IN THE WAKE of September 11, what can a psychiatrist contribute to America's defense? Nothing, of course, to defend the nation from bombs, but something perhaps to defend it against confusion--and here America certainly needs help.
At the University of Pennsylvania, the provost called several neuroscientists together to consider whether the terrorists should be viewed as bad or mad: evildoers or sufferers from an exculpating mental disease. The group reached no conclusion, but one participant thought "brain images" might give the answer.
Editorialists argued about whether the atrocities should be considered acts of war or crimes. The blame-America-first group wanted the events called crimes and proposed prosecutions at the Hague. Some even opposed military retaliation, concerned that it would kill innocent people, produce martyrs, and generate recruits to the terrorist cause, along with endless war.
One distinguished Boston psychiatrist, speaking to anchorman Peter Jennings on ABC, explained the emotional distress of Americans as castration anxiety provoked by seeing the destruction of these two "phallic symbols" on the tip of Manhattan and suggested more psychoanalytic insight for us all.
Against this backdrop, there may be a place for some psychological realism--about what terrorists do, how they think, the steps necessary to protect ourselves from them, and the price those steps are likely to exact from us. The observations that follow spring from long clinical experience with similar matters. The layman should judge them by the light of common sense and what he knows about the ways of the world. Where these insights overlap with and reinforce ideas from other relevant sources--diplomatic, legal, economic, military--they may enhance confidence in the course of action we must take.
A REALISt can begin by rejecting the castration-anxiety idea--even though it provided the only humor in the whole affair. Americans felt emotional distress not because the towers of the World Trade Center were longer than they were wide, but because witnessing the cruel deaths of so many of our fellow citizens--horribly killed as they went about their daily lives, unsuspecting and unprotected--naturally provokes grief, anger, and fear. The brutal, indiscriminate slaughter of thousands of people in an instant, along with the sight of their bodies dropping like debris from dizzying heights, should produce pity, grief, rage in anyone with an ounce of fellow-feeling.
Next, having rejected a far-fetched theory, the pragmatic behavioral scientist sets aside for the time being questions about whether the actions at issue were mad or bad, crimes or acts of war, and examines the phenomenon of terrorism itself. The hijacking of airplanes and the piloting of them as missiles into large buildings, he notes, the deliberate targeting of civilians with the aim of producing fear, dread, and their political profits, is purposeful action. It is behavior.
Terrorist behavior is different from behavior such as eating, drinking, or sex in that it springs not from any innate drive or instinctive motive, but from a set of assumptions, attitudes, and beliefs that the actors have taken from their culture and share with many others. In contrast to their fellow citizens, however, these actors bring a ferocious passion to these ideas, a passion that leads them to ignore all other considerations such as personal safety, humane feelings, compromise, or temporizing alternatives.
In everyday speech, we call such people "fanatics." Psychiatrists, however, have their own, less loaded term. They say that people with this passionate attitude have an "overvalued idea." This conceptual distinction in mental life was first made by the late-19th-century German psychiatrist Carl Wernicke.
An overvalued idea is a thought shared with others in a society or culture but in the patient held with an intense emotional commitment capable of provoking dominant behaviors in its service. An overvalued idea differs from a delusion in that delusions are false ideas unique to the possessor, whereas overvalued ideas develop from assumptions and beliefs shared by many others. An overvalued idea differs, too, from an obsession in that, although it dominates the mind as an obsession does, the subject does not fight an overvalued idea but instead relishes, amplifies, and defends it. Indeed the idea fulminates in the mind of the subject, growing more dominant over time, more refined, and more resistant to challenge.
The major contemporary clinical disorder prompted by an overvalued idea is anorexia nervosa. Patients suffering from this illness take an idea common among young women in our society--thinner is better--and amplify it into a commitment so dominant that they starve themselves. At first an anorexic may claim that she is no different from any woman "thinking thin." As she persists with a worrisome starvation diet, she may justify eating only low fat salads as her way to "health." All therapeutic attempts to correct the behavior by dissuading her of this idea or uncovering its root cause fail, because the overvalued idea--one cannot be too thin--resists logical argument and compromise. Only stopping the behavior--which may require bringing the patient under 24 hour supervision--can lead the anorexic to recover.
But overvalued ideas also crop up outside the clinical setting. Two recent examples of individuals with overvalued ideas are the Unabomber and Jack Kevorkian. The Unabomber, preoccupied with what he saw as the materialism and destructive reliance on technology of our society, carried out vicious and cowardly letter bomb assaults against many defenseless people he associated with these enterprises. When his rambling, expansive, and tedious explanations were published in the Washington Post, many readers reported that they agreed with much of what he said.
Jack Kevorkian, despite killing scores of sick, emotionally vulnerable people in Michigan, persuaded several juries that his ideas about assisted suicide were well intended, even though contrary to law. Juries repeatedly freed him, until his indiscriminate killing and disdain for the courts became too much to stomach. Kevorkian and the Unabomber now sit in jail because only incarceration could keep them from continuing their violence. Neither of them is mad in the sense of being out of contact with reality, but both of them are bad because of their vile opinions and vicious behavior. Their "brain images" would make no difference to such judgments.
Three historical figures with overvalued ideas are Adolf Hitler with his anti-Semitism, Carrie Nation with her excessive devotion to temperance, and John Brown the abolitionist. Note that an overvalued idea may not in itself be wrong. Enough people agreed with Carrie Nation to pass the 18th Amendment; and all now agree with John Brown that slavery is evil, even though they deplore his assaults on defenseless farmers in Kansas and his killing spree at Harpers Ferry.
Overvalued ideas develop as ruling passions in some vulnerable individuals. Anorexics tend to be introverted young women, impressionable and easily conditioned by criticism of their physical appearance. The Unabomber, Jack Kevorkian, and the World Trade Center terrorists also tended to a personality type, arrogant and over-confident, suspicious of others, lacking in warmth, and tediously argumentative, shifting their ground to justify their fixed opinions when faced with strong objections. Cold, paranoid, and aggressive are terms that describe them. All efforts to correct the behavior of such people by addressing its "root causes" will fail because those "causes" are not actually motivating these people's behavior--their passions are.
DEFINING the September 11 attacks as behavior and the terrorists as men driven by the overvalued idea that America is a satanic nation whose citizens deserve death has implications for ways of defeating them. Here, recent psychiatric experience in treating behavior disorders can help.
Before about 1975, psychiatrists treating patients with destructive behaviors such as anorexia, alcoholism, and sexual disorders believed that one should first find the psychological roots of these behaviors by uncovering their meaning in the patient's mental conflicts. They thought that if these meaningful conflicts could be resolved, the abnormal behavior would wither away. This approach failed. Treatment programs for anorexia, for example, that ignored the failure to eat while attending to its meaning had death rates of between 10 percent and 15 percent of their patients. Alcoholics continued to drink, sex offenders to offend, even while their psychiatrists claimed to be reaching an understanding of their problems.
These results eventually caused doctors to try treatments that directly interrupted the harmful behavior. Anorexics were brought under dietary supervision, alcoholics were detoxified and sent to clinics implementing the 12 step program of Alcoholics Anonymous, and sex offenders were given testosterone-suppressing medications and vigorous group therapy concentrated on discrediting their activities and their justifications. These treatments worked far better: Many more anorexics, alcoholics, and sex offenders recovered.
This experience taught psychiatrists that behavior, once begun, maintains itself. Anorexics like to see their weight and dress size steadily shrink. Alcoholics, drug addicts, and sex offenders get immediate pleasurable reinforcement to continue their activities.
The same is true of terrorists: Their behavior is maintained by its consequences, especially the publicity that draws attention to the terrorist and his ideas. The Unabomber hated to be pushed off center stage by Timothy McVeigh and so killed two more people right after the Oklahoma City bombing. Jack Kevorkian started videotaping his killings for CBS TV when Michigan ceased bringing him to court. Although the September 11 terrorists died in their assault, they were sure of worldwide publicity for their actions and their views. Their success brought dancing to the streets in certain Muslim cities and recruits to their war against America--far more recruits than any "root cause" of terrorism, such as poverty or anger at Israel, had brought.
By implication, then, to stop terrorism, the American government should devote its energies to interrupting the terrorists' behavior in all its aspects. The government should use every reasonable method to apprehend individuals who could carry out terrorist actions. It should protect vulnerable sites and situations. And most crucially, it should alter the consequences of the September 11 assault: To our injuries it should promptly add injuries to those responsible for the attack.
This policy should be judged simply and tough-mindedly by its success in preventing more terrorist behavior. Preventing terrorist events must be our prime aim, not just because each atrocity is an evil in itself, but also because terrorism, like every other behavior, grows with its performance. To accommodate ourselves to it as a "fact of life" is to sustain it.
Our government can ignore certain matters for the moment. We should not expend much energy unearthing the "preconditions" for terrorism or pay credence to the justifying explanations offered by spokesmen for terrorists, no matter how reasonable they may seem. In truth, there are as many reasons offered for terrorism as there are terrorists--just as Alcoholics Anonymous has learned that there are as many reasons offered for drinking as there are drunks.
Stop the behavior first, and then, once peace is restored, we can deal with underlying issues. We will very likely find that many of the justifications now offered for terrorism were only rationalizations intended to excuse it. But we need not waste our energies trying to change the opinions of terrorists about us and our aims. These people, like the Unabomber and Jack Kevorkian, have overvalued ideas that are inaccessible to argument and persuasion. Their behavior will continue unless they are captured or killed.
Whether we call the terrorists' atrocities acts of war or crimes should be determined by one thing: which term best helps us stop the behavior. It seems more likely that we can keep terrorists from striking again if we treat them as soldiers captured committing acts of war on a battlefield of their own devising than if we treat them as individuals indicted for crimes and innocent until proven guilty. The IRA terrorists and sympathizers confined to the Maze prison at Long Kesh in Northern Ireland demanded the status of soldier-prisoners rather than criminal-prisoners. Certainly our laws can accommodate their Muslim counterparts.
FINALLY, what of the concern that military action will generate martyrs, draw recruits to the terrorists' cause, and produce endless conflict? Psychiatrists are familiar with this worry. It crops up whenever they propose a treatment aimed at interrupting a behavior. Patients and relatives all see and object to the intrusion on the patient's autonomy--such as the demand that the anorexic stay in a hospital so that her eating can be supervised or the requirement that the sex offender take libido-reducing medications. They wonder whether this will only cause patients to "dig in their heels" or "lose self-esteem." They propose that the psychiatrist should discover and resolve some meaningful conflict behind the behavior and so spare the patient a distressing treatment. Psychiatrists must explain to patients and their families that every effort to interrupt or change behavior elicits short-term losses, which are the price of recovery. Clinicians must weigh the inevitable short-term losses against the potential long-term gains.
Sometimes the likely losses are excessive. The classic illustration is stopping a lynch mob. One had best not attempt this alone, as the short-term cost to oneself could be terminal. Better to bring an army to stop a mob. Then, after order is restored and the hard feelings that are the short-term cost of preventing the crowd from working its will have dissipated, work to end the ideas and attitudes that support lynching.
In America's effort to interrupt the behavior of terrorists, many of whom are nestled in our country, the government may need laws that temporarily reduce civil liberties. We may have to go on a war footing, with special authority turned over temporarily to the military. We may have to sacrifice privileges in travel and tax relief. Discussion and careful judgments should aim to minimize and justify these losses. All such measures should be reassessed regularly. But they should be understood as the inevitable short-term costs of interrupting terrorist behavior.
The same sort of reasoning applies to our dealings with other countries. We have spent decades building up certain political and diplomatic relationships during peacetime. Some of these relationships will be damaged as we vigorously bring war to terrorists and their sympathizers and demand help from those who would call us friends. Again, we should consider what immediate losses might be irreparable and avoid actions that produce them. A nuclear winter would obviously be an unacceptable short-term cost. An increase in the vociferous complaining about America on Arab TV, however, can be expected and tolerated.
Some short-term costs deserve extensive discussion, informed by the concerns of diplomats, economists, lawyers, and others, before they are accepted or rejected. Psychiatrists have little to contribute to these proceedings other than to point out that the criterion for judging a policy is clear: If terrorist behavior continues, then--given that each successful attack makes subsequent attacks more likely--efforts to stop it should be enhanced, even though short-term losses will increase.
When we prevail in stopping terrorist behavior, we will likely discover much support for us in the oppressed Muslim world, support now hidden by the clamor for war. We can be sure that most Muslim mothers and fathers do not want their children lured to violent deaths in the name of some wild, overvalued idea promoted by charismatic tyrants whose own sons never get sent on suicide missions. Freedom will be welcomed once the majority can speak openly. We already see this in Afghanistan. The short-term losses of the bombing phase have been overcome by the joy of long-term release from the Taliban.
In sum, a realistic, pragmatic psychiatric depiction of terrorism--one that avoids dubious theories about meaning, as well as wishful thinking about how to manage it--can dispel confusion and offer a context for the understandings contributed by other disciplines. Thus, the proposals advanced here about managing terrorism fit with the idea of proceeding with a just war.
This approach allows us to assure our critics that, even as we know short-term losses to be inevitable when behavior must be changed, we also presume that many of the losses will be repaired by the long-term gains of success. All can agree that force and destruction are not enough for a sustained peace. Eventually we must repair some of what is damaged and develop our understanding of the grievances and concerns of our adversaries. To any who doubt our capacity to use more than force to gain a long-term peace, we can offer the historical instances of American magnanimity and devoted efforts at rebuilding where we had conquered, as after the Civil War and the two world wars of the 20th century.
We are a forgiving people, but now, at the start of the first war of the 21st century, is the time for action--action directed by a coherent view of our adversaries and of what they are trying to do to us. Churchill defined these matters better than any psychiatrist. "Our aim," he said, ". . . is victory, victory at all costs, victory in spite of all terror, victory, however long and hard the road may be; for without victory, there is no survival."
Paul R. McHugh is University Distinguished Service Professor of Psychiatry and Behavioral Science at the Johns Hopkins School of Medicine and former psychiatrist-in-chief of the Johns Hopkins Hospital.