An Interview of H. Steven Moffic, MD by Chuck Buck
BUCK: At this writing, Dr. Moffic, protests and riots continue in Minneapolis and elsewhere over the death of George Floyd, a black man who died last week while in police custody. A former police officer, Derek Chauvin, who is white, has now been charged with third-degree murder. He was seen on a since-gone-viral video, pressing his knee on Floyd’s neck for nearly nine minutes. What might be the underlying causes for the officer’s reactions?
DR. MOFFIC: Chuck, I’d like to be able to give you a quick Twitter response, like “Chauvin was a racist.” Or that the best predictor of violence is past violence, so he must have been violent before. However, the scope of the process and outcomes suggest that we have to look much further than the officer himself for the answers.
You’ll note, Chuck, that I am using the term “African-American” instead of black. I am taking that liberty because it connects better with history and the continent that we all came from. Using terms like “black, brown, red, and white,” instead of darker or lighter skin color, divides people. We are all people of color.
Historically, when people in Africa were forcibly and traumatically taken to America to be slaves, they were not considered to be equals and were murdered at the will of their owners. Even after slavery, lynchings became common in the South. In more recent times, we have had other violent tragedies similar to that of Mr. Floyd. And so, there is a history of condoning such violence of light-colored men toward African-American men, and sometimes women, too. That historical generational transmission and approval of such trauma can’t help but seep into our collective modern systems and psychology, leaving us with structural societal racism.
Therefore, to answer your question adequately, we have to have a general systems approach and ask even more questions. How is racism present in any city’s police system? What are the overt or covert messages about how to react to an African-American male for possible criminal behavior? Of course, police officers also have had violence perpetrated against them, which could leave some of them with more or less of a trigger finger that reacts too strongly and quickly to a perceived threat. Are police officers screened and helped to deal with their own trauma? In the situation of George Floyd, there were four officers involved, and at least three were holding him down, leading to a conclusion that such behavior was condoned in some way in that police department. That the Minneapolis police department has been led by a reforming African-American chief indicates how endemic and resistant to change racism may be.
As for Officer Derek Chauvin himself, what could have made anyone like him do what he did? Going from his childhood on, what were his parents’ attitudes toward African-Americans? In a study of what produced righteous gentiles in the Holocaust, the main factor was parents who taught tolerance of others. How about the influence of his peers and friends? What was his own history of being traumatized, whether in his police work or elsewhere? Did he ever have any psychiatric treatment? What sort of relationships did he have with loved ones? It wouldn’t surprise me at all that there would be warning signs that were ignored.
How about media coverage? Does their ongoing focus on the violence exploit our brain’s tendency to pay attention to divisiveness, repeatedly stimulating our fight-or-flight response? What should they cover, and what should we watch, that will unify rather than divide us?
However, there is one more factor to consider, and this is the timing. Why did these riots, consisting of people of various motivations, start now, and not after similar episodes? Most likely that is because we are still in the midst of the existential anxiety of the coronavirus pandemic, with its uncertainties, over 100,000 deaths, economic losses, and some desperation to get back to normal. Here we are in the beginning of summer, without the usual outlets of festivals and other big social gatherings that help us to gather peacefully in our diversity. We are devoid of the comfort of touch. Already, the deaths in the riots have surpassed that of Mr. Floyd. Not only that, but the physical closeness of the protesters, especially without masks, will inevitably lead to more infections and possible deaths. Right on the horizon is a presidential election in the midst of escalating “culture wars” once again, after a brief period of cooperation with stay-at-home guidelines.
BUCK: Meanwhile, the highest infection rate per capita in the country is among members of the Navajo Nation. So, these are two populations and two serious, albeit different, issues. Are there any similarities between the two?
DR. MOFFIC: That is such a fascinating and important connection you are making with African-Americans and the Navajo Nation, Chuck. Indeed, the plight of our Native Americans is usually ignored, but your question rightfully incorporates them into understanding this challenge.
Here, too, as in thinking about Mr. Chauvin, it is important to lay out the historical backdrop. Both population groups were clearly subject to major trauma and exclusion with the coming to America of European settlers, who ironically were seeking their own freedom in a philosophy of manifest destiny. One group, the African-Americans, were used as slaves for economic property and prosperity. The other, Native Americans, of which the Navajo Nation is one of numerous tribes, were killed in wars, and for those who survived, often resettled on reservations, sometimes far away from where they had lived, and far away from our major cities. In earlier times, African-Americans and Native Americans did develop important alliances, as signified by the Black Indians.
Moreover, that has been more or less the genocidal history of native peoples in most all countries taken over by European imperialism. Similarly, Africans also became slaves outside of America, too.
Although Native Americans are only about 1 percent of the population in Minneapolis, they represent a disproportionately high percentage of arrests for both minor and major offenses. African-Americans are still concentrated in the inner city and overrepresented in our jails and prisons.
Is it any wonder, then, that members of both populations have such high rates of coronavirus infection and deaths? How could it be otherwise, with more poverty, more crowding, more medical illness, and fewer medical resources? Not only do they have higher prevalence of the coronavirus, but also substance abuse and PTSD.
Of course, some Native-American tribes have done well, especially financially, with the development of casinos, as well as many individual African-Americans, since the civil rights era of protests, prayer, and “black power,” culminating in an African-American President! That should give us some realistic optimism for the future. The separation of Native Americans on reservations also has caused us to ignore their traditional spiritual methods of healing, caring for the environment, and generosity toward others.
BUCK: In Minneapolis, the word “rage” comes to mind when seeing reports of the violence. There is an ICD-10 code for anger and irritability. What about the Z codes for the social determinants of health (SDoH)? Are they applicable to the situation unfolding there?
DR. MOFFIC: I personally just had a surprising encounter with internal rage. When I was recently working on an article about the “Navajo Nation and Our Country in the Coronavirus Pandemic” for Psychiatric Times, I was writing the end of a sentence that came out like this: “the highest infection rage per capita in the country.” Perhaps you caught that “rage” should have been “rate,” in a Freudian slip of my computer keys. But what that told me is that I had some deep-seated rage about the way Native Americans and other minorities have been treated in the country, and to which I devoted my career trying to care for the underserved and misserved.
Could my “rage” fit any category in ICD (International Classification of Diseases)-10, such as the R codes? The R45 codes are for symptoms and signs involving cognition, perception, emotional state, and behavior. So yes, I may fit R45.4, Irritability and anger. Then, again, I am fortunate not to have been “a rage almost all the time,” as the writer James Baldwin conveyed about the “Negro” in the early 1960s. Baldwin then went on to say that “the first problem is how to control that rage so it won’t destroy you.” The “you” may potentially be all of us.
There is no ICD-10 code or DSM 5 code for racism, per se. Though there have been times of debating whether racism should be a diagnosable disorder in a DSM, the decision has always been no. Reasons include that racism is too ubiquitous, as proven by implicit bias tests; plus, where do you draw the line between it being normal and minor versus abnormal and major? Yet, although there is yet no classification for social pathology, racism may better fit that, conceptually.
That leaves us with the Z codes in ICD-10 for the social determinants of health. Interestingly, studies indicate that these codes have been underused, which is consistent with less attention being paid to the “social” part of our medical bio-psycho-social model. That is why elsewhere I have recommended that the 2020s be deemed to be the Decade of the Social Determinants of Health for psychiatry. Clearly, the code Z60, “Problems related to social environment,” connects to racism.
BUCK: If you were the nation’s chief psychiatrist, like the U.S. Surgeon General, how would you diagnose the country’s mental health at this time?
DR. MOFFIC: Whew, I got anxious, Chuck, as soon as I read that question. What a privilege and responsibility that would be. Actually, I’ve come to think that we do need a U.S. Psychiatrist General, so to speak, along with a U.S. Surgeon General, because it is apparent that most Surgeon General physicians give short shrift to psychiatry. And now is a time in which we seem especially needed, yet generally we are not part of the societal discussion and search for solutions.
Let’s say that justice has been served. What next? Let’s pretend I am the nation’s chief psychiatrist for now.
Sometimes, when people perceive they are beginning to have major mental health problems, they say that they are “cracking up” or beginning to crack up. Apply that to our country, and we can say our country’s mental health is showing cracks. That will not necessarily turn out badly if we apply the Japanese concept of kintsugi. The Japanese, as we recall, were rounded up and isolated in the United States in World War II, and later did receive some financial reparations under President Reagan (or at least some initial financial support, that seem needed for Native Americans and African-Americans). In kintsugi, broken ceramics are not thrown away, but repaired by using a precious metal like liquid gold to bring the pieces together and reunify them even more beautifully. That concept is not unlike the words that Leonard Cohen sang in his song “Anthem:”
“There is a crack, a crack in everything/That’s how the light comes in”
We psychiatrists are supposed to be able to supply the light of insight to our patients’ conflicts in order to help them resolve conflicts. We also know that human nature is prone to fear the “other,” but that can be overcome by using our human pre-frontal cortex to reassess our emotional responses, if necessary. We know that implicit bias tests can help us locate where the light needs to come in. We know that, as Abraham Maslow conveyed in his pyramid of psychological needs, that self-actualization can only occur after the needs of safety, security, nourishment, belonging, and self-esteem are met.
So, as a first step in being a U.S. Surgeon or Psychiatrist General, I might appoint an expert in conflict resolution. All other things being relatively equal, I would want that to be a woman. Why? It wasn’t for no good reason that Mr. Floyd was calling out for “mama, mama” right before he died because he couldn’t breathe. As a primal plea, it didn’t matter that she was already dead herself. Mothers are our first and most major caregivers, just about from the first time we breathe in life. We call the earth Mother Earth. We are bereft of woman leaders in most countries, an exception being New Zealand, where their leader is generally trusted and has shown much success in filling in the intercultural cracks in the people there with psychological gold, not fools’ gold.
We do have an African American Surgeon General. Perhaps in the spirit of cultural diversity and cultural inclusion, our Chief Conflict Negotiator might be a Native-American woman who can connect with our desire for goodness and healing.
Like all crises, as the Chinese character for crisis is said to represent, we have the potential for danger or opportunity. Let’s try to use this to integrate all social groups that are relatively excluded from our society. Certainly, that needs to start with African-Americans and Native Americans, but also the Asian-Americans harassed for their association with what our leadership called the “Chinese Virus,” when it is a human virus; the Hispanics, who also have a higher rate of death from the virus; the Jewish people who are being blamed in conspiracy theories; the LGBTQ, the elderly, and any other group that tends to be scapegoated and suffer disparities in health and mental health. There is a saying of leaving no child behind; we also need to leave no group behind.
If we can’t repair our cracks to make our relationships stronger and more resilient, then the unity of what is called the United States is as counterfeit as the counterfeit $20 bill that led to the police call on Mr. Floyd.
A few days into this social unrest, just as I was finishing answering your questions, Chuck, we launched a new era in space. We looked up at the first space launch of U.S. astronauts on American soil in nine years, as well as for the first time, successfully using American-made private technology. Our elders may recall how our original space program in the 60s and 70s was a beacon of light in otherwise tumultuous times. Nevertheless, we shouldn’t downplay the cooperation we have had with the Russians in launching into space and to the International Space Station.
Perhaps we should use that sort of space innovation to launch a new era on race that will be proactive, not just reactive. Several years back, the stagnant NASA space program was accelerated when an open platform asked the world to help, and 3,000 people did so. So, besides adding a new kind of psychiatric leader, we need to hear from the public. Why not ask them for advice about how to reduce racism, including how structural racism is addressed where they work? We now have an International Space Station. Maybe we need international race reconciliation. By George, would that not be the way to honor the life of Mr. Floyd, not via riots wherein others are killed too?
The way to reconciliation between, and even within, so-called races, tribes, and other cultural and religious groups of people that are much more alike than different, is not rocket science, is it? Or is it more complicated than rocket science, because this is brain science? Maybe we have more questions than answers, but we won’t find the answers unless we try some new and innovative things, before we lapse back into the usual when the current crisis remits. There will be inevitable failures, but like the space program, we need to learn from these failures and adjust accordingly.
H. Steven Moffic, MD, is an award-winning author whose fifth book, “The Ethical Way: Challenges & Solutions for Managed Behavioral Health,” is considered a seminal study on healthcare ethics. Always in demand as a writer, Dr. Moffic has attracted a national audience with his three blogs: Psychiatry Times, Behavior Healthcare, and Over 65. H. Dr. Moffic, who is also a popular guest on Talk Ten Tuesdays, recently received the Administrative Psychiatry Award from the American Psychiatric Association (APA) and the American Association of Psychiatrist Administrators (AAPA).