Sally Satel, Politically Incorrect MD, Part I

GUEST: Sally L. Satel, M.D.
VTR: 12/14/2006

I’m Richard Heffner, your host on The Open Mind for the last half century.

And all of these years I’ve had a favorite informant whispering into my ears perfectly terrific suggestions about guests I should invite here, wonderful thinkers and speakers that she, my wife – as a practicing psychotherapist herself – had heard at Cornell Medical School’s provocative medical education Grand Rounds.

Well, Elaine Heffner has done it again…told me some weeks ago about Dr. Sally Satel, a practicing psychiatrist in Washington, and a resident scholar at the American Enterprise Institute, whose PC, MD – How Political Correctness is Corrupting Medicine is one of her provocative books.

Another is One Nation Under Therapy – How The Helping Culture Is Eroding Self-Reliance, which she wrote with Christina Hoff Sommers.

And I’d like today to ask Dr. Satel first to describe some of the controversies these books have occasioned. Is that fair?

SATEL: (Laughter) Yes, that’s fair. Yeah …

HEFFNER: What have you stirred up?

SATEL: Well, I think I stirred up a hornet’s nest in almost each chapter, but the first one seemed to get the most attention. That was a critique of schools of public health.

Now, don’t get me wrong. Most people who go to a school of public health can get excellent training in epidemiology and disease tracking and research methods. But many of these schools have a Department of Social Medicine and they tend to be fairly politicized. And … so that’s what I wrote about in that chapter.

HEFFNER: What do you mean “politicized”?

SATEL: Well, they don’t stick so much to data. They really have a political agenda. And example, is actually income distribution. That is one of the agendas of a few professors at the Harvard School of Public Health … I’ll just pick that one, but several others.

In fact the former Dean of the Harvard School of Public Health had said, “A school of public health is like a school of social justice.” In other words, all the ills of, of society are something that, that … many, though certainly not all public health academics see as their purview.

For example, we know that health and wealth correlate. There’s no question about that. So what would be an approach to that? Well, if we want to make everyone healthy, then we should redistribute wealth. This is a literal recommendation from some of these folks.

HEFFNER: All right, Dr. Satel, what’s the problem with that?

SATEL: (Laughter) Well, there are several …

HEFFNER: Seriously …

SATEL: … problems with it.

HEFFNER: Yeah?

SATEL: One, they’re mistaking often correlation for causation. There are a lot of reasons why people of lower income have poorer health. Certainly a part of it … there’s no question is … when you have more money, or certain kinds of jobs, when you’re sick one day, you literally can take off and you won’t lose your job. You can go to the doctor in the middle of the day … at most … a lot of jobs that our colleagues would have. And someone who works on an assembly line or that kind of job that’s an hourly rate, really does suffer if he takes any time off. And many clinics aren’t open at night. That, that kind of thing. That’s very practical and very, very true.

But there’s a lot of problems with self-care among the poor. Now I realize that when you life is … when your life is chaotic with so many other problems, paying attention to your health is, is often not the first thing on your mind … I appreciate that. But in my clinic, I work in a methadone clinic, and when I see a patient with asthma, the first question isn’t “What asthma medications are you on? It’s how many packs a day do you smoke?”

People continue in this, in that particular example, to, to smoke when they already have asthma. They’re in a methadone clinic; they often continue to use heroin. They have diabetes and they don’t watch their diet. I mean these are things that people can do for themselves and there’s very little acknowledgement of that because it would seem to them like … as if it’s blaming the victim.

HEFFNER: So you’re saying, if I understand you correctly, that there has to be a level of responsibility on the part of the patient so that you don’t treat the patient simply as a victim.

SATEL: Oh, definitely. There has to be responsibility. And always the flip side of, of … I mean someone can say you’re blaming the victim, but I … what I always say is “Well, actually, if, if … the flip side of that is showing someone where they can take, take control.

But you ask why is that kind of approach to, to health … why is this grand scheme, this global conceptual approach to public health invalid? Well, well, first of off, it … as I said, it doesn’t recognize … all of the causal dimensions. Secondly, it doesn’t work. You’re too far upstream. I mean in order to re-distribute wealth, as if that would even work, you would have to essentially re-organize our entire society.

I mean and that’s not a job for a public health professional. That’s jobs for politicians and, ahhh, not that public health folks can’t participate in those debates, but I think that they’re, they’re most constructive role is to provide the empirical basis for these kinds of policy changes.

HEFFNER: You’re saying then that they’re not doing what they need to do.

SATEL: I’m saying they’re not doing what they need to do; they’re highly distracted by, again, political agendas. There’s, there’s now big literature on something called “Health Disparities”. Now “disparity” is a perfectly neutral word, it just mean different. But it has come to now mean “injustice” and it refers to the difference in, in health status between Whites and Blacks, or Whites and minorities. And there, there’s no question that there are these differences.

Whites have longer life expectancy. They’re generally more healthy, better … lower infant mortality rates. Often more likely to get certain procedures in a hospital. All this is true.

But one of the, the major inferences on the part some folks in public health and in medicine, in general, is that this difference is actually due to racism, or to prejudice on the part of the health care system. And, you know, I’ve done work on this … first off, it’s a very hard thing to prove that there’s any kind of bias, unless we’re talking about, you know, direct discrimination in which case we have a legal system to help, help resolve that.

What … you know what we’re talking about are differences that stem from socio-economic class … again, self-care. If you want to invoke bias as any … an explanation … that’s always, essentially, a diagnosis of exclusion, it’s when you’ve ruled out everything else … the geographical variation in health care availability, the … again … socio-economic status of people, of their access to care …

HEFFNER: But the question I would think that would be most important, would be … what do we lose … what does this approach … what does this politically correct approach … where does it damage? The patient? Or society?

SATEL: Ah, it damages the professions that practice it because they’re really not focusing on what they’re expertise is. For example, last year the American Psychiatric Association came out in favor of gay marriage. Look, I’m not against it … I’m not for it, I’m not against it … that’s irrelevant. And that was my point. This is irrelevant for a professional organization which is supposed to specialize in research, education and, and patient care to take on these social issues.

It’s just … first off … at, at minimum, it’s a distraction from what they should be doing. They lose their credibility. I think it damages the credibility of a professional organization when they, they take on these social issues.

It’s also not representative, I think it causes tension within those professions because not everyone, we’re not a monolith … they’re not representing me when they, when the APA gets up there and talks about gay marriage. As I said, either way, the particular policy decision is not what I care about, it’s the fact that they’ve engaged that debate at all.

So that’s one, I think it damages the profession. And also loses credibility in the eyes of the public. And … yeah … they’re not doing the kind of … whenever they work on issues that are, are really not their … within their professional domain … they are not doing the important things.

We’re not, we’re not in psychiatry, for example, I don’t believe we’re worried, nearly enough about the severely mentally ill. But instead we’re worrying about vague kind of trauma initiatives and we can talk about that another time.

But the idea that, you know, if you were abused as a child, 30 years ago … you know, that that is the reason why you’re troubled as an adult now. And it’s such a, it’s such a distraction. We should deal with people, obviously, and their distress as they present … but to have special initiatives for people that, that inculcate them further in the idea that they’re victims and that they’ve been … and that they then often can’t move on because they get so entrenched in this sense … it almost becomes their identity sometimes … that it can lead to bad treatment as well.

HEFFNER: Trauma. This is a subject that does interest you and that you have written and spoken about.

SATEL: Yes.

HEFFNER: What’s happened in the world of psychiatry given the question of new definitions of illness that relate to trauma?

SATEL: Well, you know, there is … no one questions the reality that a person can experience a truly horrific event, you know, a rape, combat, terrible accident, a hurricane in which your life was almost threatened … that people can experience these, these catastrophic events and, and also develop mental illness afterward. In other words, what we’ve come to now call post-traumatic stress disorder, marked by re-experiencing of the, of the event … you keep having these horrible, intrusive memories, can’t sleep, hyperarousal. A kind of phobic avoidance of the situation, which can get to the point where it really does impair someone’s life significantly … most of the cases, it’s self limiting. Doesn’t mean one shouldn’t get treatment.

My point is that this is a real phenomenon. That people can be, go through horrible situations and develop some kind of mental pathology from it. But, unfortunately, that diagnosis … PTSD, Post Traumatic Stress Disorder … has been so watered down that, to the point where if you just experience something distressing, or hear about a horrible event that’s befallen someone else … you, too, can qualify for PTSD.

It, it’s almost become, you know, a narrative of suffering. And it medicalizes what are often normal human reactions to very, very tragic events. 9/11 being one of the most striking examples.

HEFFNER: Now you don’t see this as a response to some mass demand for help, you see this … if I understand correctly, as a new business.

SATEL: Well, I do think some of it’s manufactured. I think there’s a very crass level of, of commercialization of it. And, for example, there’s a group called the International Critical Incident Stress Foundation. It’s just run by someone who’s a former EMT. And they give workshops and they get contracts after a tragedy and they all run out … you know, the busloads of grief counselors, and trauma counselors they have to send on these scenes. And, and they get paid for these kinds of things. These are not usually physicians or Ph.D.’s … these are people at a Masters level or lower. Not the most sophisticated. Often well meaning. But, but that’s business and I gather it’s a … quite a successful one.

But I’m also talking about academics who … and this is no surprise … I mean people who spend their whole career in a, in a specialty and they need to get grants and they need to, to fund their research empires … have an investment … it may not even be that conscious, but there’s no question there’s an investment and I do think that, that they have very much contributed to the popularization and the dissemination of this construct.

HEFFNER: And what is this construct doing to us as a people?

SATEL: Well, that, that’s always a good question. I can tell you what it’s doing to Veterans at the VA.

HEFFNER: Yeah.

SATEL: … the VA Hospital, because that’s, that is an institution where it’s most concentrated. I think it has largely back-fired. As you know, Post Traumatic Stress Disorder, while it always existed in nature, as I said before … as essentially a fear reaction that didn’t extinguish after the trauma subsided, but as a formal diagnosis, it didn’t exist till 1980 when it was adopted in something called the Diagnostic and Statistical Manuel of the DSM, which is the APA’s diagnostic handbook.

HEFFNER: You mean making it legitimate?

SATEL: Yeah.

HEFFNER: Crowning it.

SATEL: Definitely legitimizing it. And it was put there … this not a really disputed point … it was largely put there by two psychiatrists, who were self-avowedly anti-war. It was very much embedded in the context of the Vietnam War. And, in fact, the first iteration of PTSD, when it was proposed … because it was proposed in 1972 and APA thought about it and thought about it for years, actually. They, they spend a lot of time on each new edition of this diagnostic scheme. And …but when it was first proposed it was called “Post Vietnam Syndrome”. Now, heaven forbid, you … you know, someone’s spouse dies or the lose their job, or they get divorced and they get depressed about it. There’s no “post-divorce depression”, or, you know, “post-disappointment depression”. It’s depression. And, and … again, you treat the individual based on what his situation is. So Post Vietnam Syndrome was just, you know, unacceptably specific and unacceptably …

HEFFNER: Political?

SATEL: … politicized. In fact, the anti-war psychiatrists who were pushing … Chaim Shatan, Dr. Lifton were, I think, unabashedly trying to also signal that it was a … an anti-war slogan … you know, “go to war and your mind is annihilated afterwards”.

And they also introduced the idea that PTSD could be chronic, that this could go on for years. And, and they basically gave rise to a PTSD industry within the VA. And I worked there, in fact, in the mid-eighties … ‘88 to ’93, excuse me. And I saw how … and I should say … the clinicians were very well meaning. And this was … a lot of it was state of the art therapy at the time. But how they saw every problem that someone who had once been in war …you know, once you’d been in a war … that anything that happened in your life subsequently … you know, could be walked back to that seminal event.

And it’s true, there are some patients … I think they’re quite a minority … some patients who were so de-railed, you know, so, so traumatized by the war that they never did regain their footing. And that they did become chronically mentally ill because of it. And the VA has a very generous disability program and they just … they certainly deserve that.

But there are a lot people who came back and probably had some readjustment problems. But it wasn’t pathological. It was some social dislocation. And, and later in life … 20 years later, often, they had some life problems because who doesn’t … and they came to the VA and this was the narrative, that so many clinicians would even impose on them. In fact I just got an e-mail, I get a lot of e-mails from veterans … most hostile, but yesterday I got one from someone who was, was very reasonable, I thought … and he said that “they’re convincing me that I have post traumatic stress disorder now from Vietnam.” Which is a very interesting phenomenon … can someone develop a stress reaction 30 years after an event? I, I don’t think so, I’m very skeptical of that.

HEFFNER: Now. A little aside. For a moment you said most of them are hostile, these e-mails …

SATEL: E-mails. I knew that would … I knew that would …

HEFFNER: Why?

SATEL: … catch your attention. Well, they think that I’m denying the very existence of post traumatic stress disorder. And, and I don’t do that. But I am skeptical and I’m certainly not going to, to muzzle my, my doubts about the fact that as I just said, someone 30 years later can present to the VA and want lifetime disability after this.

HEFFNER: You’re pretty skeptical about a lot of things that relate to social medicine. Or medicine that has a social or political content.

SATEL: Well, of course, because you’re not serving the data first and you’re often not even serving the, the patient first, you’re serving a larger mission. And that’s always … that should make anyone skeptical and it also should also make any one worried that, you know, we did take an oath and the patient always comes first, not your politics.

HEFFNER: When you say “the patient comes first”, you are dealing with individuals here …

SATEL: Right.

HEFFNER: Someone who wants the benefits of this new philosophy … are you really thinking of the patient then when you express your dislike for what is happening to us as a society? Becoming less and less self-reliant, more and more reliant upon these kinds of social objectives?

SATEL: Ahh, I’m not quite sure I understand the question.

HEFFNER: Well, I, I don’t blame you …

SATEL: (Laughter)

HEFFNER: … because as I went on I was wondering what I was asking you because I was trying to avoid asking you whether you’re reflecting a political point of view?

SATEL: Oh, I see what you mean. I, I really don’t think I’m reflecting a political point of view. Unfortunately these days championing personal responsibility puts someone on the Right, which I think is, is silly and you never serve your patient if you don’t consider that.

In fact, as I said before, that is the flip side … the constructive flip side of blaming the victim … it’s … would I blame you if you got breast cancer … well … would I blame you if you some kind of cancer. Well, if you smoked … yeah, obviously there is, there is a correlation there. But, you know, I wouldn’t blame you anyway. I’d feel sad and we’d work, you know, to go through the chemo and, you know, treat you.

But if you’re using, if you’re using heroin and the use and I … is largely under your control … and let me amend that because that’s also a provocative thing to say. I mean in the context of my methadone clinic … methadone as you know is a substitute for heroin. When people are on methadone they don’t …they don’t go through withdrawal and although they may want to get high because sometimes, you know, you even want a buzz after work … I know I do with wine or something like that. But that’s a natural human instinct to sometimes want to change your sensorium a bit. But the point is they’re not in withdrawal, which is often what, what drives heroin addicts to use again. And because they’re in the … because they’re in the clinic, it’s a … we hope … it’s stabilizing and organizing influence on their daily life. So when those folks use cocaine at night or, you know, one night … or heroin, they’ve clearly used it in a voluntary way and they’ll tell you … because they used it twice a week, they didn’t use it every night, they didn’t use it in a compulsive fashion, they used because they want to.

HEFFNER: And what do you do with them?

SATEL: Oh, well, you know what … truthfully you could say that’s their choice … and I do … (laughter) … obviously it is their choice …but I have to … but the reason why that is not a good thing for them to do is because anyone who is still using drugs, even if it’s in a sporadic way, while they’re on methadone … is almost guaranteed to go back to a full fledged habit once they’re off of the methadone. So that’s why I care that they’re using while they’re on the methadone.

HEFFNER: Well, you see, that’s what I saw. I told you before we started the program that I had watched a videotape, a DVD of your talk and questions and answers at Cornell, at the Grand Rounds. You’re a profoundly, deeply, sympathetic person when you’re talking about your patients. Somehow I think you manage to tic people off a little because they think there is a political agenda. And now, you know that last question that you were asked … it was near the end …

SATEL: MmmHmm.

HEFFNER: … about your association with the American Enterprise Institute … is there any validity to asking you … you, you were quite indignant … what does that question have to do … or the answer to that question have to do with your work at a psychiatrist?

SATEL: Yeah. I, I do … that’s what I did challenge him with. And that’s … ah, I would say that most of my work is, again, empirically based. Some much more quantitative than others … you know, I mean, for example when you work with a patient, not everything is scripted. And certainly there’s not a, a book you can consult on … every interaction. But, you know, it’s experience and you get to see what works better.

Maybe it’s, maybe it’s the nature of the interaction you develop with patients that’s more idiosyncratic to you, but the point is it’s reliably … has a better outcome, better meaning … the patient is less symptomatic, he has more choices, the problem he came in with is resolved, he can think about himself more clearly … and I would just say to that gentleman, “Well show me where, where am I in the, in the very, very circumscribed domain of the interaction between you and the patient … how is any kind of politics intruding on that?”

I wouldn’t even know what it would look like … well maybe get them to vote for Bush. I mean I don’t even know what that, what that really means.

HEFFNER: So you …

SATEL: So when I …

HEFFNER: Go ahead.

SATEL: … when I question PTSD as something that’s over, over … often over diagnosed, it’s sometimes gratifying to patients … I mean it’s the ultimate, it’s really the ultimate diagnosis for a victim society because you … going to say, “Well, something happened to me and, you know, I have no responsibility for anything thereafter.”

As I said there are people who have some investment in it. But I also said, you know, when you really think about it as clinicians, we don’t have to call … we don’t … it doesn’t even matter what we call this particular … if we call something PTSD because when you have someone before you who says “I’ve been in this horrible situation and now I can’t, my relationship with my wife is damaged, I can’t concentrate at work, I can’t do all these various things.”

You say, “Okay, well, let’s go through your problems.” If the person has a phobia, we have special desensitization procedures for that. If they can’t sleep, we can prescribe medicine. If they’ve got an existential crisis, which some … people are often thrown into when they, they have a life threatening situation … oh, well let’s think through that and the meanings of it.

I mean dissect out the aspects of the problem that someone presents with … you don’t even need to resort to diagnoses that much. At all sometimes.

HEFFNER: Are you recommending that?

SATEL: Well, you have to put something down on the insurance …

HEFFNER: To get the money.

SATEL: That’s for sure. You do. And don’t think I haven’t called someone, you know, major depression when I thought they just had a lot of … they were just demoralized at the time and we helped … because, you know, we had to get paid. So that’s true. But, but I’m saying that, yeah, when you’ve got a diagnosis like PTSD that is so frayed and so politicized and it’s all … nowadays one hardly knows what the, the whole purpose of the DSM was, was to essentially codify a language so when I said, “Oh, I just saw Mr. Smith, and he has a major depression.” The psychiatrist down the hall would know exactly what I was talking about.

Now when you say, “You know I just treated someone, they have PTSD.” Who knows what that means. Does it mean they were just in a horrible car accident and they have those classic symptoms that are highly treatable? Or does it mean that something happened to them years ago and this is the social story that they they’ve … excuse me, the, the personal story that they’ve essentially elaborated around that ancient problem?

HEFFNER: As we bring the program to an end, I suggest maybe you do mean a social story.

SATEL: MmmHmm.

HEFFNER: Rather than a personal story.

SATEL: As well, yeah.

HEFFNER: Let’s talk more about it next time. Okay? Dr. Sally Satel, thank you for joining me today.

SATEL: Thank you.

HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. For a transcript of today’s program, please send $4.00 in check or money order to The Open Mind, P. O. Box 7977, FDR Station, New York, New York 10150.

Meanwhile, as an old friend used to say, “Good night and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.