Ten years of blogging

This month marks a decade of blogging on “Reidbord’s Reflections.” This is the 130th post. My posting frequency dropped precipitously over the years, from 20 posts in the first two months to one every couple of months now. I imagine I share with most bloggers a limited set of rehearsed topics, things I always wanted to write about. Once these were exhausted, new ideas came more slowly, often spurred by news articles.  Lately I’ve been more inclined to write about current events and news items, less about psychiatry.  I find people’s minds and ideas engaging.  As for the practice of psychiatry — tweaking this med or that, arguing over nuances of psychotherapy technique, weighing ethical goods like beneficence and autonomy — well, my interest waxes and wanes.  Psychiatry doesn’t change quickly, and as a result I feel little time pressure to write about anything particularly psychiatric.

I don’t track my readership here, but I crosspost to a blog on Psychology Today’s website, and they keep records. Far and away, my most read post there is “Countertransference, an overview” with nearly 400,000 views.  It’s fairly well written in my humble opinion, but not especially so.  I can’t account for its outsized popularity.  Other favorites of mine, never mind their popularity, include the two-part posts on placebos and psychiatric disability; my ethics piece on Pharma and doctors; my post on charging patients for missed sessions (with a record 130+ comments); “Antidepressants are just a crutch“; my sailing analogy; whether therapists should accept gifts; and my one attempt at fiction.  Actually, there are more, but I’ll stop there at ten.

Also, I was surprised to learn that my “Brief History of Psychiatry,” a page deep in the website for my practice — not in my blog — is quite popular.  It’s often found by folks searching for… a brief history of psychiatry.  As it happens, roughly 50% more people search this phrase and go directly to that page on my site, than search for psychiatric services and go to my landing page.

I somewhat regret naming my blog after myself.  If I’d known I’d be at it ten years later, I might have thought harder about a better name.  I envy the creative titles of some psychiatry blogs: Shrink Rap, Thought Broadcast, The Alienist, 1 Boring Old Man, The Last Psychiatrist.  Sadly, however, none of these are active anymore.  Dinah Miller shut down Shrink Rap in August, Mickey Nardo (“1 Boring Old Man“) died nearly two years ago, The Alienist stopped posting in 2015, the anonymous Last Psychiatrist went silent in 2014, Thought Broadcast in 2013.  Psych Practice and Psycritic haven’t posted for over half a year, either.  It’s nice to see George Dawson still posting long, thoughtful, frequent pieces on Real Psychiatry, even if I sometimes disagree with his conclusions.  There are, of course, other psychiatry blogs I’m less (or not) familiar with.

I was pleased that a content aggregator called Feedspot ranked “Reidbord’s Reflections” number six out of the “top 50” psychiatry blogs and websites.  I don’t know how they decided this, but I thank them nonetheless.  I even added their badge to my blog several months ago.  I didn’t pay them or anything.

The future of this blog? With the demise of Shrink Rap, a longtime favorite, it crossed my mind to shut down too.   I realized early on that the 1000-word cerebral essay isn’t ideal for blogging.  It’s not my style to post quickly and often, nor to repost cute cartoons and jokes from other sites.  By only occasionally posting anymore, I imagine that long ago I lost the regular readers I once had.  (I miss the dialog we sometimes had in the comments in the early years.)  I’ve thought about turning some of this writing into a book.  Or maybe try more seriously to publish op-eds in old-fashioned newspapers.

On the other hand, I’d feel bad to kill this creature I created.  On balance, I figure I’ll keep posting here as ideas occur to me. I enjoy writing (and crossword puzzles, and other wordplay).  As long as it’s fun there’s no reason to stop.  And you’re more than welcome to keep reading — and commenting, and even tossing me a writing-topic suggestion now and then.  It’s good to have you along.

The photo is an iPhone calendar from 2008.

We are one

E pluribus unum strikes the pluribus lately as a threat, not a promise — more like assimilation by the Borg than a patriotic ideal.  Instead of striving for the common good, we’ve split into factions, each defined largely by its enemy.  Feminism fights patriarchy, Black Lives Matter fights police brutality, the 99% fight the 1%.  Elsewhere on the political spectrum, midwesterners fight coastal elites, populists fight the “deep state,” white supremacists fight immigration.  There’s an awful lot of fighting going on, and a lot of circling the wagons, i.e., huddling together with the like-minded, or at least the like-identified.

“Identity politics” was coined in 1977 by the black feminists of the Combahee River Collective, but the term no longer carries its original meaning.  Identity politics was a starting point, a catalyst for political activity.  To the Collective it was not an end in itself.  Cultural critic Kimberly Foster writes:

Their ideology began with self, but it was not self-obsessed. Ultimately, they knew their work would benefit everyone…. An identity politics that is not principally concerned with dismantling all forms of inequality quickly devolves into a never-ending game of oneupmanship where self-satisfaction is all that’s won.

For both the Left and Right, identity politics is now a substitute, not a catalyst, for benefiting everyone.  Identity has become a credential for oneself and a prejudicial discrediting of others — the very definition of argumentum ad hominem.

This degraded sense of “identity politics” reflects a much older human propensity: tribalism.  Tribalism stands opposed to universalism, inclusive regard for humanity as a whole.  The two exist in dynamic tension, with universalism arguably gaining ground over time.  To paraphrase Martin Luther King, the arc of history is long, but it bends toward expansion of our “tribe”: from families to villages to nations, and eventually to supranational coalitions like the European Union and United Nations.  Looking ahead, the science-fiction world of Star Trek envisions a utopian Federation of humans joined by like-minded aliens.  As generations come and go, we slowly find common cause with those less and less like ourselves.  Yet tribalism never goes away.  There is always an enemy: a Communist or terrorist menace in real life, the Borg in our imagined future.  It’s hard to conceive of group cohesion, Oneness, without an Otherness.

Plus, the long arc isn’t smooth.  As with King’s moral universe bending toward justice, there are backlashes.  We’re currently experiencing one: a worldwide, presumably temporary regression to smaller tribes.  Brexit is an obvious example.  Here in America, our enemies these days are not extraterrestrials or even Communists, they’re our neighbors with politics opposed to our own.  And while animosity between Left and Right is as heated as ever, we also battle enemies even closer at hand: progressives fight with liberals, traditional conservatives with Trumpists, different schools of feminism with each other.  We’re in a freefall of “splitting” instead of “lumping”.  Why this backlash?

Apparently it’s fear.  Life in western-style democracies today must feel precarious indeed: in a frenzy we defend ourselves against all who aren’t explicitly in our camp.  Fearful self-preservation compels us to hunker down, circle the wagons, and make rough, seemingly vital distinctions between friend and foe.  Honoring the humanity of one’s adversary becomes a precious luxury, quickly jettisoned when survival is at stake.  Conversely, huddling with the like-identified answers the rhetorical challenge: “You and what army?”  There’s strength in numbers.

Living in a small camp under siege, or perceiving life that way, means always scanning for possible attack.  It can culminate in paranoia.  Unfortunately, there is no compelling way to refute paranoia.  Rational argument cannot convince a paranoid person to let down his guard.  Paranoia subsides as safety and trust are (re-)established; it’s an incremental process that takes time.  Trust must be earned, which is why betrayal is so devastating and reconciliation so slow.

It’s bad enough to live among myriad warring camps.  Even worse, the ammunition used in these wars are often competing claims of victimization, a tricky dynamic that in turn leads to whataboutism and charges of false equivalence and fake news.  Intersectionality, a term coined in 1989 by law professor Kimberlé Crenshaw, attempts to account for multiple simultaneous forms of oppression.  It was first applied in concrete and pragmatic fashion to the intersection of misogyny and racial oppression in the lives of black women.  However, despite Crenshaw’s disclaimer, intersectionality lately connotes a tally of personal identities, i.e. group memberships, whereby one can claim oppression.  As commonly used, intersectionality demands finer and finer screens for tribal membership.

In an insightful opinion piece, philosopher Kwame Anthony Appiah notes that intersectionality so construed precludes anyone from speaking on behalf of a tribe, no matter how narrowly defined:

If Joe had grown up in Northern Ireland as a gay white Catholic man, his experiences might be rather different from those of his gay white Protestant male friends there.

It only takes a moment to realize there is no end to this divvying up.  Identifying with a particular tribe can multiply political power, but ultimately tribes are an illusion: a strategic foregrounding of certain shared attributes while backgrounding all the others.  Barack Obama is “black” here in the U.S. but “white” when he visits Africa; it depends on whether his half-blackness or half-whiteness is in the minority and thus in the foreground.  Irish and Italians were considered non-white when many immigrated here over a century ago.  Jews are white or non-white (and oppressor or oppressed) depending on the point of the identification.  Clarence Thomas and Ben Carson are plainly in the African American camp, except when their political views argue otherwise.

Owing to the miscibility of group identification, it is always erroneous to claim to speak for a tribe, regardless of how narrowly defined it is.  I can’t speak for all Americans or all physicians — or even for all San Francisco psychiatrists who write blogs.  Likewise, no one can speak for “the disabled,” “real, God-fearing Americans,” or an identified sexual minority.  While it’s often useful to clarify one’s viewpoint by noting that it stems from experience as a manual laborer or transgender person or Hawaiian, it doesn’t imply — can never imply — a like-minded army marching behind one’s words.

We speak for ourselves alone.  Each of us is only one, no more and no less.  This prospect may sound like a lonely and desperate “Every man for himself!”  Paradoxically, however, it may pivot us back to the long arc of history.  It may gently ease our social paranoia and allow universalism to gain ground once again.

Recognizing the uniqueness of the individual and the arbitrariness of group identification complicates tribalism.  If there is no simple dividing line between friend and foe, if there is no clear-cut tribe or camp with members in lockstep, we may again permit ourselves to see humanity in our adversaries.  If we’re lucky, the role of Otherness will be played by impersonal challenges such as climate change and resource limitation, not by other people.  As we rejoin the long arc of history, identity politics will be our on-ramp to helping all in need, not just those who look, vote, or pray like us.  Inevitably — but sooner is better than later — we will again identify with expanded tribes such as nations, the human race, or all living creatures.  Like the stamp of e pluribus unum on our coins, “we are one” will mean honoring both our individuality and commonality.  We will share kinship with a great many, not a small camp.

What counts as a medical issue?

It has become a sign of legitimacy to call a personal problem “medical.”  This aims to distinguish the problem from those of morality or character.  It implies both that the problem is serious, and that it is unbidden and largely out of the suffer’s control.  Unfortunately, it isn’t clear what exactly qualifies as “medical,” so this label serves more as a rhetorical device than a scientific finding.

Alcoholism is the paradigm and perhaps least controversial example.  Through the 19th Century, alcoholism was variously declared a disease, or a matter of will and character.  The disease model gained prominence in the 1930s and 40s with the “powerlessness” identified in the 12 Steps of Alcoholics Anonymous, as well as researcher E.M. Jellinek’s descriptions of progressive stages and subtypes of alcoholism.  The American Medical Association declared alcoholism an illness in 1956 and has endorsed the disease model ever since, partly as a strategy to ensure insurance reimbursement for treatment.

The model expanded to include other abused substances with the formation of Narcotics Anonymous in the 1950s, and as a result of widespread recreational drug use in the late 1960s and early 1970s.  The specialty of addiction medicine was first established in 1973 in California.  The American Society of Addiction Medicine now states: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry.”  Proponents of the disease model of addiction cite many documented brain changes and a plausible neuropathology, as well as the presence of genetic risk factors, cognitive and emotional changes, impaired executive functioning, and disability and premature death.  The model purportedly destigmatizes addicts — they are no longer “bad” or “weak” people — thereby making it more acceptable for them to seek treatment.

Nonetheless, the disease model of addiction remains controversial.  In addition to the existence of alternative models, the disease model itself has been criticized.  Some believe it removes personal choice and responsibility, and actually contributes to the problem of addiction.  Others cite surveys of American physicians who consider alcoholism more a social or psychological problem — even a “human weakness” — than a disease.  Critics note that about 75% of those who recover from alcohol dependence do so without seeking any kind of help, and that the most popular and recommended treatment, Alcoholics Anonymous, is a fellowship and spiritual path, not a medical treatment.

Behavioral addictions to gambling, sexpornography, the internet, video games, and food are described in language that explicitly parallels addiction to alcohol and drugs.  The same brain pathways are implicated.  Accordingly, these problems are called medical as well.

Addiction is not the only domain that has been declared, often somewhat stridently, as medical.   Depression has been deemed a medical issue for several decades now, using much the same rationale.  The push to frame all psychiatry as neurobiology is a larger matter.  But here, too, documented brain changes, genetics, and characteristic signs and symptoms underlie a rhetoric that may, or may not, decrease stigma and facilitate treatment.  Moreover, a number of other behaviors and traits, formerly considered bad habits or personality quirks, are now reified as discrete psychiatric disorders (not the same as diseases, but close): shyness is now social anxiety disorder, misbehaving kids have oppositional defiant disorder, and so forth.  What are the risks in subsuming more and more of human experience into nosological categories?

One risk is that medicalizing problems may hide political or other bias.  The most shocking historical examples include drapetomania in the U.S. and the misuse of psychiatry in the former Soviet Union.  Yet even well-meaning efforts to highlight a social problem, give it gravitas, and impart a clinical, impersonal air to one’s opinions can result in this sort of over-reach.  Examples include the “politics is part of pediatrics” antiwar stance of famed physician-author Benjamin Spock, and Physicians for Social Responsibility, a group that opposes nuclear arms from a medical perspective.  Most recently, some mental health professionals have published impassioned statements characterizing President Trump’s behavior in medical/psychiatric terms.  Such statements have no medical purpose: they neither clarify Mr. Trump’s behavior (which is well known to all), nor change it.  Their effect, if any, is solely on electoral politics.  Medical language can thus amount to little more than grandstanding.

A related risk of medicalization is that it may lurch toward absurdity.  Suicide, that profoundly personal matter studied by poets and philosophers as well as scientists, also may be deemed a disease.  This confuses disease with symptom — as if “headache disease,” for example, were touted as a new diagnostic entity.  No doubt there will soon be measurable brain findings that distinguish suicidal people from non-suicidal people; no doubt such findings, too, will soon distinguish the state of having a headache from the state of not having one.  In this nascent era of functional brain imaging, is it sufficient to see something “light up in the brain” to call it a medical problem?

Doing mental arithmetic is detectable by fMRI.  Is math a medical issue?

A plainly medical disease such as diabetes results from nature and nurture, genetics and environment.  What makes it medical are not its causes.  The effect of diabetes on the human body, the fact that it historically has been treated by physicians, and to a lesser degree the nature of its treatment make it medical.  Addiction also appears to result from genetics and environment, to have consistent effects on the human body, and for a few decades at least, has been treated by physicians.  Its treatment, though, is mostly non-medical in the usual sense of the term, i.e., not pharmacological or surgical.  There are strong behavioral and psychological aspects to addiction, and often sociocultural ones as well.  It is thus not surprising that its status as medical remains, to some, a matter of debate.  However, by the time we get to war, nuclear arms, a heretofore unimagined presidency, or suicide, we are talking about matters that have no consistent findings in the human body, are not historically treated by physicians, and respond almost exclusively to non-medical solutions.  The phrase “medical issue” can’t stretch to cover this territory, no matter how fervently physicians would like to weigh in.

In the future, more and more brain function will be open to scrutiny.  As our brains mediate all human behavior, advancements in functional imaging and similar technology may tempt us to declare any and all products of the human mind “medical issues.”  Problems such as prejudice, racism, violence — or, from other viewpoints, liberalism, collectivism, and the like — may be claimed as the physician’s to treat.  It will be hard to resist this temptation; doctors like to fix things.  But the cost of succumbing is to reduce medicine to threadbare rhetoric, weakening our moral status as healers of the human body.

Graphic courtesy of Pixabay, CC0 license.

Shocking

“60 Minutes” ran a segment last Sunday on electroconvulsive therapy (ECT), better known as shock treatment.  Kitty Dukakis was interviewed as a long-time recipient and advocate of ECT for her severe depression.  The piece was almost entirely positive, save for brief mention of memory loss as an unfortunate side-effect.  This was soon left behind by video of a treated, newly smiling patient declaring no such problem: new technologies are in development, e.g., magnetic shock therapy or MST, that promise to mitigate this issue.  ECT was presented as an under appreciated miracle treatment — and miracle treatments, unfortunately, always make me worry.

In addition to reassuring the public — ECT isn’t painful and doesn’t feel punitive anymore, in contrast to its fictional depiction 43 years ago in “One Flew Over the Cuckoo’s Nest” — the segment also admonished psychiatrists who don’t use ECT often enough.  According to “60 Minutes,” severely depressed patients are languishing for years on ineffective antidepressants, imprisoned by their doctors’ outdated prejudices and unfounded fears.

Like so much in the news these days, this report oversimplified to make a rhetorical point.  The reality is rather different.  I can only recall two patients in my decades-long practice who possibly would have benefitted from ECT.  (I’m not trained to administer it, so they would have been referred to a colleague.)  All the other depressed folks I’ve seen, hundreds of them, improved on psychotherapy, standard antidepressant medicine, or both.  Or they had longstanding personality issues that made them depressed — a vexing problem to be sure, but not one ECT can fix.  The great majority were eventually helped by more benign and far less expensive treatment than ECT.

This is not surprising considering that most depression is of modest severity.  And the modest severity of most depression is itself not surprising.  In an effort to capture as many cases as possible, the DSM-5 diagnostic criteria for major depressive disorder includes chronically unhappy people who are still able to work or attend school, people with no psychomotor slowing, and people who have never given suicide a serious thought.  While severe melancholic depression looks and acts very much like a disease worthy of a medical intervention under general anesthesia, i.e., ECT, most of what we call depression these days does not.  A great many people hobble along, not really enjoying life but not being severely impaired either.  Suggesting ECT for this group is irresponsible.

The perceptions and history of ECT remain roadblocks as well.  Even voluntary ECT is the epitome of paternalistic medicine: a powerful, technological treatment done to a passive patient.  And while most ECT is now voluntary and requested, historically it wasn’t.  Some ECT in the U.S. is still court-ordered today.  This again follows from its use in the most severely depressed patients, who may exhibit nihilistic delusions, or are so impaired they can’t participate in their own treatment.  Even if it is highly effective and without better alternatives, restraining someone in order to administer anesthesia and an electric shock that causes a grand mal seizure is a tough notion for the public to accept.

Feel-good pieces on television are no match for the discomfort most of the public feels about shock treatment.  I would not hesitate to recommend it for severely depressed, non-functional patients, especially those with classic melancholic depression who have failed full trials of standard antidepressant medication.  Also, ECT may be a good first choice when depression is accompanied by mood-congruent delusions.  But these are unusual conditions where the established efficacy of ECT outweighs its attendant memory loss, cost, and apprehension.  Realistically, we ought to think of ECT as we do life-saving surgery: an essential option when needed, but hardly something to be popularized or welcomed lightly.

Managing assaultive behavior

In Toronto on April 23, 2018, Alek Minassian intentionally drove a rented van into pedestrians, killing ten and injuring at least 15. Later the same day, Constable Ken Lam of the Toronto Police Service arrested Minassian after a brief, tense standoff. As seen in a widely circulated video, Minassian dared the officer to shoot, and feigned drawing a gun, most likely to commit “suicide by cop.”

Constable Lam, however, did not shoot. Instead, he took specific steps to de-escalate the confrontation, and arrested Minassian without further bloodshed. Commenters praised his actions, contrasting them with many police confrontations in the U.S., where even unarmed suspects are killed in a hail of bullets. According to the U.S. Department of Justice, “law enforcement officers should use only the amount of force necessary to mitigate an incident, make an arrest, or protect themselves or others from harm.”

The use-of-force continuum begins with the mere presence of the officer.  It then progresses to verbal requests, commands, non-lethal physical tactics or weaponry, and ends with lethal force.  Suggested reasons for over-reliance on lethal force by U.S. law enforcement include racism, an assumption that suspects are armed and thus dangerous to the arresting officers, low rates of prosecution for alleged police brutality, an American culture of violence, a police culture of intimidation, and police training issues.

Regarding the last of these, only two days prior to Lam’s arrest of Minassian, Douglas Starr wrote an opinion piece for the New York Times arguing that police have a lot to learn — from hospitals.  Starr notes that hospital workers often deal with volatile people, yet are not permitted to attack, shoot, or otherwise harm them.  As a result, these institutions have developed techniques for de-escalating potentially violent situations.  Courses in “managing assaultive behavior” are widespread, and evidence suggests they are effective in decreasing violence in health care settings, for example by defusing it at a verbal, pre-physical stage.  Since 1993, California law (AB-508) mandates that hospital staff working in behavioral health or emergency departments receive employee training in assault/violence prevention.

While police officers in some western nations, e.g., Great Britain, all receive de-escalation training rivaling that of California hospital workers, most U.S. police officers do not.  Such training is not required in 34 states; most police and sheriff departments in those states offer little or no de-escalation training (but a great deal of firearms training).  For example, APM Reports compiled a table showing the amount of de-escalation training for police in the Twin Cities metropolitan area of Minnesota, with wide variation from one suburb to the next.  Until last year, most police and sheriffs’ departments in Georgia documented less than one hour of training per officer in the preceding five years.  Starting last year, however, all Georgia officers are required to take one hour of de-escalation training annually.

The Police Executive Research Forum, a membership organization of law enforcement leaders and academics, is developing a program called ICAT, to standardize de-escalation training nationally.  ICAT assists officers in dealing with several types of encounters that too often result in lethal force.  For example, those behaving erratically, and perhaps dangerously, due to mental illness or drug abuse often react more favorably to a slower, calming approach.  “In many instances, the goal is for the first responding officers to buy enough time so that additional, specialized resources can get to the scene….”  Non-firearms incidents, in which a subject is unarmed or armed with a weapon such as a knife or baseball bat “often present officers with time and opportunity to consider a range of responses.”  Perhaps most important, ICAT training

focuses on protecting officers from both physical threats and emotional harm…. The goal is to help officers avoid reaching the point where their lives or the lives of others become endangered and the officers have no choice but to use lethal force.

This last point is crucial, as fear and self-preservation typically provoke excessive responses in everyone, including law enforcement personnel.  Faced with a threat, the fight-or-flight response takes hold.  However, police officers cannot flee and may thus react with lethal force.  It takes dedicated training to un-learn this instinctive response, which may lead to over-reaction and unnecessary violence.

In the end, the police are much like the rest of us.  We all react as we have learned or trained.  We all act to assure our own physical and emotional safety.  And unfortunately, we all rush crucial decisions in the face of pressure and stress.  De-escalation training is not only an overdue necessity for law enforcement, it would be a highly desirable means to promote nonviolence in society generally.  Imagine how different life would be, if instead of reflexively meeting threat with threat, we learned from childhood to de-escalate and calm those who threaten us out of their own agitation or insecurity.  Imagine how different our current politics would be.

Yes, there will always be criminals and sadists who stop at nothing but lethal force.  However, a drug-addled screamer on the street corner is not such a person.  Nor, apparently, is a mass murderer such as Alek Minassian.  He was stopped with firm words and a cool head.  That should be a lesson to American police officers — and to us all.

Road rage is all in your head

Two cars arrive at a stop sign at the same time.  Both start into the intersection.  One driver speeds through, while the other jams on the brakes, avoiding a collision.  This driver feels insulted, offended, diminished.  Who the hell does that other driver think he is?  He nearly killed me!

This scenario, and countless others involving merge lanes, contested parking spaces, and aggressive rush hour traffic, are set-ups for road rage.  The aggrieved party feels a flash of anger and hostility, and may swear aloud within the confines of his vehicle.  He may “give the finger” in a way the other driver may or may not see.  He may grumble to passengers about the lousy drivers in his town.  Sometimes the response is louder and more direct: yelling at the other driver, or even giving chase.  At the extreme, enraged parties physically retaliate with weapons, or by using their cars as battering rams.

What’s going on?  In a practical sense, the initial harm is often trivial.  A moment’s delay at a stop sign would be ignored under other circumstances.  The real trigger is what the behavior says about the perpetrator’s attitude — or more precisely, how it was interpreted by the “victim.”  Did the aggressive driver proclaim his time was more valuable?  Did he disregard or disrespect the other driver?  Was it a power play, a demonstration that “I can do whatever I want, and you’re powerless to stop me?”  Was it contemptuous?  “I don’t have to wait for the likes of you, you’re beneath my consideration.”

Actually, the offended driver doesn’t know.  One reason road rage is so prevalent is that the outsides of motor vehicles are inscrutable.  We can’t read the nonverbal cues of other drivers.  A car with a mean, aggressive driver who couldn’t care less whether you live or die looks very much like a car with a driver who honestly thought it was his turn to enter the intersection, and who would be mortified to know you were offended or frightened as a result of his actions.  While you were cursing and giving the finger, he may have been wincing and muttering “Oops, I’m sorry!”  But that was inside his own car.  You didn’t know.

Road rage, therefore, is nearly always self-generated.  It’s all in your head.  Do you tend to think of others as mean-spirited opportunists, ready to take advantage of you, disdainful of your wants and needs?  Or do you give strangers the benefit of the doubt, assume they meant no harm and didn’t aim to insult or diminish you?

Either attitude is contagious.  I recently visited a country with polite drivers.  I never felt stressed even if it wasn’t clear whose turn it was at an intersection.  It didn’t matter; we were all content to defer to the others.  In contrast, when traffic is dog-eat-dog, and when our self-worth rises or falls with our ability to cut through it efficiently, then everyone else is a rival and an obstacle.

None of this is unique to road rage.  Yesterday I was in a supermarket express checkout line, “15 items or less.”  (Um, “fewer.”)  Ahead of me another shopper was packing up three bags of groceries.  I stood there steaming as she slowly ended her cellphone call and took her good old time to pay the $63 she owed.  I rehearsed angry comments in my head: “I guess even people who can’t count still need to eat.”  I didn’t actually say anything.

Later I wondered what exactly irritated me so much.  I could have been equally delayed, yet completely untroubled, by any number of things.  It wasn’t the wait itself, it was my perception of the perpetrator’s attitude.  Apparently the supermarket’s rules didn’t apply to her.  She was self-important and inconsiderate.  Looming even larger psychologically was her attitude toward me.  I imagined she didn’t care about me at all.  My inconvenience was not her concern.  I felt disrespected, not taken into account.

These situations happen all the time.  A patient of mine recently shared how angry he feels when his teenage kids fail to turn off lights after he’s reminded them repeatedly.  We agreed it’s not the trivial increase in his electricity bill that bugs him.  It’s his perception of their laziness, their disrespect towards him and his values, perhaps their willful defiance.

In all these settings, indeed throughout our lives, we react to interpersonal transactions taking place in our own heads.  Occasionally our perceptions of contempt and disdain are accurate.  Sometimes brats, narcissists, and sociopaths really do put themselves first, and either don’t care about us or actively seek to hurt us.  But more often we’ve concocted a story.  We’ve been insulted, pushed around, treated like dirt.  And in response we self-righteously strike back.

How can we escape this hall of mirrors?  Most simply, we can remind ourselves that our assumptions about others may be mistaken.  We may recognize that we tend to assume the worst in people, and take this bias into account.   There’s no need to assume evil intent when sheer stupidity — or momentary confusion or misunderstanding — can account for the behavior.

More psychoanalytically, we may reflect on our unconscious wish for care-taking and nurturance from others, and the anger that results when real life inevitably falls short of this yearning.  Such insight may spare us from projecting our own anger onto anonymous others.  And more philosophically, with years of meditation and discipline we could learn to detach our egos.  Slights from others have no effect upon the Self.  I believe this is one small aspect of Buddhist enlightenment, but don’t quote me.

Meanwhile, on that long road to enlightenment it doesn’t hurt to drive defensively.  And take a few deep breaths.

Does severe remorse require a specialist?

In her recent New Yorker article, “The Sorrow and the Shame of the Accidental Killer,” author Alice Gregory claims there are no self-help books for anyone who has accidentally killed another person.  Nor published research, therapeutic protocols, publicly listed support groups, nor therapists who specialize in their treatment.  She profiles several such tormented souls who bear their burdens largely alone.

Yet dealing with guilt, shame, and regret is a mainstay of both self-help and professional therapy.  A simple online search reveals page after page of self-help websites, therapist and clinic practices, newspaper and magazine articles, all about forgiving oneself, learning to accept one’s failures, and letting go.  In that sense the piece misleads about the lack of help available.  Indeed, although I don’t “specialize” in the treatment of those who accidentally kill another person — as best I recall, I’ve never worked with this specifically — I join many of my colleagues in welcoming any such person into my practice.

Gregory implies this particular remorse is unique: qualitatively different and far worse than regrets about bad marriages, abusive parenting, ruined businesses, accidental self-harm, and so on.  And so it is, in the same way that murder is usually considered the worst crime.  Taking a life, even unintentionally, is irrevocable and can’t be remedied.  Each life is one of a kind.

Does this render all the self-help moot?  the army of therapists clueless?  Does it take an elusive specialist to help in such severe cases?

Experience can’t hurt, of course.  Just as an experienced addiction therapist readily spots enabling and codependency; just as a therapist well versed in psychodynamics quickly senses subtle inner conflict; just as an expert cognitive therapist knows how to tailor a welcome intervention; so too a therapist who has worked with many guilt-ridden, self-punishing CADI (“Causing Accidental Death or Injury”) clients would know which interventions are usually helpful.

Lacking such an expert, should a sufferer reach out for the far more accessible, if less tailored, help out there?  By all means.  Although CADI is an extreme case, no one’s life story or emotional burden is exactly like another’s.  No one’s guilty remorse — or depression, anxiety, or self-sabotage — is quite the same as anyone else’s.  No therapist, no matter how experienced or specialized, can know beforehand exactly where a patient or client is coming from.  To one CADI client, the phrase “accidental killer” (in the title of the New Yorker piece) may feel just right, to another painfully harsh.  Even the value-neutral term “CADI” covers very different situations, e.g., a subway operator unable to stop the train before hitting a suicidal person on the tracks, versus a driver who falls asleep at the wheel and veers into unsuspecting traffic.

A widely-read New Yorker article highlighting this forgotten, suffering group is surely a gift to these folks and their loved ones.  Yet it would be sad if it left the false impression that only hard-to-find, specialized help is worth seeking.  In this situation especially, it’s important to remember our human connection with others, not just our differences.

Image courtesy of Stuart Miles at FreeDigitalPhotos.net