Thursday, May 19, 2005

Cruel Compassion, The American Enterprise Online

Cruel Compassion
Karlyn H. Bowman (, Sally Satel, Christina Hoff Sommers

TAE contributing editor Karlyn Bowman recently sat down with Dr. Christina Hoff Sommers and Sally Satel, M.D., resident scholars at the American Enterprise Institute, to discuss their new book One Nation Under Therapy: How the Helping Culture is Eroding Self-Reliance.

TAE: You criticize what you call "therapism." What is that?

CHRISTINA HOFF SOMMERS: Therapism celebrates emotional self-absorption and the sharing of feelings. Its proponents believe that vulnerability, not strength, characterizes the American psyche. They see us as an anguished, emotionally apprehensive population that requires a vast array of counseling to cope with the trials of everyday life.

TAE: Let's start with the myth of the fragile child.



At 2:44 PM, Blogger Mira de Vries said...

Satel seems to belong to the "only my pet diseases are real" club, like Healy, Horwitz, Thomas, Shorter, Caplan, and many others.

At 7:24 PM, Blogger Lee Killough said...

Satel belongs to the "responsibility without liberty" crowd.

That people don't deserve freedom to engage in vices, but if they transgress, they deserve punishment and compulsory intervention.

That drug users can decide to quit, and that addiction is a choice, but that forced rehabilitation is morally justified.

She often cites her personal experience with prednisone, saying it caused her to become depressed and suicidal. She turned her personal experience into a crusade.

Sort of like, "I almost killed myself while being depressed. But I got myself out of it, because I'm so moral. I don't want anyone else to go through what I did, so I'll do anything to force them not to make the same mistakes that I did, and I'll prevent them from ever having to make the kinds of decisions I made."

At 7:15 PM, Blogger Nicolas Martin said...

The Objectivist Center has a positive review Satel's earlier book, "PC, M.D.," which also mentions -- and misapprehends -- Dr. Szasz:

Frequently, P.C. advocates deny the identity of these disorders by seizing upon the phrase "the myth of mental illness," which was the title of a famous book by Thomas Szasz. For the record, Szasz's book was a thoughtful if iconoclastic argument probing the mind-brain issue and criticizing the use of the so-called "medical model" in psychiatric disorders. Today, victim advocates use Szasz's phrase about mental-illness-as-myth to deny the existence of any mental pathology whatsoever, which was not Szasz's view. Szasz himself left that door open through problems in his account of clinical entities such as schizophrenia, which is clearly more than just a "labeling" issue. To be sure, Szasz was a great crusader against abuses by his own profession, such as the often-questionable use of compulsory hospitalization, which is also a target of the postmoderns And because Satel does not give a guiding principle to clarify the proper use of involuntary treatment, she fails to answer Szasz's legitimate concerns here. For this reason her arguments against the postmoderns lack bite on precisely this point.

We should note, too, that (unlike Szasz) the P.C. crowd is only too happy to use labeling when it suits their ideology, as in the case of pitcher John Rocker, whose ill-advised remarks were considered prima facie evidence of his need for psychological counseling, echoing Harvard psychiatrist Alvin Poussaint's claim that racism is a form of mental illness.

At 7:26 PM, Blogger Nicolas Martin said...

Jacob Sullum's Reason review of Satel's "P.C., M.D." is, unsurprisingly, far more perceptive:

Yet elsewhere in the book Satel unintentionally provides evidence that the psychiatric survivors are at least partly right. In her discussion of victim-oriented psychotherapy, she argues that "multiple personality disorder" is overdiagnosed, and she cites one expert who "is skeptical that the personality condition exists at all except as an artifact of the therapist's suggestion." So here is a condition listed in the Diagnostic and Statistical Manual of Mental Disorders, one that psychiatrists presumably continue to diagnose, that may well be a figment of their (and their patients') imaginations. That sounds pretty "socially constructed" to me.


Satel does not explain how psychiatrists determine when someone is "too ill to exercise free will" -- an important issue, since that judgment can transform a patient into a prisoner. What is the diagnostic test for schizophrenia? If it is simply a matter of observing what someone says and does, how is this "psychosis" different in kind from an overdiagnosed (and possibly nonexistent) "neurosis" such as multiple personality disorder? And if schizophrenia truly is a brain disease, like Alzheimer's or Parkinson's, why is it treated by psychiatrists rather than neurologists? Why is there no need for a competency hearing before the patient is deprived of his freedom?

Critics such as Thomas Szasz have been raising questions like these for many years, and Satel surely is aware of them. Perhaps she has satisfying answers. If so, it would have been appropriate to share them before rejecting the complaints of people who object to their confinement and involuntary treatment at the hands of psychiatrists. It will not do to admit past abuses while insisting that things are much better now, since coercion remains a central aspect of psychiatry. Nor can Satel neutralize the complaints of the psychiatric survivors by observing that "not all psychiatric patients oppose involuntary treatment" and offering a few examples of people who are thankful for the forcible interventions they credit with saving them. Psychiatrists cannot know ahead of time who will be grateful after the fact, and the satisfied patients cannot give consent on behalf of the aggrieved.

At 8:13 PM, Blogger Nicolas Martin said...

Satel has had a couple of debates in Slate. To her former professor, Peter Kramer, she said:

[O]ur field of psychiatry isn't particularly good at distinguishing between someone who is just being "difficult" and someone who has a personality or mood disorder. Nor is it obvious to us when a person, say, can't tolerate "stress" because of an actual illness (such as bipolar disease) or because it's "just the way they are."


My clinical population comprises drug abusers who are maintained on methadone. That means they are no longer addicted to heroin but may actively abuse cocaine, alcohol, or marijuana. In other words, they're not addicted to these drugs, but use for pleasure or to reduce anxiety. In either case, the episode of use is generally fairly brief.
-- Slate, 1997,

In her response to Mike Gray, she said:

Now, if this were a libertarian world, where people had to endure the consequences of destructive behavior, we could talk about liberalizing drug policy. I'd be willing to have that conversation, because I suspect that a libertarian regime would actually be more systematically vigilant against drugs than we are now. With no Americans With Disabilities Act, no publicly supported treatment facilities, and no social safety net, the consequences of drug "misuse" would be certain and sometimes severe, as it was earlier in the century. In addition, drug testing by property owners--of the highway you drive on, the apartment you rent, the factory that hires you --would be widespread and routine ... and perfectly legal.

This might be an excellent program for relapse prevention. It wouldn't be a world I necessarily welcome, but it's an interesting one to contemplate. At the very least it has elements that encourage personal responsibility by the user. The scenario you paint, on the other hand--drugs for everyone and public support for those who fall apart--pushes the responsibility onto the rest of us. Can some people use drugs without peril? Yes. But I'm not talking about the person who smokes a joint while watching Fantasia. That's not whom prohibition is for. It's for all teen-agers and for the adults who can't handle intoxicants.
-- Slate, 1998,

At 8:48 PM, Blogger Nicolas Martin said...

Perhaps I overdue this topic, but I just can't seem to get enough of The Medico-Totalitarian World of Sally Satel. This time she appeared at Cato Institute to answer the question, "Time to Rethink the War on Drugs?" (2001). Wouldn't it be divine for Cato to put Satel and Szasz on the same stage?

DR. SATEL: My patients, though, when I talk to them, will tell you that it would be so much harder for them to relinquish their habits and stay clean if drugs were cheaper, purer and more available. And under those same conditions, they may have even sunk deeper into the abyss of intoxication and compulsion before coming to the clinic.

When I do an intake on people, I take a drug history. I always ask, "When was the last time you were clean?" So often, the answer is, a defined period of time that people can remember with great clarify, "Oh yeah, January 1996 to February of 1997." "Well, what was going on then?" "I was on probation." They basically had some kind of surveillance. I have patients who are in supported housing programs. These are residential programs that they get into through some social service. And those supported houses test their urine. Those are my patients who are frequently doing the best. And those who are sent in by their employer, again, you can pretty much count on them to be doing the best in my clinic. I had some women who knew that their welfare benefits were going to be expiring pretty soon and they would have to go to work, and part of that work or work training would involve drug testing. And again they managed to clean up.


MALE VOICE: This question is for Dr. Satel. If
somebody comes into your office and says, "I have a big drug problem and I need a fix," do you have the wherewithal or the authority to help this person by giving him the fix he needs and helping him get past this initial problem? Is there something like that in your programs? And if so, how are they working out? There is methadone, for example. Suppose somebody wants something a little stronger than methadone; they need something stronger?

DR. SATEL: We just raise the dose.

QUESTION: So you give them what they need?


QUESTION: And how has this been working? What is your success rate?

DR. SATEL: The success rate nationally? Let’s put it this way. Methadone is a great socioeconomic investment, in that people will use fewer drugs, will end up in ER’s less, more stay in employment. I would say that for our patients, maybe a third are able to be completely drug free while they are on methadone. That is not a great outcome, but it is much better than being on the street and using heroin.

At 3:52 AM, Blogger Mira de Vries said...

Nicolas said:
Nor can Satel neutralize the complaints of the psychiatric survivors by observing that "not all psychiatric patients oppose involuntary treatment" and offering a few examples of people who are thankful for the forcible interventions...

I call this the Ayn Rand argument. In all of her novels Rand had women enjoying being raped. And this woman is hailed as a great libertarian?

At 2:54 PM, Blogger Nicolas Martin said...

Stockholm syndrome?


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