Monday, February 13, 2012

GW Psychiatric Treatment: Letter 7/17/95

July 17, 1995 (rev'd 10/22/95)
3801 Connecticut Ave., NW
Washington, DC 20008-4530

D. Georgopoulos, M.D.
Dept. Psychiatry
GW Univ. Med. Ctr.
Washington, DC 20037

Dear Dr. Georgopoulos:

An interpretation that you offered at my consultation on July 10, 1995 prompts a consideration of the interpretation's irrational (counter-transference) nature since the comments were premised on a gross distortion of facts of which you had prior knowledge.

PATIENT'S REPORT

I am attracted to the idea that there may be an aspect of folie a deux in your pharmacologic recommendation. I believe it is possible that, unconsciously, I want you to prescribe medication solely so that I can rebel against the prescription [which I perceive as an injustice]. According to this interpretation your act of recommending medication would satisfy my need to suffer an injustice, thereby providing a reality orientation to my reed to re-experience the defiance of victimization by a dictatorial authority.

I am reminded of a case study in Dr. Spitzer's DSM-III-R casebook about a man in the Soviet Union who was arrested by the KGB after it was discovered that he had written a book critical of the Soviet Communist state. The man, who did not suffer from a psychiatric disorder, was treated as if he were a psychiatric patient and was administered neuroleptics. I identify strongly with that case, and referred to the case in an autobiographical writing that I prepared in late December 1991. One might offer the psychoanalytic interpretation that your act of recommending a neuroleptic satisfies my self-concept as having the identity of a dangerous political prisoner (revolutionary) whom the authorities want to punish because his ideas pose a threat to the system. According to this interpretation, your pharmacologic recommendation satisfies an aspect of the repetition compulsion, specifically, my need to master though repetition the experience of an injustice imposed by an authoritarian regime.

PSYCHIATRIST'S INTERPRETATION

You say you want me to prescribe medication only so that you can rebel against it. I am wondering whether this is like the time you sent a letter to the FBI that mentioned that you had certain dreams. You said you wanted to get attention.  I wonder whether your letter to the FBI was another act of rebellion. Maybe this rebellion is part of your problems with people. Can you tell me how rebellion has caused problems for you in your relations with people?

ASSESSMENT:

The psychiatrist's comments are interesting for a number of reasons. First, the comments are tangential and non-responsive; the comments do not address the patient's central concerns. (In previous sessions, when the patient has pointed out the essentially tangential nature of the psychiatrist's interpretation, the psychiatist states in a defensive, almost abusive way: “I am providing you a different perspective. Nobody can disagree with you? Everybody has to agree with you?”)

Second, the comments are premised on a gross distortion of the facts surrounding the patient's act of writing to the FBI and the outcome of the patients action. On a number of previous occasions the patient had detailed those facts to the psychiatrist.  On this occasion the psychiatrist seems to have blocked out any immediate recollection of those facts, which suggests that the psychiatrist's interpretation, based as it is on a manifestly defensive factual distortion, involves a strong affective component of fear and anxiety—and that there is some linkage between (1) the psychiatrist's feelings of fear in response to the patient's comments offered at the consultation and (2) the psychiatrist's presumed feelings of fear and hostility in response to the patient's complaint to the FBI. (Independent evidence suggests that disagreement with authority figures arouses object anxiety in the psychiatrist, the fear that the object will become angry and abandon him. See Letter to Dr. Georgopoulos, dated July 26, 1995, no. 2)

As historical background it is pointed out that the patient had detailed a in a letter to the Washington Metropolitan Field Office of the FBI dated October 8, 1994 his concerns relating to a defamatory accusation made against him by his former employer relating to the patient's propensity for violence, including the specific accusation made by his former direct supervisor that he might be armed and homicidal. The patient's letter to the FBI also listed certain written communications that summarized and interpreted various of the patient's dreams, which communications, in the patient's opinion, the FBI might wish to review.

The Washington Metropolitan Field Office of the FBI did not contact the patient regarding the letter, 1/ but forwarded a copy of the letter to the Washington Metropolitan Field Office of the U.S. Secret Service,

The U.S. Secret Service met with the patient in mid-December 1994. On a number of different occasions the patient advised the psychiatrist of the content of his meeting with an agent of the US. Secret Service.

The patient had related to the psychiatrist his statement to the agent: “What right did my employer have to file a false sworn statement with the D.C. Government?” in response to which the agent stated: “They had no right to do that.” The patient told the psychiatrist that the agent's tone and manner seemed sympathetic throughout the meeting. The patient further related the agent's observation that the patient's social isolation seemed inexplicable: "You seem like a friendly guy. I don't understand why you are so isolated.” 2/ In response to the patient's query “Did I do something wrong?” the agent replied. "No, you didn't do anything wrong.” One week later the agent telephoned the patient at home and wished the patient a happy birthday.

The patient fully detailed to the psychiatrist the content of a second meeting with the same Secret Service agent that took place in early February 1995. On that occasion the agent told the patient that he was aware of situations in which a group of employees “gang-up” on another employee and that this is probably what happened to the patient at his former place of employment. The agent told the patient that the Secret Service did not believe that the patient posed a threat to protectees of the Secret Service, and that it was the agent's personal belief that the patient was employable.  The agent said, “Do you have a resume printed up? Are you looking for work?”-- and “you need to get on with your life.” When the patient advised the agent that he had requested of his psychiatrist that the doctor contact the former employer to inquire about reinstating the patient, the agent stated: “Isn't that something they could do?” (The psychiatrist has expressly advised the patient that the patient is “incapacitated.”) The agent also said to the patient: “I like you.”

The psychiatrist's interpretation offered at the consultation on July 10, 1995, based as it is on a gross distortion of facts fully known to the psychiatrist at the time, is incontrovertible evidence of a counter-transference that seems to involve the psychiatrist's identification with the patient's victimizers. The psychiatrist's identification with the patient's victimizers appears to be based on shared reactions of fear hostility, an jealousy. 3/
APPENDIX

I prepared the following outline on Saturday June 24, 1995 with the intention of expanding the notes into a letter at some future time. The notes outline my speculations regarding the possible irrational meaning behind the use by a psychiatrist of the term “improbable” to dismiss an objective and factually supportable report by a patient.''

The outline attempts to relate the nature of an individual's social adjustment to the manner in which he appraises ideas.

I believe that the notes are appropriately appended to the present letter since uncannily, the conclusion of the outline relates to an issue discussed in the present letter, namely, the characterization of a victim's complaint as an “attention-seeking ploy.”

On the psychology of the term “improbable.”

The characterization “improbable” implies that if something exists at all, it will occur relatively uniformly and with considerable frequency.

Some things do exist rarely (heart disease in children). Also, some things that are rare will occur with great frequency given certain conditions (heart disease, rare in children, common in older persons).

The use of the characterization ”improbable” may relate to the psychiatrist's group affiliation needs: specifically, to his feelings of terror when forced to identify with or empathize with rarity. (Both intellectually and socially).

The rare phenomenon stands outside the great majority, just as an outsider stands outside the group.

Historically, the Jew stands outside the community. For persons who have defensive group affiliation needs (i.e., people for whom the idea of standing alone arouses feelings of terror) the Jew therefore arouses deep anxiety and terror since he symbolizes the terror of alienation, isolation, or loneliness.

The phrase “improbable” in a certain sense therefore may carry an almost inherent anti-Semitic quality. It is a defensive reaction by an individual for whom the contemplation of the “exception” arouses the anxiety associated with the idea of alienation from the group or majority (or generalized category of ideas).

CLINICAL APPLICATIONS:

A psychiatrist who is terrified by the idea of loneliness and isolation may react defensively to the slightest signs of the following common psychopathology:
  1. any criticism of a group by the patient will arouse anxiety since the psychiatrist's basic premise is that groups are good; persons acting in group situations can only benefit the individual. Groups are good, in the psychiatrist's mind, because they ward off the terror of loneliness (the terror of facing the father alone?)
A Lexicon for anti-Semitic Psychiatrists

PARANOIA: The patient's inability to recognize the benevolence of the group (here, the term paranoia indicates the psychiatrist's identification with an essential aspect of groups: the projection of group members' aggression onto outsiders together with the denial by group members that aggression directed toward outsiders may be unjust).

The psychiatrist's use of the term “paranoid” actually signifies the ability of the patient to tolerate social isolation (here, the term paranoid applied to an individualistic patient is a defense against the patient's ego strength, which arouses fear in the ego-impoverished psychiatrist).

Thus, the term paranoid can obscure a political agenda, and can be deconstructed to mean the following: The patient is a highly individualistic person who is able to tolerate social isolation and whose ego strength arouses deep fear and retaliatory aggression among individuals whose ego weakness requires and permits them to subordinate their individual egos to a group ego.

NARCISSISM AND GRANDIOSITY: A psychiatrist may use these terms to indicate the patient's inability to recognize that if any characteristic exists at all, it exists uniformly and with great frequency: the idea must exist, if at all, in a general category that contains many like ideas--”a big group.” (For such a psychiatrist, an irrational dedication to the belief in the benevolence of groups may be an aspect of his predicate thinking; likewise the contrary ideas of the “outsider” will arouse anxiety just as the “improbable idea'' will arouse anxiety.)

Thus, the inappropriate dismissal by a psychiatrist of a patient's factual report that a law professor was once angered by the patient's presentation in law school may be a defense against the anxiety of contemplating an unusual idea—it is a kind of “lonely” or “isolated” idea that doesn't fit in a general category of typical (or stereotypical) academic experiences.

The terms grandiosity or narcissism can be deconstructed to mean that the evaluator has a need to engage in stereotypical, conventionalized thinking; ideas that do not fit into generalized categories (definitionally, “the exceptions”) will arouse the same anxiety that human outsiders pose and will be regarded as nonexistent. Thus, a member of a persecuted minority who protests against the dominant group's aggression will be said by the dominant group to be engaging in narcissistic attention-seeking: the outsider wants to be recognized as existing.

___________________________________
1/ In a letter dated October 31, 1994 FBI National Headquarters responded to one of the patient's previous letters as follows:

“Your September 6th communication to our Washington Metropolitan Field Office was recently referred to Headquarters. Based on the information you provided, no violation within the investigative jurisdiction of the FBI could be identified. As much as we would like to assist you, the FBI has no authority to conduct an investigation in the absence of an indication that a federal law within our jurisdiction has been violated.” The FBI's letter is clearly sympathetic, and addresses the patient as a victim and not a perpetrator. The psychiatrist's gloss of the patient's letter to the FBI as a rebellious attention-seeking ploy transforms the patient into a perpetrator and simultaneously transforms the patient's victimizers into innocent victims. On a sexual level, the psychiatrist's reinterpretation of the facts is identical to the strategy of a defense attorney in a rape case who portrays the rapist as an innocent victim of the female's attention-seeking game of sexual seduction. Stated in general terms, the relationships (penetrated / victim) – (penetrator / perpetrator) are transformed into (penetrator / victim ) – (penetrated / perpetrator). One wonders how the psychiatrist's possible unconscious fear of anal penetration figures into his defensive distortion of the facts relating to the psychological profile of the anti-Semite as a person who possesses a paranoid fear of anal penetration. See Grunberger, B. “The Anti-Semite and the Oedipal Conflict.” Int'l J. Psychoanalysis (1964) 380-385, 381.

It is admitted that the patient's letter to the FBI may have a psycho-sexual motivation; one possible interpretation is that the patient was discharging a derivative of homosexual libido invested in the FBI by means of a parody of a provocative act.  Even so, an incidental sexual satisfaction in these circumstances would no more vitiate the appropriateness of the patient's action than would an ancillary sexual satisfaction vitiate the appropriateness of the action of a pyromaniac, adrift on the open seas, who fire flares in order to provoke a rescue. Further, to continue the metaphor, it was the very people who unjustly tossed our poor seasick pyromaniac off the ship who provided him with the flares in the first place!

 2/ Former treating psychiatrist Suzanne M. Pitts, M.D. had told the patient that he would need to be drugged in order to interact normally with other persons; in the view of this psychiatrist, the patient suffered from a debilitating social phobia that effectively barred the patient from initiating social interaction.

3/ The psychiatrist's somewhat gratuitous reference to the patient's dreams (“I am wondering whether this is like the time you sent a letter to the FBI that mentioned that you had certain dreams. You said you wanted to get attention.”) carries a suggestion of jealousy since it was at that very session on July 10, 1995, that the patient provided the psychiatrist a copy of his latest dream analysis (“The Dream of the Elephant Sanctuary”). One possible interpretation is that the psychiatrist was symbolically expressing – by means of an express reference to an ”attention-seeking” letter to law enforcement authorities—his jealous hostility to the patient's latest dream analysis, which he feared would provoke the admiring attention of the “authorities" in the psychiatry department.

1 comment:

Gary Freedman said...

According to the George Washington University Medical Center Department of Psychiatry I suffered from paranoid schizophrenia when I wrote this letter:
____________

George Washington University Medical Center
Department of Psychiatry and Behavioral Sciences

February 14, 1996

Dear Mr. Freedman,

This letter is being written per your request to know your diagnoses.

In my opinion my working diagnosis has been: Schizophrenia, Paranoid Type (295.30).

Sincerely,

[signed]

Dimitrios Georgopoulos, M.D.