During my Residency in the late 1970s there was a brief flurry of papers and conferences arranged to discuss what some thought was a new diagnostic entity. There was a fair amount of semi-scholarly interest in determining if the new type of patient we were seeing represented Pseudo-Schizophrenic Sociopathy or whether it was more properly understood as Pseudo-Sociopathic Schizophrenia.
At the New York VA Hospital, many of these troubling patients were young Vietnam Vets who were socially marginal, often drug and alcohol addicted, and seeking or maintaining Service-connected disabilities. For many of these benighted young men, their income from their SC-Disability, tax-free, dwarfed what they would have been able to earn from the entry level jobs that were the only things they were suited for. As a result, they had a very powerful interest in maintaining their disability status. At the time, the VA rules were such that the easiest way to maintain one's status as suffering from a SC-Disability was to be hospitalized at least every 6 months. Clearly, anyone who was hospitalized was severely ill and deserving of a disability.
We would typically see these people in the emergency room at the VA, often late at night, suffering from Command Auditory Hallucinations ("Voices") telling them to kill themselves. Coincidentally, these relapses almost always occurred 5 1/2 months after their previous hospitalization for the exact same symptoms. Luckily, the symptoms would resolve within a week or two, the patient would be discharged and we would see them again, (or hear from another VA ER in another county or state) 5 1/2 months later..
During this same time frame, at Bellevue Psychiatric Hospital, it was not uncommon to see severely disturbed people, often plagued by similar command auditory hallucinations, often suffering from drug and alcohol addicted, who suffered exacerbations when their services were cut.
Interestingly enough, whether at the VA or Bellevue, when a doughty Psychiatric Resident decided to resist what felt like obvious manipulation and refused admission, a predictable set of reactions occurred.
While some patients simply left the emergency room and typically showed up the next night in a different hospital emergency room, others would escalate their efforts to get admitted. This occurred especially when the weather was cold or rainy. The frustrated patient would typically become agitated, loudly threatening to kill himself; a few locked themselves in bathrooms screaming that they were going to cut their wrists. The Hospital Police were not enamored of the Residents who allowed things to get to such a level, since they had to take off the doors and subdue the agitated patient. Determined patients always managed to get admitted. Their ability to threaten harm to themselves was always greater than the Resident's ability to tolerate their threats, (though some of us became quite proficient at the type of verbal jujitsu that worked well to discourage the most obnoxious offenders.
In such cases, we were often left wondering if these were really the most seriously ill Psychiatric patients, suffering acute exacerbations because of the stress of losing their benefits or if they were exaggerating or inventing symptoms in order to manipulate us. What caused the most discussion was trying to tease out which patients were truly suffering from the terrible psychosis of Schizophrenia and which were merely manipulative liars (malingerers) determined to squeeze sustenance from the maternal state.
The more important policy message was that when sociopathic behavior was rewarded, people who were not sociopaths readily discovered the value of behaving like sociopaths. Even the most limited and damaged individuals understood enough about how the system worked that they could use blackmail and extortion to their advantage. While these people were not usually directly threatening the Psychiatric Residents and Staff, they did threaten our relationships with the staff and our sense of ourselves as Psychiatric professionals. On the rare occasion a patient threatened the staff, the Hospital Police took some relish in subduing them with less than their usual restraint; such patients rarely repeated their threats during subsequent visits to the Emergency Room.
This is generalizable to much of what plagues our world. It doesn't take a Psychiatrist to understand that when terrorist threats are acquiesced to, further threats are inevitable. Neither does it take a Psychiatrist to know that if a person is committed to getting what he wants at all costs, there is no way to stop him without using force or the threat of force. There are truly no other options.
Gordon Brown, his cabinet filled with anti-war ministers, and his countrymen, would like nothing better than to abandon the fight in Iraq; al Qaeda is almost certainly attempting to repeat their success in Spain with a similar victory in England. Yet, the threats and extortion never end with a single acquiescence; only complete surrender is ever acceptable.
Sadly, large segments of the elites of Western civilization have thus far failed to grasp these simple truths. Worse, many have turned away form understanding and prefer denial. Denial, however, has never succeeded in keeping reality at bay for long.
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