with decades if not centuries of this behavior there are
thousands if not millions of victims of this exploitation
and abuse.
For these victims, the Q-Anon narrative is not a
conspiracy theory, but a lived reality. For the most part
these victims have not been seen, acknowledged, or
supported by their communities. For them, Q-Anon
provides a community which offers the potential for
salvation. It offers the possibility of relieving the shame
of their exploitation and explaining the unimaginable
trauma they have endured. In pointing out this
connection I am not implying that all followers of Q-Anon
are survivors of child abuse, only that these survivors are
a ready audience for this community.
With this foundation of validated experience of being
abused as a child, additional layers can be added. We
know that in families where abuse occurs it is rare for
the victims to come together and support each other
against the abuser. Rather it is more common for the
victims to be competitive for the attention and support
of the abuser. When one is powerless to take revenge
against the cause of one’s suffering it is common to use
that rage against people who are lower in the pecking
order. In Freudian terms, this represents “identification
with the aggressor,” whereas in the vernacular, “shit flows
downhill.”
Formally this phenomenon is referred to as “displaced
aggression.” Based on the author’s research, experiencing
abuse as a child increases the chances that the child
victim will become an abuser as an adult. This dynamic
could explain the white supremacist, anti-Semitic,
homophobic, and misogynistic aspects of the Q-Anon
movement. “I may be a victim, but I am not as bad as
those other people. Those people brought this upon
themselves. Those people brought this upon me. Those
people who are in control and doing this to me. If I can
find somebody else to blame it can give me a sense of
control to help ameliorate my experience of helplessness
and shame.”
This rage at the other has been the core of right-wing
media for decades. Rush Limbaugh’s central message
to his audience was that “you are the victim of them, and
you have the right if not the duty to be angry at them.”
This created a feedback loop of the adrenalin rush of
communal anger while listening to the show followed by
the pain of victimhood when the show ended, causing the
listener to seek out the next episode to regain that rush
of shared anger. Now in the age of social media, shared
anger can be never ending.
Another common aspect of the experience of abuse is the
victim’s awareness of the fragility of the abuser: “He is
doing this to me because he has been hurt, because I have
hurt him.” When the abuser is a parent or other authority,
and the victim’s existence is dependent on that abusive
person, then the victim feels a sense of responsibility
to protect and support that abuser. “If I don’t take
responsibility, no one will, and disaster will happen.”
This psychology has long been known in the 12-step
community and is called the “parental child.”
Therefore, it is not surprising that the Q-Anon
conspiracy identifies with a fragile, attention seeking,
bullying, authoritarian, as their hoped-for savior. This

9
identification is facilitated when that bully vents his rage
on those at the bottom of the pecking order.
With all these components, it seems to me that what
starts out looking like a fantastical fantasy, the Q-Anon
conspiracy is supported by well-known and common
psychological and social phenomena in our world. It
has gained the attention and support of a population
of survivors of widespread abuse by powerful
people, protected by political, religious, and financial
organizations.
The recognition of these facts can give us an opportunity
to heal these wounds. First, by addressing the corruption
in these institutions that have perpetrated this long-
standing abuse and exploitation to save the future
victims. Next, by acknowledging the blamelessness
of the survivors as a first step in opening the healing
process. We must also acknowledge these survivors’
presence in our communities. This acknowledgement can
help with the healing of both the individuals and of the
communities. We must work to transform “us and them”
into “all of us.”

Summer Scenes in Quebec, Canada
Photo Spread of Arsinée Donoyan
Hopewell Rocks at Bay of Fundy - Rock formations known as sea stacks caused by tidal
erosion (New Brunswick, Canada).

11
Irving Eco-Centre, La dune de Bouctouche - It stretches 7.5 miles across Bouctouche Bay with
½ mile of boardwalk with ramps and stairs to the beach (New Brunswick, Canada).

Reversing Rapids - When the high semidiurnal tides of Bay of Fundy collide with St. John
River, they create a series of whirlpools and reverse the flow of the river (New Brunswick,
Canada).

13
Peggy’s Cove - The lighthouse dates from 1924. The granite rocks are batholiths of
400 million years that have been carved by the migration of glaciers and ocean tides
(Nova Scotia, Canada).

By Joseph S. Silverman, MD
There are two widely held but incompatible views of
government within these officially United States.
In one camp, many still view our immediate past
president as an exemplar, an American Idol. The other
camp almost unanimously regards him as Public Enemy
#1. Both assessments cannot be accurate. But, in some
fashion, can both assessments be justified?
Each camp seems satisfied with its overall orientation
though an element of the Republican party has become
even more intransigent than its majority.
As of January 2023, the legal trap seems to be closing
on Donald Trump, but potential Republican successors
operate mostly in the same mode.
That the U.S. citizenry may not be up to the job of making
thoughtful electoral choices is not a novel concern. Based
largely on older assessments, Louis Menand, in a 2004
New Yorker article, showed how casually the average
voter takes his responsibility. He concluded, “It’s not
that people know nothing. It’s just that politics is not
what they know.” Most voters rely on party affiliation as
they cast their ballots. Few understand the elements of
governmental structure or candidates’ stances on issues.
Now, almost two decades later, halfway through Joe
Biden’s first term, there has been a rise in political
temperature, though not particularly in political
knowledge. Credible refutations have not changed minds
that embrace the stolen election lie. The well-publicized
findings of the January 6 committee of the House of
Representatives, evidence considered compelling by
many experts, altered public opinion not a whit.
A R T I C L E S
Photo
by
Rosemary
Ketchum

15
No Free Will Determinism
Virtually unknown to the public and even to the medical
community, biology-informed psychology can offer
novel insights. This discipline has ancient roots and
impressive contemporary advocates. Capital Psychiatry,
in its Fall 2022 edition, featured an essay entitled,
“Free Will Illusion Perverts Law & Human Relations,”
an introduction to scientific No Free Will determinism.
Capsule reviews by Robert Sapolsky and Jerry Coyne
illustrate the controversy between “hard” and “soft”
determinism. I find the former more rigorous and logical,
though harder to grasp.
The present essay employs the insights of this new
psychology to analyze electoral decision-making. A
voter may feel confident that she is making a conscious
judgment, unaware of the network of information and
emotion that led her to that decision, that in fact made
that decision for her.
Table 1 records the basic conclusions of deterministic
psychology. These “axioms” form the basis of No Free Will
psychology.
Some Factors in Political Decision-Making
Us vs. Them: Identity & Its Conflicts
Oscar Hammerstein created these verses for the musical
South Pacific.
You’ve got to be taught to hate and fear.
You’ve got to be taught from year to year.
You’ve got to be taught to be afraid.
Of people whose eyes are oddly made
And people whose skin is a different shade.
A charming sentiment. But from the viewpoint of science,
not a valid one. Evidence points to the exact opposite. The
tendency to conceptualize relationships in terms of Us
vs. Them is now understood to be inborn, hard-wired in
human beings. This instinct, I will try to show, needs to be
unlearned for the good of humanity.
In its early weeks, the newborn child, with its primitive
nervous system, cannot distinguish between parents and
strangers. Around five months begins the appreciation of
the familiar. Eighth-month anxiety when confronted with
strangers has long been recognized.
As time goes on, the child perceives certain persons and
settings as comfortable and reassuring, differentiated
from others that are not. Typically, racial compatibility
provides comfort; this instinct is likely to persist. The rule
seems to be: what is familiar is congenial.
It is respect for unlike Others, and more than that, it is
linkage with — identification with — unlike Others that
needs to be carefully taught.
This Us. vs. Them, this uneasiness with the unfamiliar,
this intolerance of different-from-me, forever expressed
in American politics, has taken an even more malignant
turn. Targets have ranged from despised sexual, racial,
and religious minorities to condemned public-serving
professionals, librarians, school board members, doctors
and nurses. Attacks against these newly vilified targets
have become increasingly physical and even lethal.
In the U.S., as Ezra Klein pointed out, individuals have
multiple identities stemming from their connections with
groups — regional, religious, racial, social, etc. But the
most powerful identification these days is political. Great
numbers of people build their political philosophies not
through conscious reasoning but rather from attitudes
inherent in groups they identify with.
An ideal universal resolution may be impossible to
achieve, but, for some, it may not be hard to imagine.
As documentarian Ken Burns expressed it, “We are all
Us!” Irrespective of complexion, geography, culture, or
language, all humans belong to the same species, all
immersed in a shared atmosphere, all facing a shared
array of perils.
Currently, few can even imagine Burns’ global solidarity.
Conservatives have long dreaded a New World Order.
Internationally, worst cases are not lacking: Russian and
Chinese leaders seeking to conquer smaller, dehumanized
neighbors. But this primitive lust for land need not exist
forever.
Moral insight grows slowly within a society until it
suddenly takes hold and endures. Enslavement of
the vanquished was routine throughout history. Yet,
millennia later, not only is slavery unacceptable but
women serve as physicians and genders number more
than two.
The Moral Dimension: Egoism vs. Altruism.
No contrast between the two leading parties is as striking
than this one. For most voters, on a conscious level, this
dimension does not even exist. Yet pick an issue, and
what do you find? “I demand my Second Amendment
rights absolutely!” vs. “The threat of firearm violence
uniquely terrorizes the United States!” Or “I insist that
my faith tradition, my religious imperatives, should be
required for everyone!” vs. “Individuals should be free
to follow any spiritual inclination — or none at all!” Or
“Climate change is unproven, too controversial to be a
federal priority” vs. “Science and realism require that we
all do what we can to protect the environment.”
A modified version of the work of Lawrence Kohlberg
remains a serviceable gauge of moral level. In this
schema, derived from the Harvard study of children’s
changing notions of right and wrong, the lowest level

is exclusive self-interest — “I want what I want right
now.” The highest level, rarely achieved, represents an
identification with humanity in general.
Critics of conservatism show little patience for what
they see as stubborn rejection of progress. These critics
have no inkling that there is likely a physiological basis
for conservatives’ climate change denial, abhorrence of
abortion rights, or suppression of minority voting rights.
Genetics
Younger psychiatrists may not fully appreciate how
much our specialty has changed in the last seventy years.
Obviously, medicine in general has been transformed
in that interval, especially with respect to technology.
Progress in psychiatry has centered on ascertaining
the nature of psychopathology and the utility of
psychopharmacology.
During my psychoanalytically oriented psychiatry
residency in the early 1960s, the most significant
disorders — schizophrenia, depression, addictions,
childhood hyperactivity — were viewed as psychological
in nature and treated as such. Brain dysfunction
was rarely considered as a basis for illness, and
pharmacological treatment was seen as useful for
symptoms but not for the core features of these
conditions. In the U.S., little attention was paid to the
genetics of mental disorders.
Outside of academic circles, genetic contributions to the
development of political commitment, even to this day,
are not well known to the public. For instance, Hatemi’s
research on identical and fraternal twins has revealed the
impressive effects of genes on political orientation.
Mooney, a science journalist, contrasted “The Republican
Brain” of his title with the liberal brain. He cited evidence
that the former is characterized by traditionalism, closed-
mindedness, conscientiousness, loyalty, and fear of
threat. The latter is notable for openness to experience
and evidence, comfort with complexity, and empathy.
Personality traits were judged to be significantly
heritable, accounting for more than 40% of the variance.
The parties’ difficulty in reaching compromise is
understandable in this light.
There is a good chance that the capacity for empathy is
substantially genetic. So, for example, people who possess
a low level of empathy are likely to be skeptical of foreign
aid and domestic welfare.
Fantasyland
Kurt Andersen’s book of the same name (2018) details
400 years of American history, tracing the ebb and
flow of fantasy and realism. At times, one emphasis has
prevailed, only to reverse later. Early settlers, who arrived
on our shores dreaming implausibly of limitless wealth,
often came to rue their decision.
But there has been perhaps no time like the present,
when a large proportion of one political party has
been captivated by conspiracy theories in general
and QAnon and hate groups in particular. Suggested
causal factors have included stressors like the COVID
pandemic, disruptive effects of climate change, and
the contentiousness of political discourse. To top it off,
social media’s algorithms have intensified the public’s
fury. Fantasy, which, sprinkled over routine days,
brightens one’s existence, has boiled over — distracting,
misleading, and fomenting violence.
Traditionalism and Religiousness
These motifs are closely associated with conservatism.
It is natural for adherents to cling to their established
ideas, inadvertently limiting their adaptability to an ever-
changing world.
Lies, Misinformation, Disinformation
Unfettered free speech at first strikes one as a basic
American ideal. But neuroscience warns that false input
can lead to unfortunate results like hate speech and
violence toward those seen as different.
Science-minded liberals marvel at those who mine
social media for data. Anecdotes get mischaracterized as
evidence. Few Americans are skilled at critical thinking.
Even doubted input can leave a lasting mark on anyone.
When one dispenses with the illusion of free will, one
becomes more alert to how thoughts originate — namely,
from information and sentiments, stored and newly
acquired. Advocates of absolute free speech have no
idea that “garbage in, garbage out” applies to more than
computers. Although the brain is vastly more complex
than a computer, understanding the logic of computers
helps us imagine the mechanics of brain function.
Attraction to Sadism (Adam Server)
Snarky humor is congenial to many people. It can become
addictive. This factor is especially prominent among
MAGA Republicans.
Neighborly Accommodation
Since one has more frequent contact with one’s
neighbors, it lessens tension to establish uniformity in
support of local athletic teams and political favorites.
Unsophistication: Intolerance of Complexity/Lack of
Critical Thinking/ Gullibility
This proposed factor can be seen as having a common
core with separate facets. My small “armchair” research
group recognized a trait like this among many COVID
vaccination rejectors. Unsophistication seems to dispose

17
its bearers to an affinity for conspiracy theories. Although
occasionally manifested by liberals, conspiratorial
thinking is rampant among conservatives. Personality
traits like these are seen as substantially genetic in origin.
Psychopathology
Trump supporters have never been intrigued by
questions about their leader’s mental status. Instead, they
obsessed over the question, “Is Joe Biden senile?” But
Trump’s opponents, seeking to explain the President’s
unusual comportment in office, did pay attention to this
subject, most notably in Bandy Lee’s The Dangerous Case
of Donald Trump. Evidence of sociopathy in a national
leader clearly deserves concern.
Conclusions
Darwin would be disappointed to learn that 140 years
after his death, few humans understand the basic rule of
determinism — nothing totally original can exist in nature.
Preceding elements must have united to produce the
“new” development. The illusion of self-invention has been
so powerful that its impossibility is universally overlooked.
But Darwin survives in No Free Will neuroscience and
biology (Table 1). Accordingly, his successors recognize
that no thought or act arises independently, that we
all are limited by our unique repertoire of language,
concepts, and impulses. We all have different brains and
are all guided by our individual nervous systems. What
we do at any given moment is the best we are capable of
at that moment.
I would have been excited to discover and share an
egalitarian view of American politics. “Both parties are
well-intentioned and offer ideas of value to the nation.”
But such a statement would lack verisimilitude and
would be unfit for a scientific publication.
The sad truth is that the Republican party, over the past
sixty years, has traded its liberal left for racist white
Southerners and their ideology. Responsive to its leaders’
emotional constitutions, it has gravitated to its present
political positions.
With that transformation came an ethos of victory and
power. Drawn to the remodeled GOP were wealthy tax
minimizers, science-deniers, New World Order phobics,
White Nationalists, militia recruits, conspiracy aficionados,
Us vs. Them separatists, and paler versions of those
contingents. Furthermore, as Menand showed at the top of
this essay, most voters lack cohesive political philosophies.
Photo
by
Rosemary
Ketchum

References:
Andersen K. Fantasyland: How America Went Haywire. Random
House; 2017.
Andersen K. Evil Geniuses: The Unmaking of America, Recent History.
Random House; 2020.
Eagleman D. Incognito: The Secret Lives of the Brain. Pantheon
Books; 2011.
Frances A. Twilight of American Sanity: A Psychiatrist Analyzes the
Age of Trump. HarperCollins Publishers; 2017.
Hatemi P, McDermott R. Man Is by Nature a Political Animal:
Evolution, Biology, and Politics. University of Chicago Press; 2011.
Kandel E. The Age of Insight. Random House; 2012.
Klein E. Why We’re Polarized. Simon and Schuster, Inc.; 2020.
Lee B. The Dangerous Case of Donald Trump: 27 Psychiatrists and
Mental Health Experts Assess a President. St. Martin’s Press; 2017.
McIntyre L. The Scientific Attitude: Defending Science from Denial,
Fraud, and Pseudoscience. MIT Press; 2019.
Menand L. The unpolitical animal: how political science understands
voters. NewYorker 2004: August 30.
Mooney C. The Republican Brain: The Science of Why They Deny
Science and Reality. John Wiley and Son; 2012.
Moore B: Critical Thinking, Sixth Edition. Mayfield Publishing
Company; 2001.
Moore B., Bruder K., D’Arcy A.: Philosophy: The Power of Ideas 11e.
McGraw Hill LLC; 2023.
Nichols T. Our Own Worst Enemy: The Assault from Within. Oxford
University Press; 2021.
Provine W. No free will. Isis. 1999: S117-132.
Rest J, Navaez D., Bebeau M, Thoma S. Postconventional Moral Think-
ing: A Neo-Kohlbergian Approach. Lawrence Erlbaum Associates, Inc.;
1999.
Sapolsky R. Behave: The Biology of Humans at Our Best and Worst.
Penguin Books; 2017.
Sapolsky R. Determined: A Science 0f Life Without Free Will. Bodley
Head; 2023.
Serwer A. Cruelty Is the Point: The Past, Present, and Future of
Trump’s America. Random House Publishing; 2021.
Silverman J. Free will illusion perverts law and human relations.
Capital Psychiatry 2022; fall edition: 20-22.
Welch B. State of Confusion: Political Manipulation and the Assault on
the American Mind. Bryant Welch; 2019.
Westen D. The Political Brain: The Role of Emotion in Deciding the
Fate of the Nation. Public Affairs; 2007.
*****
Full Disclosure. Although a Republican for most of my life, I gave
up on the national party after the Nixon presidency (insight arrived
later) and left the state party as well in 2007.
Those who seek truth at any cost face a conundrum.
They live in a democracy; they believe in democracy.
But in many communities they are outnumbered by
the fervently irrational, unamenable to evidence and
disrespectful of sources that knowledgeable, reasonably
objective people find credible. And all votes count
equally! This is democracy.
But wait! Doesn’t everyone do as well as they can with
the brain that they have?
Exactly! The typical Republican brain, laden with
information and sentiments from non-objective sources,
insulates believers from uncomfortable realities.
“Garbage in, garbage out” once again. Simply put, liberals
at best operate on an intellectual “channel.” MAGA
Republicans automatically operate on an emotional
“channel:” fear; uneasiness about change; anger, and
“Don’t Tread on Me! I Tread on You.” Political clashes are
inevitable.
Without at least two formidable and rational parties, the
U.S. is in big trouble.
Table 1. Axioms of No Free Will Determinism
1. We humans do not know why we think as we do
and act as we do.
2. Unconscious input is highly influential though
unsuspected.
3. You can’t outperform your brain.
4. The brain is formed by genetics as modified by life
experience.
5. In a moral sense, individuals should not be held
culpable for the operation of their brains, which have
been created by automatic processes independent of
conscious control.
6. Thoughts and impulses that become conscious we
mistakenly assume to be our personal creation, and,
rationalizing, we readily take responsibility for them.
7. Because sensory input alters thoughts and actions,
protection against misinformation is warranted.
8. All humans merit compassionate understanding.
9. Root causes of unfortunate behavior are determinative
and should be sought and remediated.
10. Political statements incompatible with our conscious
preferences are automatically pushed out of
consciousness. (Drew Westen)
11. Since sensory input influences future behavior,
editorial excision is needed to protect against
misinformation and disinformation.

19
CAPITAL PSYCHIATRY’S PSYCHOANALYTIC CLINIC:
Out-of-Control Control Cases or When a Low-Fee is no Bargain*
By Nathan Szainberg, M.D.
Because of psychoanalytic institutes’ autonomy, there
are varying approaches to recruiting control cases for
candidates. Further, with shifts in cultural mores, fewer
people pursue analysis, even at low fees. Finally, with the
rise of additional institutes, (Wallerstein, 2000), more
candidates seek patients.
These synergistic forces result in greater vicissitudes for
candidates seeking patients, particularly when compared
to the 1950’s/60’s ethos in the US. Other pressures
include external realities of lengthy training analyses, and
idiosyncratic countertransference issues of the candidate
— not only countertransference of childhood origins, but
also of current life circumstances.
I describe and discuss the interaction among the
character traits of three prospective control cases,
the Institute’s referral process, and the candidate’s
countertransference issues.
First, the circumstances of the Institute. The Institute
chose to shift its evaluation and referral process of the
low-fee clinic, established for finding control cases for
candidates. Rather than having prospective low-fee cases
see a senior analyst over several sessions, patients would
Summary: I describe three consecutive referrals
from a Psychoanalytic Institute’s Low-Fee clinic, to
demonstrate the inherent organizational and possibly
characterological difficulties in such cases that could
interfere with successful analysis by a candidate. All
three cases were discussed with at least two training
analysts, both of whom recommended against
accepting all three cases into treatment because
of ego and superego difficulties that would have
interfered with a successful psychoanalytic treatment,
and in fact, might have resulted in a pseudo analysis
(Winnicott, 1972). I discuss the specific challenges
faced by candidates in communities with a shortage
of low-fee cases and the countertransference issues
specific to a middle-aged candidate hearing time’s
winged-chariot beating behind. My intent is to open
discussion of weighing advantages and disadvantages
of any process for accepting low-fee analysands in a
psychoanalytic training program, particularly when
fewer patients come for analysis and more institutes
and consequently candidates seek patients.

be seen once, possibly twice, then referred to a candidate.
Patients were told that the fee would be negotiated with
the candidate, based on the patient’s finances. But, many
prospective patients told candidates that they had heard
from others that the fee could be as low as $10/session.
Child psychoanalytic candidates were so desperate for
cases that they bantered amongst themselves about
paying parents to bring children.
Candidates were expected to meet several times with
the prospective patient, then present the case to a
supervisory analyst to decide upon accepting the case.
The issue of “analyzability” was discussed, but with
sensitivity that a patient may not be analyzable with
one candidate/analyst, but may be with another. If the
supervisor and candidate agreed not to accept a patient,
the latter was referred back to the clinic for a referral to
another candidate. I will briefly report each case, then
discuss their presentations and the difficulties for both
the candidate and prospective patients.
Case One
Mr. Z., in his mid-30’s drove up to the analyst’s home
office in a bright yellow Hummer, with an Eddie Bauer
logo and Burberry plaid interior. The analyst could
see the details of the car, for Mr. Z. had parked on the
sidewalk in front of the analyst’s home and partially
blocking a neighbor’s driveway.
He was a handsome, lean, tan, well-groomed fellow, who
entered with a sense of self-assurance. He removed his
butter-soft black, tailored napa leather jacket, folded
it twice, and laid it upon the couch, smoothing, then
caressing the jacket before he sat down. He smiled. He
had bought this Armani jacket, he began, on his last trip
to Italy; brought back good memories.
He had changed careers. He had been in retailing, an
executive, inheriting his father’s business, and was
remarkably successful: took early retirement to enlist in
a psychology graduate program, at one of several new
Psy.D. professional programs that had sprouted up in
the last few years. After buying a house in a tony San
Francisco suburb, he and his new wife agreed that they
could live off his golden parachute from his last job.
He was delighted to be training in psychotherapy. He
had majored in business in college, entered the family
business, but really wanted to do therapy. He was
pleased to be accepted in this graduate school, since his
GRE scores were too low for the local traditional Ph. D.
programs. Now, he wanted to have his own analysis, since
he had heard much about Freud and thought that this
would make him a better therapist. He did not think that
he had neuroses, but he thought that an analysis would
better help him understand his patients.
He missed his second visit and called afterwards. He
arrived for the third visit, with a jaunty enthusiasm. They
had a new baby (the first the analyst heard of this) and
he looked forward to learning much about development
even as he was in analysis; he had learned that the
candidate was a child psychiatrist, specializing in infancy.
He had never been in therapy, relished new experiences,
challenges. Periodically, he reached over to smooth an
unseen wrinkle in the leather jacket lying on the couch.
He looked forward to using the couch.
Finally, the candidate introduced the fee.
The patient was surprised; sat back with a jerk. What was
to discuss? He had heard from fellow psychology students
that the fee was ten dollars.
The candidate ventured that the Institute’s policy is that
the fee would be based on his ability to pay.
The patient leaned forward angrily. “I’m unemployed!
Would you take food from the mouth of my baby” to
charge a higher fee? He was outraged. He said that the
analyst should think about this, since he knew that
candidates were hungry for patients. He would return
to the low-fee clinic, report the candidate and request
another referral.
Case Two
Mr. R. was in his mid-fifties. He had just finished a
graduate program in fine art, having taken early
retirement from a dot.com, after helping found the
company and bringing it public. His lover had urged him
to become a conceptual artist, perhaps do performance
art, his dream. He enjoyed his three years in art school
and now looked forward to devoting full-time to art. He
would not work but would create art all day.
He had been the oldest student in his school, but hoped
that by doing art full-time, unlike his fellow students who
had to work during the day or wait tables on weekends
and evenings, he would have one-man shows soon. He
had had various psychotherapies. But he thought analysis
would be good for his art; after all, he had heard, read
many stories about artists of the ’50’s and ‘60’s and their
analyses. Look at Woody Allen. Analysis would help
him get in touch with his inner self, enrich his artistic
processes.
He was glad to hear about the low-fee clinic. Otherwise,
he said, he would have to return to work at least part-
time to pay for his analysis. Ten dollars a session was a
good deal, he said. Anything more would be theft.
The candidate, after discussing the case with two training
analysts, referred the patient back to the low-fee clinic.

21
Case Three
Ms. W. came to the first meeting, after a senior analyst
telephoned the candidate. The senior analyst really liked
this patient; if she could have afforded a private fee, the
analyst would treat her herself. The referring analyst was
glad that they had but one meeting, otherwise the analyst
would have developed too strong an attraction to the
patient, an attraction — the candidate learned — which
was mutual.
This training analyst had heard about the candidate; that
he was a seasoned therapist and was looking for a fourth
case. She thought that this would be an excellent case
for the candidate. Could the candidate call back after the
evaluation?
Oh, by the way, the patient was a neighbor and friend
of Dr. X, a very prominent training analyst. Dr. X. had
referred the patient saying that he wanted her to have a
more senior candidate.
This woman arrived, poised, dressed in an understated,
but classically elegant manner. Although it was winter
in San Francisco, she arrived in a skirt and nylons, and a
slinky, silk beige blouse with revealing décolletage. She
had been through a terrible divorce from a very wealthy
man who had “ripped her off” in the divorced because of
a pre-nuptial agreement.
She had been a successful writer before the four-year
marriage, her first, then was out-of-work for almost a
year. Finally, she just got a job that paid $90,000 a year,
well below the standard of living to which she had been
accustomed. They had no children, and she was relieved
that she had gotten the house in(a desirable village),
mortgage-free.
She thought that she had issues that had contributed to
her marrying late and to her unsuccessful marriage. She
remarked wryly, “I didn’t marry this wealthy guy because
of his looks.” She wanted to address these issues in
analysis so that she would not repeat them.
Dr. X., a close friend, recommended analysis. He would
treat her, but he explained that he could not because they
were friends. Dr. X. assured her that he would help her
get a good candidate. The candidate should call him with
any questions, she offered.
On the second visit, we discussed details of frequency,
use of the couch and the nature of free association. The
candidate raised the issue of fee. The patient drew herself
upright. She was assured by Dr. X. that I would charge her
ten dollars a session. She drew her chair forward, until
her knees leaned against the candidate’s ottoman, her
décolletage offered. She spoke huskily, “ I am making a
commitment to this process already, offering to come four
times weekly…. I have a great deal to offer.” Surely the
candidate would take this into account in accepting the
ten dollar fee.
On second thought, she felt as if the candidate was
ripping her off like her former husband. She would be
sure to telephone Dr. X. about this. This Institute would
take notice, she insisted.
Discussion
In all three cases, the candidate felt both internal and
external pressures to accept the last control case, having
waited two years. Externally, the director of the low-fee
clinic had explained that there was a shortage of cases to
refer. He gave preference to first year candidates. In the
third case, the director of the clinic thought that since
the patient had significant narcissistic issues, the patient
would do well with an experienced candidate, who had
had training in Kohut’s work during his residency. The
candidate also felt the peer pressures of colleagues
seeking patients. Most candidates insisted that it was
better to get patients from one’s own caseload, rather
than the low-fee clinic.
An internal pressure was the candidate’s approaching
his fifth decade with a family to support. These
countertransference issues were discussed in
supervision. He discussed specific countertransference
issues raised with these patients.
The artist, only a few years older than the candidate,
had rubbed against the grain when he said that he
was pleased that he would not have to work to pay
for his analysis. The candidate had worked as an ICU
nurse during medical school on the graveyard shift
to pay for his first analysis. It is quite possible that
another candidate (or analyst) who did not have these
experiences, would not have reacted adversely to the
artist’s remark.
The same issues applied to graduate student/former
retailer. Stepping back, one could see with greater
empathy that the student’s driving a Hummer, wearing
Armani leather, laying his “skin” and caressing it on the
couch, were manifestations of a narcissism in which
external valuables might be covering a core emptiness,
worthlessness.
One can’t be certain from only two interviews. But
the sense of entitlement and remarkable wealth,
evoked feelings in this candidate that permitted only
an intellectual formulation of the patient’s narcissism,
without sincere empathy. One training analyst, upon
hearing the case, offered trepwerter, “after thoughts,”
that he might have said: “I don’t blame you for trying to
get away with anything. You’re welcome to try. But do
you expect me to be blind and dumb?” He recommended
against accepting this as a training case.

The third case, if I described it clearly, raised additional
difficulties. As this attractive woman leaned forward, the
candidate felt a sense of seduction. He did not find that
this was an idiosyncratic countertransference, rather
one being brought in by the patient very early in the
evaluation. Her case raised additional complications of
the “special patient,” first discussed by Thomas Main
(Main, 1956; Szajnberg, 1985; 1994). The “special”
patient brings along complications that are not
necessarily in the patient’s best interest. (The senior
training analyst, Dr. X, did call after the woman’s last
visit, expressing disappointment that the “experienced”
candidate would not reconsider his decision and accept
the patient into treatment. Of course, Dr. X., did not want
to interfere in the process, but wanted to let the candidate
know that she was a very fine person.)
One training analyst supervising the candidate in another
case, was concerned that the characterological issues in
two of the cases were so severe that a several-year course
of exploratory (preparatory) psychotherapy would be
necessary before an analysis (one that fulfills the criteria
for certification) were feasible. Given the candidate’s
age and desire to complete his training, the analyst
recommended against accepting both patients. In fact, he
thought that both patients would present challenges to
an experienced analyst. In each case, I want to emphasize,
a different candidate or analyst might have been able to
treat the patients successfully, addressing issues such
as entitlement, seductiveness and certain aspects of
narcissism.
Freud first wrote about entitled patients in his “Some
Character Types met within Psychoanalytic Work”
(1916). His paper is remarkably atheoretical, more a
descriptive account of three character types: “exceptions,”
wrecked by success, and criminals from a sense of guilt -
in which he did not give clinical material, using references
to literature.
While Freud initiated our inquiry into what we now
call character analysis, of the three character types,
the “exceptions” present with the expectation that
the analyst make special exemptions. “They say that
they have renounced enough and suffered enough and
have a call to be spared any further demands…” such
as psychoanalytic work expects. On exploration, these
patients give a history of early “suffering…of which they
knew themselves to be guiltless…’ (1916; 312-3).
But it is Kohut’s work (1967) that brought the character
disorder of narcissism to the fore. To a significant degree,
such patients have become the coin of the psychoanalytic
realm. While Kohut eventually developed a detailed
theoretical developmental model of two lines of parallel
development and a lack of parental empathy, his early
work focused on revised psychoanalytic technique with
such patients.
Kernberg (1975), Giovacchini (2000) and Andre Green
(2002), among many others, have suggested that the
narcissistic character is along a continuum of character
disorders. Further, Giovacchini and Kernberg in
particular have articulated healthy aspects to narcissism,
distinguishable from that in character pathology.
Ironically perhaps, it was a social historian, Christopher
Lasch (1974), who raised our awareness of narcissism
as a characteristic of American culture arising in the
late twentieth century. In an encyclopedic review of
changes in American society — a shift in capitalism,
bureaucratization of work, government and decrease
in family power and responsibility — Lasch describes
narcissistic elements in society, including a sense of
entitlement, emptiness and associated pursuit of desires,
trivialization of personal relations, and a pseudo-
self-awareness and self-absorption with a search for
identifications (as opposed to identity) and various
“therapeutic” modalities of self- realization or self-
improvement.
That is, Lasch sees the Narcissistic Personality Disorder
only as an epitome of an ailment in contemporary
American society. In terms of the patients who presented
here, this complicates our diagnostic challenge: we need
think not only in terms of specific character pathology,
but also an overlay of entitlement (and underlying
emptiness) in the culture.
But in terms of these three patients, there were specific
aspects of narcissism that (combined with this analytic
candidate’s needs for a timely finish of training) mitigated
the likelihood of successful analysis: an overarching sense
of being an exception, being entitled; an unusual lack of
awareness of their presumptuousness; a sense that they
could appeal to higher powers to prevail on the candidate
(or others); and a demeaning of both the analytic
situation and the analyst/candidate.
In terms of demeaning, all three prospective patients
were from monied backgrounds, were prepared to pay
well for what they valued. None of these aspects are
insurmountable in a sufficiently lengthy analysis with
an analyst aware of the countertransference issues
involved — countertransference in the more recent
sense of counter identification or evoked response,
rather than Freud’s thoughts of a more idiosyncratic
countertransference.
In the early psychoanalytic institutes, “free” or low
fee clinics brought many, many patients (Makari,
2008). When Eitigen and colleagues opened the free
psychoanalytic clinic in Berlin, there was a press of

23
patients, almost overwhelming the capacity of the clinic.
Circumstances have changed profoundly.
What does this imply for candidates? There were at
least three interacting factors here: the manner in which
prospective patients were referred; societal valuation
of this matter of psychoanalysis; the candidate’s need to
finish particularly nearing training.
Any institutional decision about screening and referring
has implications with advantages and disadvantages.
The advantages of this Institute’s minimal screening
— include brief patient contact with a training analyst
and accepting that a patient may not be treatable by
a particular candidate, but possibly by another —
theoretically provides greater openness, receptivity
to patients; avoiding disappointment associated with
extended assessments by a training analyst before
referral; and offers greater hope that lack of “fit” with
one candidate does not preclude “fit” with another. The
disadvantages include referring to a candidate before
an experienced analyst can assess not only the patient’s
formal diagnosis, but also what Winnicott (1972) or
Schlesinger (2002) referred to as assessing the nature of
analytic process.
My paper addresses possible complications of a more
“open” screening process. This is simply a caution
to training centers. Now, as a training analyst, I have
discussed these three cases with colleagues.
Reactions have been complex. One suggested at first,
that she would have tried to interpret their attitudes,
such as seeing the analysis as a “good deal,” a cheap
treatment - but she could not think of an interpretation
at the moment. Then, she described a recent referral — a
graduate student in psychology — who insisted on either
a lower fee or lower frequency, as she was planning to
buy a new car.
Another colleague recounted a more complex situation:
in his Institute, one must be in analysis for one year
before applying for training. An older therapist came
for analysis, as she had heard he was highly regarded at
the Institute and on the Education committee. But, she
warned him, that if she were not accepted at the Institute,
she would not continue her analysis. He was concerned
that a false analysis was in process.
I write this paper as a caution, without offering solutions.
I write this to open discussion among candidates and
Institutes to recognize the dilemmas associated with any
referral process, particularly low-fee cases.
The low-fee clinic may attract prospective patients with
specific characterological constellations: entitlement,
a pseudo-investment in psychoanalysis, and possibly, a
not- too-subtle demeaning of the analyst/analysis. If this
References:
Freud, S. (1916). S. E. Volume XIV. Some Character-Types
Met with in Psycho-
Analytic Work. The Standard Edition of the Complete
Psychological Works of Sigmund Freud, Volume XIV
Giovacchini, P. (2000). Impact of Narcissism: The Errant
Therapist on a Chaotic Quest. Jason Aronson.
Green, Andre (2005) Psychoanalysis: A Paradigm for
Clinical Thinking. Karnac.
Kernberg, O. (1975) Borderline Conditions and
Pathological Narcissism. Jason Aronson.
Main, Thomas (1956), “The Ailment.” The British Journal
of Medical Psychology, 29.
Makari, G. (2008) Revolution in Mind. Harper Collins.
Schlesinger, H. (2002) The Texture of Treatment. NY:
Analytic Press.
Szajnberg, N. (1985), “Staff Countertransference, in the
Therapeutic Milieu: Creating an Average Expectable
Environment.” The British Journal of Medical Psychology,
58; 331-6.
Szajnberg, N. (1994). Educating the Emotions: Bruno
Bettelheim and Psychoanalytic Development. NY: Plenum.
Wallerstein, R. (2000), The Talking Cures NY: IUP.
Winnicott, D.W. (1972) True and False Self, In The
Maturational Processes and the Facilitating Environment.
NY: IUP.
*Reprinted with permission from Dr. Nathan Szajnberg’s
Website
is the case, then it is useful for Institute clinics, training
analysts and candidates identify and address such issues
to facilitate more successful referrals and psychoanalytic
treatment, less encumbered by character traits that may
require lengthier analyses.
****
1
I thank Drs. Robert Wallerstein, Alan Skolnikoff, and
Owen Renik for supervising the intake of these cases and
others.

Vincenzo Di Nicola and Drozdstoj Stoyanov. Psychiatry in Crisis: At the Crossroads of Social Science, The Humanities, and
Neuroscience. Foreword by KWM Fulford, MD, Afterword by A Frances, MD. Cham, Switzerland: Springer Nature, 2021.
ISBN 978-3-030-55140-7
(Extract from: Part III – Renewal in Psychiatry, Chapter 7: Cleaning the House of Psychiatry; pp. 128-133)
By Vincenzo Di Nicola
Reductionism in
Medicine and Psychiatry
Excursus: “I Traded My Lederhosen for a Kilt” or “Reinventing Ancestry”
“Ancestry” and “23andMe” are direct to consumer genetic testing companies. Such companies make two
pitches to the public - genetic testing for health and disease on one hand, and ancestry and cultural heritage on
the other. The first claim is exaggerated, the second one is distorted and absurd!
The Ancestry ads typically show a situation where someone has a cultural identity based on their family
history. After genetic testing, they discover some previously unknown genetic link to another cultural group
and suddenly their understanding of themselves (e.g., habits, interests, tastes) is discredited and they suddenly
adopt a new cultural identity.
“Katherine” confesses in an Ancestry ad: “I thought I married an Italian,” but Ancestry shows that Eric is “only
16% Italian” and “34% Eastern European”! In another Ancestry ad, “Kyle” testifies: “Growing up, we were
German. We danced in a German dance group, I wore lederhosen.” Then he did his ancestry testing and found
that, “52% of my DNA comes from Scotland and Ireland, so I traded in my lederhosen for a kilt.” In each case,
the expressed identity is a caricature of national character and identity.
As their commercial ironically asserts, 23andMe is “reinventing ancestry.” The announcer promises that,
“You’ll learn about your ancestry through your 23 pairs of chromosomes that make you who you are.” This is
false, tragically false! As the great developmental biologist C.H. Waddington demonstrated 50 years ago in his
metaphor of the epigenetic landscape, nature carves out the channels where marbles will roll on a hill with
“valleys” and “forks,” but as they roll they also adapt biologically, at the cellular level (Noble, 2015).
Since then, social and cultural studies of nurture in child psychology, psychiatry and their allied fields have
amply demonstrated that our lives are also shaped by the history of our attachments and the adaptations of
our cultures, the memory of our personal and collective histories, and the uniquely human counterfactual
capacity to imagine and build different futures that will impel us beyond all possible biologies and imagined
limits of the human imagination.
See: https://www.youtube.com/watch?v=tJcODboSSEg Accessed March 1, 2020
In this section, we will cover several examples of how
reductionism in medicine and psychiatry distorts our
understanding and blocks true progress: (1) depression
and the “chemical imbalance theory,” (2) simplistic
biological models for the schizophrenias, and (3) eating
disorders and the search for medical explanations over
broader social psychiatric ones.
First,letusexaminehowtheintersectionofthepowerful
laboratory tools of genetics and consumer culture are
distorting the public discourse about disease, risk,
identity, and culture. Today’s major cultural meme
about identity is provided by the personal genomics
or consumer genetics industry by companies such as
“23andMe” and “Ancestry.com.”

25
This is precisely our concern with such technological
reductionism. This translation of technology into practice
is misapplied and misguided. The curiosity to “know
yourself” is understandable but personal, family, cultural
and religious identities are complex and based on shared
experiences and values over a lifetime, over generations
in fact, and not narrowly determined by genes. While the
family stories are portrayed positively (although there is
no statement as to whether they are true or not), they are
a caricature of belonging and identity, culture and history.
Furthermore, it’s a short step to crude biological
identifications and all that goes by the name of “nativism”
and “racism” in the current cultural climate. Since
biologists and population geneticists have demonstrated
that “race” is a myth (Cavalli-Sforza, et al., 1996), we
should reject these terms and affirm that belonging
and identity are historical and cultural constructs, not
biological givens that can be understood under the rubric
of “race.”
When I was in medical school, one of my professors used
to joke that when evolution is complete, we’ll all be Irish.
The race myth smacks more than a little of the notion of
evolution understood as “progress,” with its attendant
hierarchies and implied “superiority.” Nonetheless, while
biologically speaking race is a myth, its deployment as
an apparatus for prejudice and discrimination is a tragic
social reality.
Now, what does this have to do with psychiatry and our
current crisis? Everything! If we want to understand the
pathologies that psychiatry studies, we have to resist the
reduction of mind to brain, and ancestry merely to genes.
Let me express this personally. I was born in Italy of
Italian parents. When I was a child, my maternal family
moved to Canada where I was raised in English and I now
practice in French in Montreal.
Does my family background make me less of a Canadian
or a Quebecker? Even more tellingly, I did not meet
my father before my 40s, limiting his influence on me
to genetics and family stories. Am I my father’s son?
Biologically, yes; but culturally, psychologically, only
partially, and that by choice.
I chose to visit Brazil where he lived and to learn
Portuguese, developing a secondary career there, and
to marry a Brazilian psychologist. But these are choices
that have little to do with DNA and much to do with how
families construct myth and meaning out of the virtues
and vicissitudes of our lives.
Finally, many theorists are reluctant to argue against
reductionism for fear of being called dualists, or believing
in ghosts (cf. Ryle’s “ghost in the machine,” 1966). There
are many ways to construe “brain” and “mind” without
resorting to dualism or indeed any other philosophical
commitment to explain them. They are separate domains.
Just as brain does not explain mind, neither does mind
explain all relational patterns in culture and society.
Critics of psychiatry often criticize the “medical
model” as reductionistic. This is a gross simplification:
misconstruals of the medical model — and I give three
examples from psychiatry below — do not disqualify
its value properly understood. In arguing against
reductionism, I am not against the medical model of
psychiatry, but for an enlarged, broadened medical model
that includes brain, mind, society, and culture (cf. Gardner
& Kleinman, 2019).
1. Depression and the “chemical imbalance” myth.
For decades, both the profession and public have
believed in the biological story that depression reflects a
chemical imbalance in the brain. They were misled. The
original catecholamine hypothesis of mood disorders
was carefully qualified by its originators in the 1960s,
recognized as significantly flawed and inadequate, and
significantly modified to reflect more complex biological
mechanisms in major mood disorders (France, et al.,
2007; Pies, 2019).
Besides mischaracterizing the neurochemistry associated
with mood disorders, the “chemical imbalance”
myth gave false hope to patients about the promise
of antidepressant drugs and vastly underplayed the
impact of psychological, interpersonal, and social
factors and their role in preventing and treating mood
disorders. Reductionism in psychiatry is not mere
oversimplification; it misdirects investigations and
undermines effective treatments.

2. Schizophrenias and their reductions.
Robin Murray (2017), a distinguished British researcher
in the schizophrenias, acknowledged the role of social
factors in the etiology of psychoses late in his career: “The
truth was that my preconceptions,” Murray now admits
about the neurodevelopmental hypothesis, “had made me
blind to the influence of the social environment.”
No less an authority than Manfred Bleuler, the son
of Eugen Bleuler the psychiatrist who named the
schizophrenias as a psychiatric disease, clearly identified
family and psychosocial factors as major factors in every
stage of this potentially devastating groups of illnesses.
And this was published in Murray’s own department in
London where it was no doubt ignored because Michael
Shepherd (1982) was a professor of social psychiatry.
The larger lesson here is that the complexity of disorders
like the psychoses makes them fertile ground for
attenuating family and social risk factors or amplifying
biological ones. Biological psychiatrists severely criticized
family observations about the schizophrenias, such as
the now discredited “schizophrenogenic mother” (cf.
Seeman, 2016), although the Expressed Emotion (EE)
paradigm confirmed suspicions that negative family
environments play a crucial role in triggering relapses or
worsening outcomes in these illnesses (Butzlaff & Hooley,
1998; Di Nicola, 1988).
The complex interplay of biological, psychological, family,
and social factors in the psychoses is amply confirmed by
the research in Murray’s own department that developed
the EE paradigm as well as the pioneering research by
British psychologist Richard Bentall (2004). In psychiatry
as in medicine, complexity is rarely served by simplistic
reductions.
3. “Anorexia multiforme”: A cultural chameleon.
The history of eating disorders and their socio-cultural
distribution (Di Nicola, 1990a, 1990b, 2021) show that
after anorexia nervosa was first described in London
and Paris in the latter part of the 19th century, little
progress was made in understanding and treating this
social psychiatric illness. What slowed it down was the
discovery of Simmonds Disease in 1914 and Sheehan’s
Syndrome in 1939 - both related to the pituitary gland
with clinical manifestations that have little to do with
anorexia nervosa except for weight loss.
Lesson: when a medical explanation is available no
matter how imperfect the fit with clinical reality, it
is preferred over social, relational or psychological
explanations, to the detriment of genuine understanding
and effective treatment. Anorexia nervosa has severe
medical consequences while the causation is not only
multifactorial but the socio-cultural aspects are far
more salient for its treatment. Another lesson here
about the nature of anorexia nervosa is that it has no
“nature” in two senses of the word: it is not inherently
genetic or biological with a fixed phenotype (or clinical
manifestations) and is thus best understood as a
“cultural chameleon,” responding fluidly to individual,
interpersonal, and socio-cultural sensitivities in an
exquisite interplay across place and time. That is why
I characterize it as, “Anorexia multiforme” (Di Nicola,
1990a, 1990b).
4. “Bracket creep” versus slim promises.
The criticism of Allen Frances, past chairman of the DSM-
IV, is that the APA’s DSM project suffers from diagnostic
“bracket creep,” meaning that it has become overly
inclusive, allowing the criteria “bracketing” the categories
of psychiatric disorders to balloon to bulimic proportions.
From the slim pages of the initial DSM in 1952 to the
expansive 1,000 plus pages in small type of DSM-5 in
2013, something has gone awry. If DSM’s nosology has
become bulimic, then NIMH’s Research Domain Criteria
(RDoC) is positively anorexic!
It is instructive to read the humanities. The 20th century
produced two great Irish writers who straddle extremes.
Joyce was a synthesizer who “worked with all knowing,
with putting everything in,” whereas Beckett was an
analyser who “worked … by taking everything out”
(Knowlson, 2006).
DSM-5 puts in as much possible as possible, a veritable
encyclopaedia of psychopathology, to compensate for
its lack of a theory of human psychology. And under
Insel, NIMH’s project, dismissing the previous DSM
lexicon and nosology as a “mere dictionary,” takes clinical
descriptions out in favour of mechanisms in the brain.
After the “decade of the brain” and much fanfare, it makes
for a meager understanding of the brain, much less of the
mind.
In the final analysis, whether by adding or removing
too much, both approaches reduce human psychology
to an atheoretical manual of psychopathology, based
either on clinical descriptions or brain mechanisms.
Neither approach has integrated a general psychology of
human beings into its understanding of psychopathology.
Bulimic diagnostic “bracket creep” (DSM) versus the slim
promises of brain science (NIMH).
5. Bread and Words.
A final rejoinder from the humanities to reductionists
of all stripes, whether biomedical, psychosocial, or
ecocultural. Psychologist Abraham Maslow (1954)
proposed a hierarchy of human needs that is often
invoked as if it is a law of nature. It is not. Meaning
trumps nutrition, even security, even in extremis. Think of

27
References:
Bentall, Richard. Madness Explained: Psychosis and Human Nature.
Foreword by Aaron T. Beck. London: Penguin Books, 2004.
Butzlaff, Ronald L, Hooley Jill M. Expressed Emotion and Psychiatric
Relapse: A Meta-analysis. Arch Gen Psychiatry. 1998;55(6):547–552.
doi:10.1001/archpsyc.55.6.547
Cavalli-Sforza, Luigi Luca, Menozzi, Paolo, Piazza, Angelo. The History
and Geography of Human Genes, Abridged edition. Princeton, NJ:
Princeton University Press, 1996.
Centeno Hintz, Helena, Godoy Santos Rosa, Maria Inês, Di Nicola,
Vincenzo. “Pão e Palavras”: Um Diálogo Relacional com Prof. Dou-
tor Vincenzo Di Nicola, MD, PhD [“Bread and Words”: A Relational
Dialogue with Prof. Vincenzo Di Nicola, MD, PhD]. Revista Pensando
Famílias, dezembro 2013, 17(2): 3-34.
Chomsky, Noam. Psychology and ideology. Cognition, 1972, 1(1):
11-46.
Di Nicola, Vincenzo. Expressed emotion and schizophrenia in North
India: An essay review. Transcultural Psychiatric Research Review,
1988, 25(3): 205 217.
Di Nicola, Vincenzo F. Overview: Anorexia multiforme: Self starva-
tion in historical and cultural context. I: Self starvation as a historical
chameleon. Transcultural Psychiatric Research Review, 1990a, 27(3):
165 196.
Di Nicola, Vincenzo F. Overview: Anorexia multiforme: Self starvation
in historical and cultural context. II: Anorexia nervosa as a culture
reactive syndrome. Transcultural Psychiatric Research Review,
1990b, 27(4): 245 286.
Di Nicola, Vincenzo. Review article—“A person is a person through
other persons”: A Social Psychiatry manifesto for the 21st century.
World Social Psychiatry, 2019, 1(1): 8-21.
Di Nicola, Vincenzo. Antonella—“A stranger in the family”: A case
study of eating disorders across cultures. In: DS Stoyanov, CW Van
Staden, G Stanghellini, M Wong & KWM Fulford (Eds), International
Perspectives in Values-Based Mental Health Practice: Case Studies and
Commentaries. New York: Springer International, 2021, pp. 27-35.
France, Christopher M, Lysaker Paul H, Robinson Ryan P. The “chemi-
cal imbalance” explanation for depression: Origins, lay endorsement,
and clinical implications. Prof Psychol Res Pr. 2007;38:411-420.
Gardner, Caleb, Kleinman, Arthur. Medicine and the mind—the
consequences of psychiatry’s identity crisis. N Engl J Med 2019;
381:1697-1699.
Kandel, Eric R. The Age of Insight: The Quest to Understand the Uncon-
scious in Art, Mind, and Brain, from Vienna 1900 to the Present. New
York: Random House, 2012.
Kirsch, Adam. Art over biology. In: Rocket and Lightship: Essays on
Literature and Ideas. New York & London: W.W. Norton & Co., 2015,
pp. 3-21.
Knowlson, James. Beckett and His Biographer: An Interview with
James Knowlson. The European English Messenger, 2006, 15(2): 58-
63.
Mandelstam, Osip. Selected Poems. Translated by Clarence Brown
and W.S. Merwin. London: Oxford University Press, 1973.
Maslow, Abraham. Motivation and Personality. New York, NY: Harper,
1954.
Murray, Robin. Mistakes I have made in my research career. Schizo-
phrenia Bulletin, 2017, 43(2): 253–256.
Noble, Denis. Classics—Conrad Waddington and the origin of epi-
genetics. The Journal of Experimental Biology, 2015, 218: 816-818.
doi:10.1242/jeb.120071
Pies, Ronald W. Debunking the two chemical imbalance myths, again.
Psychiatric Times, August 2, 2019, 36(8). https://www.psychiatric-
times.com/depression/debunking-two-chemical-imbalance-myths-
again Accessed February 2, 2020
Ryle, Gilbert. The Concept of Mind. New York: Viking Penguin, 1966.
Seeman, Mary V. Schizophrenogenic Mother. In: J Lebow, A Chambers
A, & D Breunlin (Eds), Encyclopedia of Couple and Family Therapy.
Springer, Cham, 2016. https://link.springer.com/referenceworkentr
y/10.1007%2F978-3-319-15877-8_482-1
Shepherd, Michael (Ed). Manfred Bleuler. In: Psychiatrists on Psychia-
try. Cambridge: Cambridge University Press, 1982, pp. 1-13.
Skinner, Burrhus Frederic. Beyond Freedom and Dignity. New York:
Knopf, 1971.
Bobby Sands, an IRA political prisoner, starving himself to
death on a hunger strike in a British prison in Northern
Ireland.
Osip Mandelstam, writing from Stalin’s Gulag where he
nourished his fellow prisoners with the hope of poetry,
knew that the people need poetry not less than they
need bread (Mandelstam, 1973). “Poetry is like bread”
(Russian poet Mandelstam, French mystic Simone Weil),
that we cling to like a “redemptive handrail” (Polish Nobel
laureate for poetry, Wisława Szymborska), “opening a
window” (Brazilian gaúcho poet Mario Quintana) in the
prisons we live in, some imposed, some chosen through
misguided ideologies.
None of the reductionistic approaches to our work,
from behaviorism to neuroscience, can make sense
of the power of poetry. Skinner’s (1971) apologia for
behaviorism was severely criticized by linguist Chomsky
(1972) for its explanatory and creative poverty. Kandel’s
(2012) neuroaesthetics, attempting to understand “art,
mind, and brain” through neurobiology was similarly
found wanting by noted literary critic Adam Kirsch
(2015). Only a human science that acknowledges that
mind evolves in the context of a healthy brain, bathed in
a supportive social context nourished by attachment and
belonging can have a dialogue about bread and words
(Centeno Hintz, et al., 2013; Di Nicola, 2019).

MENTALLY ILL ON THE STREETS:
An Open Letter to our Mayors
By David V. Forrest, M.D.
E S S A Y S
The issue of the mentally ill homeless is of concern to many physicians, legislators,
public officials, statewide organizations such as the Medical Society of the State of New
York, and local organizations such as the New York County Medical Society (NYCMS).
This article is in respaonse to discussions with my psychiatric colleagues, and with
NYCMS Associate Director Susan Tucker, who provided editorial suggestions.

29
Dear Mr. and Madam Mayors:
Unconscionable neglect of the mentally ill has
become a reality in our major cities, with the
support of a well-meaning public who have cru-
elly construed this neglect as a gift of freedom
and the resulting suffering as a civil right. In New
York City, Mayor Adams’ proposed policy of res-
cue and delivery to places of treatment, to be
enacted by the police, has raised fears of police
brutality and violation of rights. But solutions are
certainly needed; the presence of the untreated
mentally ill, together with a greater tolerance of
and facilitation of street crime, have unhealthily
degraded the commons and the life of our cities,
and so have harmed the public as well, in general
well-being and not just by incidents.
The demand on our social systems is now more
as future immigrants from our southern border
flood our same big cities that are suffering most
from homeless encampments. The great major-
ity of these immigrants are likely physically well
enough and mentally sufficiently integrated
to have made the journey. They will demand
social services but may be less likely to add to
our untreated mentally ill and addicted home-
less populations, at least initially, if support and
work opportunities remain available for them.
However, some of these immigrants may add
to the homeless burden, depending on whether
they can be absorbed into existing communities,
especially communities of their own ethnicities.
Of the many immigrants added to the homeless
in our cities, we in medical professions ethically
ought first to support policy that aids those who
are demonstrably helpless because of their men-
tal and physical illness. If municipalities plan to
curtail all outdoor camping on streets, it is essen-
tial that they provide temporary campground or
stadium reservations, or hospital ships. But first,
as a separate priority, the mentally ill, the addict-
ed, and dual-diagnosis folks (people who are
both mentally ill and substance-abusing) need to
be rescued and removed as a separate priority.
The Rescue
One contribution to a solution might be to
change the focus from the point of rescue to the
destination for delivery of care, which would be
an emergency room or other medical facility and
not a police holding facility. This is planned for
New York City. A destination for appraisal of the
person’s mental status and need for intervention
and treatment by psychiatric physicians, clinical
psychologists, or psychiatric social workers is less
likely to raise alarm.
The Rescuers
The police must be retained as partners in the
identification and safe delivery of the mentally ill
persons, as they do with suspected impaired driv-
ers, whose definitive assessment is made both on
the spot and later at the police station. Possible
danger to self and others is an implicit criterion
of removal from the road and loss of licenses.
Confidence has been weakened in police fairness
and equitable administration of traffic stoppages
and narcotic apprehensions. How could their
approach to the homeless be made positive?
Apart from offering cannabis lollipops or the
slice of chocolate cake or pie that ER nurses keep
ready to mollify angry or disruptive patients,
the approach of the police should signal their
compassionate mission and not be aggressive.
The signaling could be put out to the interested
public for suggestions. Short of carrying balloons,
might there be special clip-on patches?
Even people with the most anti-police feelings
regarding law enforcement also have pro-police
feelings in other situations. Police are welcomed

when a baby needs emergency delivering or a
citizen needs CPR--and when they do not arrive
with guns drawn, so to speak. They become blue
knights when shooters or terrorists threaten.
Their prowl cars say “to serve and protect.”
Police are perceived by the public as having two
sides, and the “good” side might be built upon by
their addressing the public problem of the men-
tally ill. This is an opportunity to help the men-
tally ill while improving the public image of the
police — for those who feel it needs improving.
But how to do this? The devil is in the details.
Who is Expert?
In fact, a reasonable judgment of dangerous-
ness, inability to look out for oneself, and even
whether a person is psychotic or not, may usu-
ally be within the ability not just of police, who
see thousands of possible cases, but perhaps the
common sense of most people. Medical profes-
sionals may tend to perceive more dangerous-
ness than the police or courts. Often medical
professionals come from more protected envi-
ronments than average citizens and are more
street naive.
In my years of teaching interviewing, I found
medical students regularly poor at detecting
manipulative behavior when they were being
conned by a charming sociopath. Many judges,
even though those who make mental illness hos-
pitalization decisions, do not understand mental
illness. In the 1970s our Educational Research
lab at the New York State Psychiatric Institute
made a videotape library named The Electronic
Textbook of Psychiatry and Neurology, which was
distributed to 400 medical centers. James Ryan,
MD, who led the project, showed the tapes to a
nationally prominent judge who said he had not
before seen a schizophrenic patient up close.
Some have proposed defunding the police and
replacing them with social or mental health
workers. The cost of this aside, the idea is risky
for dealing with homeless mentally ill on the
street, for reasons I shall explain. But the police
could benefit by expert mental health backup.
Abundant examples show how easily interven-
tions can go wrong: In the days prior to my writ-
ing this there was the news that a man resisting a
roadside stop had fled and had a heart attack, for
which the police were blamed; an uncooperative
mentally ill person was restrained prone by EMTs
and died of asphyxiation; and a trooper was
shot attempting to clear an encampment. Expert
backup can be provided safely and economically
via remote expert video consultation, like the
way emergency medical technicians are super-
vised by medical staff en route to the hospital.
Individually, mentally ill persons in the streets
are usually committing no crimes worse than
loitering, using the streets as a toilet, and pos-
sessing illegal drugs, but together they comprise
a threat to public hygiene and health. However,
rescue should not be by force. The great major-
ity may cooperate if approached benignly with
gentle social pressure. If some do not, they may
be asked why. Most do not want to lose their
belongings, meager though they may be, and
these must be removed with them and secured.
Dangerousness
A small percentage of the mentally ill and addict-
ed are violent, but fear of potential violence as
a motivation for intervention need not replace a
focus on empathy in addressing the main prob-
lems of humanitarian needs. Police are trained to
detect risk and manage the rare dangerousness.
Medical, psychological, and social work profes-
sionals do not have this training and, in my judg-
ment, should not accompany the police in per-
son. They could be available virtually to aid com-
munication with and understanding of mentally
disordered people, but not to encumber police as
they approach homeless citizens.
In Vietnam in 1968-69 I was chief of the largest
neuropsychiatric clinic at the height of that war.
Our patients were often teens and armed with
M-16s, which we had a sign to check voluntarily

31
before coming in. Rarely, a psychiatric examinee
would threaten to act out violently. As with the
“Hey Rube” calling of all hands of circus folk, they
would be encircled and dissuaded by more than
a dozen of us young and generally fit military
officers and NCOs.
I once told this to a police lecturer who said that
“polyester pile-ons,” as he called them, were
frowned upon by police. I would defer to their
expertise, but must say our improvised, non-
violent group-pressure-surrounding solution
worked. We would be wise to remain concerned
for the safety of any accompanying mental health
workers, who are untrained in and unused to
resorting to physical restraint or even projecting
authority of any kind.
A Gift, Not a Punishment
But the most important step might be to make
the police intervention on behalf of the mentally
ill a welcome kindness instead of a punishment.
It would need to be seen as a gift of care lead-
ing to greater well-being. Some of the ill per-
sons might refuse help because they lack insight
into their condition because of psychosis, des-
peration, and suspicion of everyone, especially
authorities such as the police.
Many choose to avoid existing shelters and
would resist any government housing. But some
who receive antipsychotic medication and psy-
chotherapeutic care will be able to regain reality
and realize the squalor in which they live. At the
request of a family doctor to accompany him,
years ago I went to the apartments of psychotic
patients along with a policeman, to take them
involuntarily to care. And I was thanked by them
later when they returned to their senses.
Some of those removed from the street may
require longer term, or even so-called custo-
dial care, if they do not sufficiently recover.
There was a time when we had mental hospitals
instead of jails for them. The ones I went to in
New York State as a requirement of my residence
were not snake pits. The patients had jobs and
roles and, to borrow from the sitcom about a
bar, everybody knew their name. The best one
I ever saw was in Lyon, France, where the doc-
tors and patients ate together the food that the
patients had farmed.
I replicated this in small in a locked ward at New
York State Psychiatric Institute as the senior resi-
dent. All the patients who could cooked a dinner
for themselves and us staff. The most disturbed
participated in simple tasks like setting the table.
We do not now provide well for chronic needs
for hospitalization and assisted living.
The Rewards
Whatever the destination of the mentally ill,
the encounter with the police who will deliver
them to medical care needs to be decompressed
emotionally and made not just punitive, but also
rewarding. An atmosphere of high emotional
expressivity adversely affects schizophrenic and
borderline people. Various rewards could be
emphasized:
1. Debugging: removing fleas, ticks, lice, and sca-
bies mites, and providing other medical/dental
checkups.
2. Laundry and cleaning of clothes, and replace-
ment of clothes if necessary. The individual can
be given a package of disposable underwear.
3. A warm indoor bed, and food.
4. Medicated detoxification.
5. Antipsychotic medication, perhaps by depot
injection to aid compliance (though Robert
Rosenheck (Krystal JH, Lew R, Barnett PG, et al.,
for the CSP555 Research Group], Long -acting
risperidone and oral antipsychotics in unstable
schizophrenia, N Eng J Med 2011; 264:842-851,
Mar 3, 2011) has shown the non-inferiority of
long-acting oral pills). Patients may refuse anti-
psychotic medications, but cooperation may be
fostered by bundling the medications with other

rewards. These medications do pose a risk of
metabolic or neurologic side effects, but those
effects are treatable, and the medications are
beneficial. Untreated psychosis is brain-toxic and
should not be romanticized.
6. Cash payment of perhaps several hundred dol-
lars could be offered for going quietly and coop-
erating with evaluation, that the individual could
be allowed to keep, whatever the outcome of the
evaluation. This approach would cost much less
than jail or hospitalization. Granted, a “Catch-22”
arises here: Those who agreed and received the
payment would likely not be the most psychotic.
But they might be the most amenable to inter-
ventions to improve their lives. Finally, some of
those in need who refused to accept payment
for evaluation, might eventually need involun-
tary — but not physically forceful — rescue, with
rewards.
Resistance
A series of letters appeared in The New York
Times of December 21, 2022, foreshadowing
resistance to programs of the sort planned by
Mayor Adams, based on the writers’ personal
experience or organizational observation. Among
the concerns expressed in these letters: Side
effects of drugs administered during involuntary
hospitalization, the need for preventive measures
before homeless persons’ conditions become
severe, and the need for more facilities for dis-
position after hospital discharge. Some of these
problems may be lessened by:
1. Use of psychiatric expertise in selecting those
homeless individuals for intervention.
a. Delusions or paranoid ideas are insufficient.
These ideas are often subjective to define and
are intermittent; they require interviewing
to reveal. Delusions are found in functioning
people. People at both ends of the political
spectrum are thought delusional and paranoid
by those on the other end.
Many delusions are popular. Large swaths of
the well-functioning public who are considered
within normal limits believe in ghosts, aliens,
Elvis still alive, leprechauns or whatever ideas
their cultures provide. Religious beliefs defy
ordinary logic and demand faith. Even idio-
syncratic beliefs that are not shared by any
community, but that have little or no practical
impact, do not warrant focus. Hallucinations,
as of the whole bodies of the deceased, are the
norm in some cultures. In my study of machine
gaming, I found that some slot machine play-
ers believe the random spins contain messages
from beyond the grave.
b. Interventions instead should focus on:
1) uncontrolled, irresistible, or unbearable
emotional states.
2) motor behavior, especially agitated or
hyperkinetic, that endangers the person or
others (not strange thoughts or beliefs).
3) command auditory hallucinations that
compel dangerous action.
4) evident lack of personal care.
5) evident public inebriation.
6) altered states of consciousness, seizures,
and seizure-like behavior; these require EMT
transport and neurological evaluation.
2. Caution in prescribing and committing the
patient to certain antipsychotic medications.
Substitution of milder medications for anxiety
may be recommended for temporary care if
practical. Employment of non-pharmacological
interventions is always desirable when possible.
Better results are obtained when anti-psychotics
are supplemented by co-morbidity medica-
tions. Most psychotic patients have comorbid
anxiety and depressive disorders, and adding
medications to target those conditions, too,
can greatly improve outcomes. For example,
as André Barciela Veras MD and Jeffrey Paul

33
Empower you and
your patient for a
better path forward
Using genetic data for better
medication management
• various psychiatric disease states
• treatment resistant conditions
• complex medication regimens
Learn more at genomind.com
Kahn MD (Editors, Psychotic
Disorders: Comorbidity Detection
Promotes Improved Diagnoses
and Treatment, Elsevier, 2020)
have argued, adding fixed-dose
clonazepam to anti-psychotics
may significantly improve out-
come for schizophrenia with
voices. I would add that with
such augmentation, lower doses
of the primary anti-psychotic
medication may be feasible, with
less toxicity and greater patient
compliance.
The individual may resist or
refuse even judicious prescrip-
tion of potentially problematic
medications such as antipsychot-
ics. In today’s climate of opinion,
which leans toward release in
almost every case, the program
should not gain the reputation
of force. If the person’s condi-
tion convinces the holding facility
that release is too dangerous,
the person can be retained invol-
untarily without medication and
thus protected. The usual lawful
re-evaluations can protect their
rights, and if necessary prevent
them from being a danger to
themselves and others. Some
may recover untreated; oth-
ers may require more extensive
retention without forced medica-
tion.
But it all starts with rehabilitat-
ing the image of the police and
giving them expert mental health
assistance; and ends after treat-
ment with dispositions other
than a return to the street, with
continuing care.

Ed Smith* is a beloved resident who came to
Woodley House because he needed support ser-
vices and was homeless. When Ed Smith first came
to Woodley House in December 2018, he told staff
about his long daily runs in Rock Creek Park. “I love
running,” he told them. They eventually learned
that Mr. Smith, who is 62, had advanced osteoar-
thritis in his knees. He wasn’t running anywhere.
Diagnosed with schizophrenia, he was not in close
contact with his family and had difficulty interacting
with them. He had trouble sitting still and needed
assistance with everyday tasks such as preparing
food, doing laundry, and remembering to take his
medicine.
As his symptoms stabilized, he began volunteer-
ing to help other residents with chores and to
help the maintenance staff with tasks around the
house. His recovery also brought back his ability
to communicate and think more clearly so that he
was able to reconnect with his family.
Mr. Smith improved so much that he was able
to move into one of our Supported Independent
Living apartments in December 2021. He is an
By Ms. Sue Breitkopf
Chief Development Officer of Woodley House

35
excellent example a resident who has come
through Woodley House’s continuum of care,
transitioning from 24/7 supervised care to inde-
pendent living with proper support.
Founded in 1958, Woodley House provides per-
sonalized mental health supportive services and
housing for Washington, DC residents like Mr.
Smith. The organization has enabled tens of thou-
sands of people access to mental health care
and to live independently in our communities.
Woodley House operates 32 homes for more than
300 residents per year across four Wards.
Over the course of the last 65 years, Woodley
House has seen many changes, but its spirit of car-
ing and innovation that started with its founder,
Joan Doniger, has not changed.
Joan Doniger, while working as an occupational
therapist at St. Elizabeth’s Psychiatric Hospital in
the 1950s, recognized that not all patients benefit-
ed from long-term psychiatric hospitalization. She
understood that hospitalization often resulted in
worse outcomes for patients with treatable men-
tal health issues. Doniger envisioned an alternative
to chronic hospitaliation: therapeutic housing in
a neighborhood setting. Her carefully researched
framework provided a place where residents could
learn to live with their illness, set personal goals,
and work toward recovery.
In 1958, Joan Doniger wrote out a preliminary
plan for establishing a special “residence club”
intended to be a “demonstration project based
on the idea that many mentally ill people can be
integrated into the community, can work, and can
enjoy increased freedom.”
Joan’s idea was new to the East Coast of the
United States, so much so that there was still no
name for what she was establishing. Her vision,
where residents were expected “to live within the
rules and boundaries laid down by our society”
and have a large say in controlling their own lives
still sounds radical today. Back then, people with
behavioral health disorders were institutionalized.
Joan believed: “Every day out of a hospital is a
good day.”
Woodley House was initially called the “Potomac
Residence Club,” a name designed to avoid stig-
matization from its neighbors and began in one
half of the building now called Valenti House on
Connecticut Avenue, N.W. in Woodley Park. In
early 1959, the first resident entered this new
world between hospitalization and independent
living. Despite Joan’s careful planning, it was not
an easy beginning — referrals were slow and Joan
was the main funding source.
Thankfully, the Eugene and Agnes Meyer
Foundation gave a $25,000 grant and the National
Institute of Mental Health awarded a $101,000
demonstration grant, which produced academic
and community recognition, resulting in two
books about halfway houses, more referrals, and
other funding. Woodley House then hired two
new important people: Edith Maeda, who became
co-director (and later Executive Director), and
Barbara Rothkopf, who became the administrator.
Woodley House then grew to become a pillar of
the mental health community for the rest of the
decade.
Joan passed away in 1972 after having seen her
dream come to fruition.. Today, Woodley House
lives on as a legacy to her pioneering and compas-
sionate spirit. Edee (Edith Maeda) had become inte-
gral to Woodley House and took the helm in Joan’s
absence. Under her leadership, the organization
expanded the services from the original building to
several additional buildings and apartments.
Crossing Place, an innovative crisis stabilization
program, was started and offered an original
model of a community-based alternative to psy-
chiatric hospitalization for adults experiencing
acute symptoms. Founded and designed by Dr.
Loren Mosher and Marilyn Kresky-Wolff in 1977, it
was a model that has since become the nationally
recognized best practice for a residential crisis and
stabilization program.
While most of the people who come to Crossing
Place are stabilized within days, averaging about
14 days per stay, a few need a little more time
so that they have all the necessary resources to
remain out of hospitals for long periods. Many
never require another hospital stay.
George Glass,* who arrived at Crossing Place in
October 2021, is exactly why this service is so
necessary in our city. Aside from experiencing a

"Reductionism in Medicine and Psychiatry" - Extract from "Psychiatry in Crisis" by V Di Nicola & D Stoyanov

"Reductionism in Medicine and Psychiatry" - Extract from "Psychiatry in Crisis" by V Di Nicola & D Stoyanov

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"Reductionism in Medicine and Psychiatry" - Extract from "Psychiatry in Crisis" by V Di Nicola & D Stoyanov