Current Psychiatry

The therapeutic alliance (interchangeably, the therapeutic relationship) is a subjective measure of the relationship between a clinician and a patient. It is an indicator of clinical trustworthiness: what a patient is referring to when she (he) expresses trust in her provider. The therapeutic alliance also is known as the working alliance, the therapeutic bond, and the helping alliance,¹ and it is an important factor in patient satisfaction ratings—the gauging parameter through which clinicians and institutions measure the quality of care they provide.²

A therapeutic alliance is essential to the delivery of psychiatric care. Itself, it can be a healing factor³ and has been linked to patients’ adherence to treatment and continuation of care.⁴ For example, psychiatric patients who perceive the therapeutic alliance more positively have:

• a better long-term health outcome after discharge
• a significantly better psychological quality of life⁵
• a better follow-up record of outpatient care after inpatient discharge^4,6
• better adherence to prescribed treatment⁷
• a reduced likelihood of relapse and readmission.⁶

Patient satisfaction is an indirect measure of the therapeutic alliance; many variables of the therapeutic relationship can affect that satisfaction. In this article, we call those variables patient factors and delivery factors; our aim, using the example of 2 hypothetical cases, is to highlight their importance in patients’ perception of the therapeutic alliance they have with providers.

CASE Paranoid delusions lead to termination of care
Mr. D, age 21, unmarried, unemployed, and with no medical or psychiatric history, is transferred from the medical floor to the inpatient psychiatric unit after coming to the hospital’s emergency room (ER) with a report of chest pain. Workup on the medical floor was negative for a serious cardiac event.

On questioning, Mr. D tells the team that his chest pain is caused by National Security Agency (NSA) satellites “locking” onto his heart and causing veins in his heart to “pop.”

Mr. D agrees to be transferred to the psychiatric unit. Once there, however, he refuses to take the psychotropic medications that have been prescribed or to comply with the balance of the treatment protocol. He is adamant about the influence of NSA satellites, and requests daily imaging to locate evidence of the path of the satellite tracking device that he claims is inside his body.

The treatment team repeatedly refuses to comply with Mr. D’s demand for imaging. He becomes angry and says that he does not think he is getting proper care because the nature of his problem is medical, not psychiatric.

Mr. D repeatedly asserts that he will not take any of the psychotropic medications that have been prescribed for him and will not attend follow-up appointments with the psychiatry team because he does not need treatment. He accuses the treatment team of conspiring with the NSA and causing his chest pain.

Mr. D asks to be discharged.

Patient factors: Unmodifiable and static
As Mr. D’s case exemplifies, patient factors are a set of elements, intrinsic to a given patient, that affect that patient’s perceptions independent of the quality of the care delivered. Included among patient factors are personal sociodemographic and psychopathological characteristics. These patient factors influence the therapeutic relationship in many ways.

Sociodemographics. It has been reported that patients of minority heritage and those who are male, young, and unmarried tend to be less satisfied with medical treatment in general and with psychiatric inpatient treatment in particular.^8,9 Females and older patients, on the other hand, are more likely to be satisfied with the perceived delivery of care and the therapeutic alliance.^8-10

Psychopathology affects patients’ perception of the delivery of care and the therapeutic alliance. Patients who are highly distressed psychologically and those who suffer chronic psychiatric illness, for example, tend to perceive themselves as having benefitted less from treatment than healthier counterparts.^9,11 Such patients also tend to see their therapeutic outcome in a much less favorable light.^11,12 Patients with borderline personality disorder and antisocial personality disorder^12-14 and those hospitalized involuntarily⁸ tend to (1) be less satisfied with their therapeutic outcome and (2) see the therapeutic alliance less favorably compared with those who do not have these psychopathologies.

CASE Denied a blanket, she feels like a 'burden'
Ms. X, age 34, married and a homemaker, has a history of bipolar I disorder. She brings herself to the ER complaining of depression and suicidal ideation.

After Ms. X is seen by the psychiatry consult service in the ER, she reports that she feels frustrated and angry and thinks that the hospital’s physicians do not really want to help her. She states that she felt that the ER staff “dismissed” her, in part because she spent 4 hours in the ER waiting room before she was given a bed.

Ms. X says that, once she was placed in a room, she felt that the nursing staff and medical assistants ignored her because they did not give her the extra blanket she requested. She said she was cold as a result, while she waited to see the psychiatrist and the ER physician.

Ms. X states that she came to the ER seeking help because she felt depressed and thought that no one cared about her. Coming to the hospital made her feel worse, after all, she said, because there she has been treated like she is a burden, much like she is treated at home.

Delivery factors: Amenable to change
These mutable elements of the therapeutic alliance are dependent on the quality of the care, as they were in Ms. X’s case; they can be changed. Included among delivery factors is the quality of the relationship between provider and patient—that is, how the psychiatrist and the nursing staff relate to the patient.

Perceptions are key. Delivery factors rank as one of the most important elements that influence the patient’s perception of the therapeutic alliance.^15,16 Given the objectives of psychiatric treatment—to relieve psychiatric symptoms, improve patient functioning, and alleviate psychological distress—it is no wonder that delivery factors play an important role in the perception of the therapeutic alliance: The quality of the provider−patient relationship is the axis around which treatment takes place. This relationship constantly ranks high on surveys of what is important to patients¹⁵—especially in an inpatient psychiatric setting.

Attitudes are modifiable. From the treating psychiatrist to nursing and ancillary staffs, all team members need to express attitudes and behaviors that reflect positively on the patient.¹⁷ Behaviors such as involving the patient fully in therapeutic decision-making; exuding an attitude of caring, equanimity, empathy, sincerity, and respect; and listening to the patient’s concerns can go a long way to improving the therapeutic relationship. Displaying such attitudes and behaviors also help improve the larger vision of psychiatric intervention: to bring about positive therapeutic changes.

Summing up
Ratings of the therapeutic alliance are the currency of patient satisfaction. The value of this therapeutic currency is affected by delivery factors, which are adjustable, and patient factors, which are not. Taken together, however, both types of factors are the foundation of patient satisfaction and the therapeutic alliance.

The therapeutic alliance (interchangeably, the therapeutic relationship) is a subjective measure of the relationship between a clinician and a patient. It is an indicator of clinical trustworthiness: what a patient is referring to when she (he) expresses trust in her provider. The therapeutic alliance also is known as the working alliance, the therapeutic bond, and the helping alliance,¹ and it is an important factor in patient satisfaction ratings—the gauging parameter through which clinicians and institutions measure the quality of care they provide.²

A therapeutic alliance is essential to the delivery of psychiatric care. Itself, it can be a healing factor³ and has been linked to patients’ adherence to treatment and continuation of care.⁴ For example, psychiatric patients who perceive the therapeutic alliance more positively have:

• a better long-term health outcome after discharge
• a significantly better psychological quality of life⁵
• a better follow-up record of outpatient care after inpatient discharge^4,6
• better adherence to prescribed treatment⁷
• a reduced likelihood of relapse and readmission.⁶

Patient satisfaction is an indirect measure of the therapeutic alliance; many variables of the therapeutic relationship can affect that satisfaction. In this article, we call those variables patient factors and delivery factors; our aim, using the example of 2 hypothetical cases, is to highlight their importance in patients’ perception of the therapeutic alliance they have with providers.

CASE Paranoid delusions lead to termination of care
Mr. D, age 21, unmarried, unemployed, and with no medical or psychiatric history, is transferred from the medical floor to the inpatient psychiatric unit after coming to the hospital’s emergency room (ER) with a report of chest pain. Workup on the medical floor was negative for a serious cardiac event.

On questioning, Mr. D tells the team that his chest pain is caused by National Security Agency (NSA) satellites “locking” onto his heart and causing veins in his heart to “pop.”

Mr. D agrees to be transferred to the psychiatric unit. Once there, however, he refuses to take the psychotropic medications that have been prescribed or to comply with the balance of the treatment protocol. He is adamant about the influence of NSA satellites, and requests daily imaging to locate evidence of the path of the satellite tracking device that he claims is inside his body.

The treatment team repeatedly refuses to comply with Mr. D’s demand for imaging. He becomes angry and says that he does not think he is getting proper care because the nature of his problem is medical, not psychiatric.

Mr. D repeatedly asserts that he will not take any of the psychotropic medications that have been prescribed for him and will not attend follow-up appointments with the psychiatry team because he does not need treatment. He accuses the treatment team of conspiring with the NSA and causing his chest pain.

Mr. D asks to be discharged.

Patient factors: Unmodifiable and static
As Mr. D’s case exemplifies, patient factors are a set of elements, intrinsic to a given patient, that affect that patient’s perceptions independent of the quality of the care delivered. Included among patient factors are personal sociodemographic and psychopathological characteristics. These patient factors influence the therapeutic relationship in many ways.

Sociodemographics. It has been reported that patients of minority heritage and those who are male, young, and unmarried tend to be less satisfied with medical treatment in general and with psychiatric inpatient treatment in particular.^8,9 Females and older patients, on the other hand, are more likely to be satisfied with the perceived delivery of care and the therapeutic alliance.^8-10

Psychopathology affects patients’ perception of the delivery of care and the therapeutic alliance. Patients who are highly distressed psychologically and those who suffer chronic psychiatric illness, for example, tend to perceive themselves as having benefitted less from treatment than healthier counterparts.^9,11 Such patients also tend to see their therapeutic outcome in a much less favorable light.^11,12 Patients with borderline personality disorder and antisocial personality disorder^12-14 and those hospitalized involuntarily⁸ tend to (1) be less satisfied with their therapeutic outcome and (2) see the therapeutic alliance less favorably compared with those who do not have these psychopathologies.

CASE Denied a blanket, she feels like a 'burden'
Ms. X, age 34, married and a homemaker, has a history of bipolar I disorder. She brings herself to the ER complaining of depression and suicidal ideation.

After Ms. X is seen by the psychiatry consult service in the ER, she reports that she feels frustrated and angry and thinks that the hospital’s physicians do not really want to help her. She states that she felt that the ER staff “dismissed” her, in part because she spent 4 hours in the ER waiting room before she was given a bed.

Ms. X says that, once she was placed in a room, she felt that the nursing staff and medical assistants ignored her because they did not give her the extra blanket she requested. She said she was cold as a result, while she waited to see the psychiatrist and the ER physician.

Ms. X states that she came to the ER seeking help because she felt depressed and thought that no one cared about her. Coming to the hospital made her feel worse, after all, she said, because there she has been treated like she is a burden, much like she is treated at home.

Delivery factors: Amenable to change
These mutable elements of the therapeutic alliance are dependent on the quality of the care, as they were in Ms. X’s case; they can be changed. Included among delivery factors is the quality of the relationship between provider and patient—that is, how the psychiatrist and the nursing staff relate to the patient.

Perceptions are key. Delivery factors rank as one of the most important elements that influence the patient’s perception of the therapeutic alliance.^15,16 Given the objectives of psychiatric treatment—to relieve psychiatric symptoms, improve patient functioning, and alleviate psychological distress—it is no wonder that delivery factors play an important role in the perception of the therapeutic alliance: The quality of the provider−patient relationship is the axis around which treatment takes place. This relationship constantly ranks high on surveys of what is important to patients¹⁵—especially in an inpatient psychiatric setting.

Attitudes are modifiable. From the treating psychiatrist to nursing and ancillary staffs, all team members need to express attitudes and behaviors that reflect positively on the patient.¹⁷ Behaviors such as involving the patient fully in therapeutic decision-making; exuding an attitude of caring, equanimity, empathy, sincerity, and respect; and listening to the patient’s concerns can go a long way to improving the therapeutic relationship. Displaying such attitudes and behaviors also help improve the larger vision of psychiatric intervention: to bring about positive therapeutic changes.

Summing up
Ratings of the therapeutic alliance are the currency of patient satisfaction. The value of this therapeutic currency is affected by delivery factors, which are adjustable, and patient factors, which are not. Taken together, however, both types of factors are the foundation of patient satisfaction and the therapeutic alliance.

The therapeutic alliance (interchangeably, the therapeutic relationship) is a subjective measure of the relationship between a clinician and a patient. It is an indicator of clinical trustworthiness: what a patient is referring to when she (he) expresses trust in her provider. The therapeutic alliance also is known as the working alliance, the therapeutic bond, and the helping alliance,¹ and it is an important factor in patient satisfaction ratings—the gauging parameter through which clinicians and institutions measure the quality of care they provide.²

A therapeutic alliance is essential to the delivery of psychiatric care. Itself, it can be a healing factor³ and has been linked to patients’ adherence to treatment and continuation of care.⁴ For example, psychiatric patients who perceive the therapeutic alliance more positively have:

• a better long-term health outcome after discharge
• a significantly better psychological quality of life⁵
• a better follow-up record of outpatient care after inpatient discharge^4,6
• better adherence to prescribed treatment⁷
• a reduced likelihood of relapse and readmission.⁶

Patient satisfaction is an indirect measure of the therapeutic alliance; many variables of the therapeutic relationship can affect that satisfaction. In this article, we call those variables patient factors and delivery factors; our aim, using the example of 2 hypothetical cases, is to highlight their importance in patients’ perception of the therapeutic alliance they have with providers.

CASE Paranoid delusions lead to termination of care
Mr. D, age 21, unmarried, unemployed, and with no medical or psychiatric history, is transferred from the medical floor to the inpatient psychiatric unit after coming to the hospital’s emergency room (ER) with a report of chest pain. Workup on the medical floor was negative for a serious cardiac event.

On questioning, Mr. D tells the team that his chest pain is caused by National Security Agency (NSA) satellites “locking” onto his heart and causing veins in his heart to “pop.”

Mr. D agrees to be transferred to the psychiatric unit. Once there, however, he refuses to take the psychotropic medications that have been prescribed or to comply with the balance of the treatment protocol. He is adamant about the influence of NSA satellites, and requests daily imaging to locate evidence of the path of the satellite tracking device that he claims is inside his body.

The treatment team repeatedly refuses to comply with Mr. D’s demand for imaging. He becomes angry and says that he does not think he is getting proper care because the nature of his problem is medical, not psychiatric.

Mr. D repeatedly asserts that he will not take any of the psychotropic medications that have been prescribed for him and will not attend follow-up appointments with the psychiatry team because he does not need treatment. He accuses the treatment team of conspiring with the NSA and causing his chest pain.

Mr. D asks to be discharged.

Patient factors: Unmodifiable and static
As Mr. D’s case exemplifies, patient factors are a set of elements, intrinsic to a given patient, that affect that patient’s perceptions independent of the quality of the care delivered. Included among patient factors are personal sociodemographic and psychopathological characteristics. These patient factors influence the therapeutic relationship in many ways.

Sociodemographics. It has been reported that patients of minority heritage and those who are male, young, and unmarried tend to be less satisfied with medical treatment in general and with psychiatric inpatient treatment in particular.^8,9 Females and older patients, on the other hand, are more likely to be satisfied with the perceived delivery of care and the therapeutic alliance.^8-10

Psychopathology affects patients’ perception of the delivery of care and the therapeutic alliance. Patients who are highly distressed psychologically and those who suffer chronic psychiatric illness, for example, tend to perceive themselves as having benefitted less from treatment than healthier counterparts.^9,11 Such patients also tend to see their therapeutic outcome in a much less favorable light.^11,12 Patients with borderline personality disorder and antisocial personality disorder^12-14 and those hospitalized involuntarily⁸ tend to (1) be less satisfied with their therapeutic outcome and (2) see the therapeutic alliance less favorably compared with those who do not have these psychopathologies.

CASE Denied a blanket, she feels like a 'burden'
Ms. X, age 34, married and a homemaker, has a history of bipolar I disorder. She brings herself to the ER complaining of depression and suicidal ideation.

After Ms. X is seen by the psychiatry consult service in the ER, she reports that she feels frustrated and angry and thinks that the hospital’s physicians do not really want to help her. She states that she felt that the ER staff “dismissed” her, in part because she spent 4 hours in the ER waiting room before she was given a bed.

Ms. X says that, once she was placed in a room, she felt that the nursing staff and medical assistants ignored her because they did not give her the extra blanket she requested. She said she was cold as a result, while she waited to see the psychiatrist and the ER physician.

Ms. X states that she came to the ER seeking help because she felt depressed and thought that no one cared about her. Coming to the hospital made her feel worse, after all, she said, because there she has been treated like she is a burden, much like she is treated at home.

Delivery factors: Amenable to change
These mutable elements of the therapeutic alliance are dependent on the quality of the care, as they were in Ms. X’s case; they can be changed. Included among delivery factors is the quality of the relationship between provider and patient—that is, how the psychiatrist and the nursing staff relate to the patient.

Perceptions are key. Delivery factors rank as one of the most important elements that influence the patient’s perception of the therapeutic alliance.^15,16 Given the objectives of psychiatric treatment—to relieve psychiatric symptoms, improve patient functioning, and alleviate psychological distress—it is no wonder that delivery factors play an important role in the perception of the therapeutic alliance: The quality of the provider−patient relationship is the axis around which treatment takes place. This relationship constantly ranks high on surveys of what is important to patients¹⁵—especially in an inpatient psychiatric setting.

Attitudes are modifiable. From the treating psychiatrist to nursing and ancillary staffs, all team members need to express attitudes and behaviors that reflect positively on the patient.¹⁷ Behaviors such as involving the patient fully in therapeutic decision-making; exuding an attitude of caring, equanimity, empathy, sincerity, and respect; and listening to the patient’s concerns can go a long way to improving the therapeutic relationship. Displaying such attitudes and behaviors also help improve the larger vision of psychiatric intervention: to bring about positive therapeutic changes.

Summing up
Ratings of the therapeutic alliance are the currency of patient satisfaction. The value of this therapeutic currency is affected by delivery factors, which are adjustable, and patient factors, which are not. Taken together, however, both types of factors are the foundation of patient satisfaction and the therapeutic alliance.

A day in the psychiatry clinic? No—just scenes from that high-stakes festival of intense human competitiveness gone awry: the current presidential election. Alas, we have no FDA-approved treatments for any of these unusual political behaviors.

More stunning is how blind some loyal voters are to the flaws of their candidate of choice. They seem to be joyfully intoxicated by sharing the unusual beliefs of the candidate, in a cultish folie en masse of epidemic proportion.

Other (rational) voters are stunned and jarred by what they see and hear; they appear to be in need of Rx: an intellectual antiemetic.

The rise of uber-narcissism
A certain amount of narcissism is, understandably, necessary to run for the nation’s highest office and to believe, against all odds, that winning is certain despite microscopic favorability in the polls. In this election cycle, the cup of narcissism has run over; yet, to adoring fans, narcissism only adds a wondrous halo to their candidate.

The history of the United States is rife with similar behavior by elected officials, including our revered Founding Fathers.¹ But today’s psychiatrists, witnessing this national charade, are perplexed and question the rationality of the national psyche. Established rules for seeking the Presidency have been demolished and the show goes on as if heightened narcissism is the new normal in human behavior.

Giving voice to my colleagues’ consternation
Here are a few thoughts that might cross the mind of psychiatrists as they watch, with a frown and pursed lips, this unconventional election cycle:

From a psychoanalytic perspective, the id has left the ego in its dust, and the super-ego went home to hide.

When boorishness trumps civility, hillaryous consequences ensue.

The gullibility of voters deserves serious scientific study. Jeste and Harris² reviewed the evidence for a neurobiology of wisdom; The National Institutes of Health should fund research into how some voters believe the candidate of their choice will provide them with everything they wish. The chicken in every pot expands to 100 in every pot, and money grows on trees (at least on 1% of the forest!).

From an evolutionary standpoint, survival of the fittest has become survival of the most bombastic.

The zeitgeist reflects an electorate that oscillates agonizingly from surprise to anger to cynicism to disgust.

The traditional internal conflict (studied by political scientists) of choosing between 2 reasonably meritorious candidates has been transformed into a conflict over whether to vote at all.

This is the least nuanced presidential campaign—ever.

All decision-making in politics is unconscious, political scientist Jon A. Krosnick proposed. In this election, however, candidates’ enunciations are so overt that it’s hard to believe there’s anything left in the unconscious. Freud spoke of the “primary process” arising from the unconscious; he definitely was not referring to the primary process we experienced during this election cycle.

From a neuropsychiatric perspective, the limbic system has kicked the cortex in the metaphorical derrière in this election campaign.

Unabashed display of character flaws, personal shortcomings, and biases prove that anyone can run for president in a democracy, and that some voters will display a flight of reason and vote for a flawed candidate.

Even an inept demagogue can be misperceived as a savior by followers. Some voters could use a few sessions of insight-oriented therapy or cognitive-behavioral therapy for their unrealistic expectations.

It is dizzying, mentally, to watch candidates’ verbal acrobatics as they try to pass several litmus tests to satisfy disparate demands of sundry constituencies and mendaciously flip-flop on many issues—ignoring the fact that everything they have said was recorded or videotaped. Intellectual transvestism is a political sin, and sinners abound.

Oh, for a Jenner, Pasteur, or Sabin to discover vaccines for the intellect
Writing this editorial has been therapeutic. It feels good to ventilate about this bizarre election process that has the nation in its grip. I would feel much better if neuroscientists would develop and license vaccines that would broadly inoculate candidates against demagoguery, dishonesty, and pandering and voters against mind-boggling gullibility.

That would make elections so boring. But also so on-label….

A day in the psychiatry clinic? No—just scenes from that high-stakes festival of intense human competitiveness gone awry: the current presidential election. Alas, we have no FDA-approved treatments for any of these unusual political behaviors.

More stunning is how blind some loyal voters are to the flaws of their candidate of choice. They seem to be joyfully intoxicated by sharing the unusual beliefs of the candidate, in a cultish folie en masse of epidemic proportion.

Other (rational) voters are stunned and jarred by what they see and hear; they appear to be in need of Rx: an intellectual antiemetic.

The rise of uber-narcissism
A certain amount of narcissism is, understandably, necessary to run for the nation’s highest office and to believe, against all odds, that winning is certain despite microscopic favorability in the polls. In this election cycle, the cup of narcissism has run over; yet, to adoring fans, narcissism only adds a wondrous halo to their candidate.

The history of the United States is rife with similar behavior by elected officials, including our revered Founding Fathers.¹ But today’s psychiatrists, witnessing this national charade, are perplexed and question the rationality of the national psyche. Established rules for seeking the Presidency have been demolished and the show goes on as if heightened narcissism is the new normal in human behavior.

Giving voice to my colleagues’ consternation
Here are a few thoughts that might cross the mind of psychiatrists as they watch, with a frown and pursed lips, this unconventional election cycle:

From a psychoanalytic perspective, the id has left the ego in its dust, and the super-ego went home to hide.

When boorishness trumps civility, hillaryous consequences ensue.

The gullibility of voters deserves serious scientific study. Jeste and Harris² reviewed the evidence for a neurobiology of wisdom; The National Institutes of Health should fund research into how some voters believe the candidate of their choice will provide them with everything they wish. The chicken in every pot expands to 100 in every pot, and money grows on trees (at least on 1% of the forest!).

From an evolutionary standpoint, survival of the fittest has become survival of the most bombastic.

The zeitgeist reflects an electorate that oscillates agonizingly from surprise to anger to cynicism to disgust.

The traditional internal conflict (studied by political scientists) of choosing between 2 reasonably meritorious candidates has been transformed into a conflict over whether to vote at all.

This is the least nuanced presidential campaign—ever.

All decision-making in politics is unconscious, political scientist Jon A. Krosnick proposed. In this election, however, candidates’ enunciations are so overt that it’s hard to believe there’s anything left in the unconscious. Freud spoke of the “primary process” arising from the unconscious; he definitely was not referring to the primary process we experienced during this election cycle.

From a neuropsychiatric perspective, the limbic system has kicked the cortex in the metaphorical derrière in this election campaign.

Unabashed display of character flaws, personal shortcomings, and biases prove that anyone can run for president in a democracy, and that some voters will display a flight of reason and vote for a flawed candidate.

Even an inept demagogue can be misperceived as a savior by followers. Some voters could use a few sessions of insight-oriented therapy or cognitive-behavioral therapy for their unrealistic expectations.

It is dizzying, mentally, to watch candidates’ verbal acrobatics as they try to pass several litmus tests to satisfy disparate demands of sundry constituencies and mendaciously flip-flop on many issues—ignoring the fact that everything they have said was recorded or videotaped. Intellectual transvestism is a political sin, and sinners abound.

Oh, for a Jenner, Pasteur, or Sabin to discover vaccines for the intellect
Writing this editorial has been therapeutic. It feels good to ventilate about this bizarre election process that has the nation in its grip. I would feel much better if neuroscientists would develop and license vaccines that would broadly inoculate candidates against demagoguery, dishonesty, and pandering and voters against mind-boggling gullibility.

That would make elections so boring. But also so on-label….

A day in the psychiatry clinic? No—just scenes from that high-stakes festival of intense human competitiveness gone awry: the current presidential election. Alas, we have no FDA-approved treatments for any of these unusual political behaviors.

More stunning is how blind some loyal voters are to the flaws of their candidate of choice. They seem to be joyfully intoxicated by sharing the unusual beliefs of the candidate, in a cultish folie en masse of epidemic proportion.

Other (rational) voters are stunned and jarred by what they see and hear; they appear to be in need of Rx: an intellectual antiemetic.

The rise of uber-narcissism
A certain amount of narcissism is, understandably, necessary to run for the nation’s highest office and to believe, against all odds, that winning is certain despite microscopic favorability in the polls. In this election cycle, the cup of narcissism has run over; yet, to adoring fans, narcissism only adds a wondrous halo to their candidate.

The history of the United States is rife with similar behavior by elected officials, including our revered Founding Fathers.¹ But today’s psychiatrists, witnessing this national charade, are perplexed and question the rationality of the national psyche. Established rules for seeking the Presidency have been demolished and the show goes on as if heightened narcissism is the new normal in human behavior.

Giving voice to my colleagues’ consternation
Here are a few thoughts that might cross the mind of psychiatrists as they watch, with a frown and pursed lips, this unconventional election cycle:

From a psychoanalytic perspective, the id has left the ego in its dust, and the super-ego went home to hide.

When boorishness trumps civility, hillaryous consequences ensue.

The gullibility of voters deserves serious scientific study. Jeste and Harris² reviewed the evidence for a neurobiology of wisdom; The National Institutes of Health should fund research into how some voters believe the candidate of their choice will provide them with everything they wish. The chicken in every pot expands to 100 in every pot, and money grows on trees (at least on 1% of the forest!).

From an evolutionary standpoint, survival of the fittest has become survival of the most bombastic.

The zeitgeist reflects an electorate that oscillates agonizingly from surprise to anger to cynicism to disgust.

The traditional internal conflict (studied by political scientists) of choosing between 2 reasonably meritorious candidates has been transformed into a conflict over whether to vote at all.

This is the least nuanced presidential campaign—ever.

All decision-making in politics is unconscious, political scientist Jon A. Krosnick proposed. In this election, however, candidates’ enunciations are so overt that it’s hard to believe there’s anything left in the unconscious. Freud spoke of the “primary process” arising from the unconscious; he definitely was not referring to the primary process we experienced during this election cycle.

From a neuropsychiatric perspective, the limbic system has kicked the cortex in the metaphorical derrière in this election campaign.

Unabashed display of character flaws, personal shortcomings, and biases prove that anyone can run for president in a democracy, and that some voters will display a flight of reason and vote for a flawed candidate.

Even an inept demagogue can be misperceived as a savior by followers. Some voters could use a few sessions of insight-oriented therapy or cognitive-behavioral therapy for their unrealistic expectations.

It is dizzying, mentally, to watch candidates’ verbal acrobatics as they try to pass several litmus tests to satisfy disparate demands of sundry constituencies and mendaciously flip-flop on many issues—ignoring the fact that everything they have said was recorded or videotaped. Intellectual transvestism is a political sin, and sinners abound.

Oh, for a Jenner, Pasteur, or Sabin to discover vaccines for the intellect
Writing this editorial has been therapeutic. It feels good to ventilate about this bizarre election process that has the nation in its grip. I would feel much better if neuroscientists would develop and license vaccines that would broadly inoculate candidates against demagoguery, dishonesty, and pandering and voters against mind-boggling gullibility.

That would make elections so boring. But also so on-label….