Trump, his worst critics, and diagnosis outside of a clinical context (2020)

Opposites playing the same game ?

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by Federico Soldani

Italiano

What is the very last thing a patient forced to be admitted to hospital for mental health cannot legally be forced into?

According to different legal contexts, with significant national and state variations, as a last resort, a patient can be forced to hospitalization itself, for observation or treatment. If necessary, physical treatment for mental health can also become compulsory: medication or, more rarely, procedures such as electro-convulsive treatment.

However, patients cannot be forced to open up against their will, or to “confess”, to use a Foucaultian term in a clinical context [1]. Even less so, no one can be legally forced to engage in psychotherapy. In the end, such decisions related to opening up remain a prerogative of each and every patient, no matter under what circumstances.

Patient collaboration can be achieved indirectly, perhaps more easily in a forensic context where stays are much longer, but in the ultimate instance, if a patient does not want to talk or open up s/he cannot be forced legally. As a counter-proof of this, as already mentioned, contrary to medicines or devices / procedures, the psychological treatments cannot be provided as compulsory measures. They require willing collaboration as a prerequisite.

Even at the stage when only observation, risk assessment and diagnosis are involved, before any treatment is contemplated or decided, a patient is aware of the clinical environment and can appeal against hospitalization; or about a clinical decision; or can take measures for other diagnoses to be considered, if warranted by symptomatology not previously pondered for instance; or can take steps for the risk assessment to account for their own views.

Psychiatric diagnoses are based on a classic, and to this day considered unequivocally essential, face-to-face interview. This is in addition to previous clinical records and collateral history from third parties. The more collaborative and open the interview, the better from a diagnostic and prognostic perspective.

In a clinical context, when the last-resort option of compulsory hospitalization is adopted, diagnosis and risk assessment can happen after a face-to-face interview. At some level a patient retains a voice, even when involuntarily committed to hospital for mental health. In addition to a sense of agency about the fact that collaboration remains their prerogative, they can actually and in all circumstances decide whether to collaborate, to open up, to engage. Or not.

But what if the basic requirement for a face-to-face interview for assessment becomes obsolete as a result of technological advancement and corresponding cultural changes?

What if, instead, we could diagnose and risk assess not only without patients consent but also without their knowledge? Or even more, without a citizen knowing to be, or to be seen as, a mental health patient in the first place? What if such diagnostic process becomes over time accepted as indeed more accurate than the one involving the patient knowingly and consciously through a classic clinical interview?

What if we could potentially assess and diagnose on a mass scale any and all citizens, treated this way not just as patients but actually having no voice at all in the process? Effectively being, in some respects at least, in a situation even worse than a mental health patient involuntarily committed to hospital?

A citizen remaining unaware of the diagnostic process, or perhaps knowing with more or less clarity that at a population level such process is potentially happening, but having no choice and no voice, possibly because of pretended public safety, about their specific case or about such collective, eminently political phenomenon?

Some of the worst critics of the 45 th U.S. President D..J. Trump, from the so-called ‘Duty to Warn’ movement, have argued that the President’s collaboration is not needed for a diagnosis and possibly even more so for an assessment of dangerousness [2].

According to such a view, existing known facts would suffice and would actually offer a more accurate diagnostic picture compared to a standard psychiatric interview, including one for risk assessment. Proponents of such view implying, among other things, that a patient could, for instance, lie during an interview; in contrast, abundant and already recorded existing facts would be difficult to change conveniently post-hoc when a psychiatric evaluation is performed.

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It is a largely unknown and forgotten fact, which I recently learned in my historical readings, that one of the two founders of Bolshevism, along with Lenin, was the physician and psychiatrist Alexander Bogdanov, born Malinovsky.

Bogdanov wrote the first Bolshevik utopia, “Red Star,” and developed a discipline of general organization called tectology, that was used for the USSR 5-year economic planning; tectology nowadays is regarded as a precursor of systems theory as well as cybernetics, the foundation of the ongoing automation revolution.

Half a century after the USSR was born, during the Breznev era, came diffused political psychiatry: dissidents were diagnosed and put in hospital against their will, typically labelled with “sub-threshold schizophrenia”.

Bogdanov had a leading role in the Bolshevik revolution. In his writings he made clear how there was no need for legal safeguards to deal with the “mentally diseased.” In a remarkable passage about the organization of the socialist society, he wrote:

“When society ceases to be anarchical and develops into the harmonious form of a symmetrical organisation, the vital contradictions in its environment will cease to be a fundamental and permanent phenomenon and will become partial and casual.
Compulsory standards are a kind of “law” in the sense that must regulate the repeated phenomena arising out of the very structure of society; obviously under the new system they will lose this significance.

Casual and partial contradictions amidst a highly-developed social sense and with a highly-developed knowledge can be easily overcome without the aid of special “laws” compulsorily carried out by “authority.”

For instance, if a mentally-diseased person threatens danger and harm to others, it is not necessary to have special “laws” and organs of “authority” to remove such a contradiction; the teachings of science are sufficient to indicate the measures by which to cure that person, and the social sense of the people surrounding him will be sufficient to prevent any outbreak of violence on his part, while applying the minimum of violence to him. All meaning for compulsory standards in a higher form of society is lost.” [3]

So, in a highly developed and organized society, science trumps law, making law unnecessary; in Bogdanov’s view, compulsion would then become not really compulsion anymore. Political dissidents are apparently not contemplated by such view; in the worst-case scenario they might qualify as a “partial and casual contradiction” in an otherwise harmonious “highly-developed” system.

Philosopher Berdyev recalled in his memoires how Bodganov tended not to pay much attention to the content of their philosophical discussions. Instead, Bogdanov appeared to focus on mental state and behaviour assessment, on actions and reactions, as if his fellow philosopher Berdyev was a biological machine in need of external observation, control and possible fixing.

“Somewhat curious were my relations with Bogdanov” – wrote Berdyev – “I was considered to be an “idealist” imbued with metaphysical seekings. For Bogdanov this was a completely abnormal phenomenon. He had originally qualified as a psychiatrist.

He began to visit me often. I noticed that he systematically put to me incomprehensible questions: how I felt in the mornings; how did I sleep; what were my reactions to this and that, and so on.

It emerged that my inclination towards idealism and metaphysics, he considered to be the symptoms of an incipient mental disorder, and he wanted to establish how far this malady had progressed.” [4]

On the other side of the political spectrum compared to Bogdanov, there was the German psychiatrist Emil Kraepelin, widely considered the most prominent figure in the history of biological psychiatry.

He made the fundamental distinction, considered valid to this day, between “dementia praecox” (more or less what we call schizophrenia) and manic-depressive psychoses.

To the extent that an interview is not required for assessment or diagnostic categorization in psychiatry, this might remind of Kraepelin, who worked largely by observing and recording patients’ behaviour over time. Indeed, he was unable to speak the language, Estonian, of most of his patients when working on his fundamental distinction.

Of note, Kraepelin was also a proponent of the political use of psychiatry, as according to his views socialists and opponents of World War I were judged to be mentally ill. [5]

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Nowadays, at the beginning of the 2020s decade, the rapidly spreading “contagious” language of psychiatry applied to politics might be referred to as “psyspeak” or “ideopathological lexicon”, as I recently proposed at the beginning of September 2019 during a talk at the Royal College of Psychiatrists in London. [6]

The latest example, among too many to count, is libertarian magazine Reason calling the political proposals of presidential primary candidate Sanders “socialist delusions.” [7]

Interestingly, the idea of diagnosing and risk assessing without the willing participation, consent or even knowledge of someone, possibly unaware even of the very fact of being seen as a “patient,” is now being taken up by the Trump administration.

The administration of a President who should be opposed, in theory at least, to some of the very same methods his critics proposed to diagnose him through. Methods that he rejected for himself, a democratically elected political figure; which is, assessing and diagnosing without a necessary interview in a clinical context.

The Trump administration is indeed seriously considering the agenda of the “digital diagnosis” for citizens, possibly through a new federal agency that might go under the name of HARPA (Health Advanced Research Projects Agency), according among other sources to the Washington Post.

Such an agency would develop “breakthrough technologies with high specificity and sensitivity for early diagnosis of neuropsychiatric violence,” according to a copy of the proposal. “A multi-modality solution, along with real-time data analytics, is needed to achieve such an accurate diagnosis.” [8]

Also, somehow relevant to such technologies, so-called “digital phenotyping” [9] is currently a brand new area of research and business. There are dedicated Californian start ups such as the one by former NIMH Director Thomas Insel, a psychiatrist who prominently studied animal models of the social brain, separation anxiety and the role of molecules such as vasopressin and oxytocin. After almost 15 years as NIMH Director he went to work for Google, later founding his own company for “digital phenotyping.”

In a similar climate of technological advancements, according to the proposals for a new federal agency reported in the press, existing known facts, coded as data, could be used by the government to diagnose citizens and to predict behaviour; to assess risk and dangerousness via any digital data source available, from smartphones, to wellbeing / fitness devices, and so on.

Once the data are in, citizens’ consent and collaboration would not be necessarily needed to store, replicate, keep the data, and, critically, to perform an assessment, either diagnostic or about risk.

If, for instance, people could opt out of such databases in the first place, either individually or collectively, this would defeat the purpose of electronically rating, tagging, or labelling individuals and predicting risky behavioural patterns based on algorithms and available digital information.

Consent for, or knowledge of, a remote assessment of such type on the part of citizens-turned-patients would not be needed.

Among the many harsh disagreements in a country polarized as never before, on one issue at least Trump and his worst critics would appear to agree at some level: Diagnosis and risk assessment based on mindful, conscious, preferably willing involvement of a subject who knows to be a patient, encompassing a necessary interview in a clinical context, looks increasingly like an institution belonging to the past.

The real risk is political and democratic. Or for such a new “clinical” technical context to extend to the whole of society, effectively bypassing established citizens’ legal and constitutional rights and safeguards.

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[1] Foucault, M. (2003). Le pouvoir psychiatrique : cours au Collège de France, 1973-1974. Paris Seuil Gallimard.

‌[2] Gartner, J., Langford, A. and O’Brien, A. (2018). It is ethical to diagnose a public figure one has not personally examined. The British Journal of Psychiatry, [online] 213, pp.633–637. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30236170.

[3] http://www.marxists.org. (n.d.). Socially Organised Society: Socialist Society by Alexander Bogdanov 1919. [online] Available at: https://www.marxists.org/archive/bogdanov/1919/socialism.htm [Accessed 27 Jun. 2020].

[4] White, J.D. (2019). Red Hamlet : the life and ideas of Alexander Bogdanov. Leiden ; Boston: Brill. 

[5] Bar, K.-J. and Ebert, A. (2010). Emil Kraepelin: A pioneer of scientific understanding of psychiatry and psychopharmacology. Indian Journal of Psychiatry, [online] 52, p.191. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2927892/.

[6] Soldani, F. (2019). Are we witnessing the emergence of a new global psychiatric power? (2019). [online] Foucault News. Available at: https://michel-foucault.com/2019/12/19/are-we-witnessing-the-emergence-of-a-new-global-psychiatric-power-2019/ [Accessed 27 Jun. 2020].

[7] Stossel, J. (2020). The Socialist Delusions of Bernie Sanders. [online] Reason.com. Available at: https://reason.com/2020/02/19/the-socialist-delusions-of-bernie-sanders/ [Accessed 27 Jun. 2020].

[8] Alemany, J. (2019). White House considers new project seeking links between mental health and violent behavior. [online] Washington Post. Available at: https://www.washingtonpost.com/politics/2019/08/22/white-house-considers-new-project-seeking-links-between-mental-health-violent-behavior/ [Accessed 27 Jun. 2020].

[9] Insel, T.R. (2018). Digital phenotyping: a global tool for psychiatry. World Psychiatry, [online] 17, pp.276–277. Available at: https://onlinelibrary.wiley.com/doi/full/10.1002/wps.20550 [Accessed 24 Apr. 2020].

This article was intended for the blog “Mad in America”, which requested it, initially accepted it, and after the last revision and addition of the Bogdanov part, finally decided not to publish it.

It was posted independently by the author via social media on the 15th of March 2020 and published on the PsyPolitics.org blog on the 27th of June.

Last Updated on September 13, 2020 by Federico Soldani