Entry 2:

Dear Walter,

There is a quality of homecoming in writing for Slate. The last "Dialogue" I participated in was with Sally Satel, who had been a medical student of mine at Brown. Now I am in a discussion with you--my supervisor during the final months of my psychiatric residency at Yale.

I don't suppose we will disagree profoundly. When it comes to medical ethics and political philosophy, the defining event for me is the Holocaust, followed by Stalinism and its sequels. I take it from your letter, and from our many conversations over the years, that the same holds for you. But as regards particular moral conflicts, I think it is important to ask how far those touchstones apply and in what fashion.

I can imagine a systematically racist, totalitarian state in which the expression of tolerance is considered crazy--grounds for evaluation for possible incarceration on the basis of mental illness. I wonder whether such a thought experiment is not behind your concern over the ordering of a psychiatric examination as a response to John Rocker's racist remarks in the presence of a reporter for Sports Illustrated. If we legitimate psychiatric consultation for Rocker, we are countenancing the political repression imagined in the thought experiment. But there is a lack of symmetry between the two circumstances.

In the imagined one--totalitarianism--the practice of psychiatry is fraught with moral pitfalls altogether. The psychiatrist is an instrument of the corrupt state. The disposition of the case will have nothing to do with diagnosis, practiced in good faith. There are other less important asymmetries that I will mention in passing: In the wider, transnational context, tolerance remains a tenable, humane belief; even if it is aberrant in a given state, the mere holding of the view hints at nothing negative about the person. And (this point is somewhat stronger) outside the imagined state, there are no mental illnesses for which the expression of tolerance would be considered a sign. Also, under totalitarianism, the consequence of the introduction of mental illness as a consideration redounds to the benefit of the state while acting as a threat against the individual.

The John Rocker case is different in every particular. First, let us be clear about the basis for the brouhaha. Rocker does not face possible punishment within his sport for holding prejudiced views. Presumably many athletes are prejudiced--that is one reason racism is a serious problem, because it is widespread. Rocker risks punishment for expressing prejudiced views. My assumption is that within the sport a common response is "You'd have to be crazy to say what Rocker said." Not to believe it--to say it. After all, athletes mostly say quite bland things to reporters. Part of the tedium in following sports is the formulaic, scripted comments. What Rocker did with the reporter is truly aberrant, taking the trash-talking that is common in the course of games (football and basketball, I take it, more than baseball) and introducing it into an interview.

I agree with you, emphatically, that we have nothing diagnostic to say about Rocker. But we do know that some of the traits attributed to Rocker in the magazine article--impulsivity, rage, persistent blaming of others, and press of speech--can be symptoms (if expressed by the patient) or signs (if noted by a doctor) of mental illness, indeed of quite severe mental illnesses characterized, in the extreme, by delusions, including paranoia. Surely we might admire Commissioner Selig if it emerged that in light of behavior similar to that described in the article (and I am not thinking especially of the racist remarks), he had repeatedly urged Rocker to undergo psychological evaluation. The subsequent requirement for testing would look fairly benign in that light--which is as much as to say that the behavior depicted in the article (where Rocker is described colloquially as a "psycho" whose behaviors display "madness") makes a reasonable case for a work-up, and would even if the racist remarks were omitted.

What is at issue is not counseling for racism but treatment for mental illness. Whatever entered into the decision to require an evaluation, we have reason to presume that the diagnostic process will be undertaken by a professional who has the patient's medical interests at heart; and any diagnosis and treatment will be intended to benefit the patient. Perhaps benefit him too much, is your worry--benefit him politically as well as medically. Well, there is that risk, a serious risk. But our usual complaint as psychiatrists is not that too many people receive the benefits of assessment, but too few. We do not know what else the commissioner knows. But if there is a likelihood that Rocker is getting himself in trouble as a result of mental illness, that condition might reasonably be taken into account when discipline is imposed. Or not--I suppose I could live with a system parallel to the "guilty but insane" standard in force in some states as regards sentencing for crimes; even so, I would want to be aware of whether the person disciplined is mentally ill.

As for the use of psychotherapy to treat moral or social pathologies, I am with you. If Rocker does not have a mental illness, one he would be seen to have anyway, without the racism, he should not receive a diagnosis and he should not be required to undergo treatment. The claim (but who makes it?) that all bad behavior is the result of mental illness is a libel against our patients. I, too, understand that psychiatric evaluation can be used cynically, to help blur lines of responsibility.

But why be so ready to condemn in a situation we both are quick to say we know little about? The constant lesson of psychotherapy is that the other is easy to mistake from any distance. How confident are you that the commissioner has no basis--no basis you and I would readily recognize--for his demand? Ought we not perhaps to be grateful when mental illness is taken into account?

My concern is that the Rocker incident is being used to further a neoconservative political agenda. I do not attribute this intention to you, but it is "in the air," as it was in the last discussion I had in Slate, on mental illness as a workplace disability. The neoconservative notion is that people should straighten up and fly right, take full responsibility for their acts lest the culture go to hell in a handbasket, etc., etc. I would prefer to keep that discussion at some distance from questions involving mental illness. If our culture is like Rome before the fall, it is not because we are too compassionate as regards psychiatric care. It might be because we pay too much attention to sports and sports celebrities.

If we are to continue this correspondence, I would like to move further from Rocker and ask you directly about racism. Do you believe that psychiatry has anything to say about racism or sectarianism? I am thinking of the whole range of theories from psychoanalysis to evolutionary psychology. Do you believe that there are instances when racism is a sign of mental illness? In your practice, how do you deal with prejudice? Do you imagine that as a racially prejudiced patient improves he will have less need to blame alien groups, or do you think such a patient would likely get better and still remain angrily prejudiced? More grandly, have you anything to say about racism as a force in international politics? Are we fated to see this millennium begin where the last ended, with a series of brutal ethnic conflicts?

It is good to hear from you, even in this somewhat adversarial setting.

Regards,
Peter