Saturday, July 04, 2009

A Visit to Auschwitz: Reflections on Biology and the Psychiatric Sequelae of Political Violence

July 2, 2009
Psychiatric Times. Vol. 26 No. 7

A Visit to Auschwitz: Reflections on Biology and the Psychiatric Sequelae of Political Violence
Joshua Sonkiss, MD

Dr Sonkiss is a fourth year psychiatry resident at the University of Utah. He visited Auschwitz in 2008.

If I closed my eyes, it would have been easy to imagine that I was visiting a peaceful city park. The sounds of birdsong and children’s laughter rang in the air, and the odor of freshly cut grass filled my nostrils. But the sweet smells and soothing sounds belied the horror of the place where I actually stood—inside the wrought iron gates of Auschwitz-Birkenau, the Holocaust’s most infamous concentration camp. Today the camp is a museum, and there is an eerie dissonance between the tranquility of its sprawling grounds and the mass murders that were carried out here almost 70 years ago. Like many visitors to Auschwitz, I experienced powerful emotions—a mixture of revulsion, anger, and a deep empathy for the millions of souls who suffered and perished there. I also felt a discomfiting sense of doubt about the goodness of humanity, including my own.

As a psychiatrist, however, I also have rational side. Like most of my colleagues, I am aware of the connection between political violence and an elevated risk of depression and anxiety disorders.1 My visit to Auschwitz made this connection tangible, and it raised questions about my profession that made me uneasy. Psychiatrists increasingly emphasize biological principles in their understanding and treatment of mental illness, but seeing physical evidence of the Holocaust made me wonder how well the biomedical model applies to the sequelae of psychological traumas like genocide. Genocide and lesser forms of political violence are still rampant, and psychiatrists are increasingly called on to treat the victims. Does biology really provide us with the best tools to help them? Could our focus on biology actually hurt the survivors? These are easy questions to ignore in everyday clinical life, but for me, visiting Auschwitz imbued them with a sense of reality and urgency.

I will confess that I am skeptical of biological psychiatry—the belief of many psychiatrists that mental illness is best understood and treated using a biological approach. My doubts are not fueled by any distrust of science—I recognize the tremendous contribution biology has made to psychiatry, both in understanding diseases like schizophrenia and bipolar disorder, and in bringing about effective somatic treatments that have become the mainstay of our profession. Rather, I fear that for many psychiatrists and patients alike, a one-sided approach to understanding mental illness—biological or otherwise—may sound the siren call of easy answers and inevitably lead to moral consequences.

Some will object that the term “biological psychiatry” is disingenuous because psychiatry is actually based on Engel’s venerable biopsychosocial model.2 While it is true that psychiatrists must pay homage to the biopsychosocial model to pass their board exams, a perusal of any respectable psychiatry journal will demonstrate that in research and clinical practice biology is king. As an example, I recently overheard a well-known genetic researcher expounding to a group of psychiatry residents that “the more we stick with biology, the better off we will be.” I hope that trainees do not heed this ill-conceived advice. One need only examine the psychiatric consequences of genocide to see what a terrible mistake this would be.

The nature and magnitude of the mistake may not be obvious to a privileged class of professionals living in a stable Western democracy. There, a dogmatic theoretical emphasis on biology may prove harmless in clinical settings, where the exigencies of clinical interaction ensure that some amount of attention will always be paid to social and psychological concerns. However, psychiatry’s role in society extends far beyond the clinic to influence public attitudes toward mental health and illness the world over3 and, in many parts of the world, social injustice and political violence rule the day just as they did in occupied Europe. In these spheres, biological dogmatism is not benign if it leads the public to abandon moral outrage in favor of a disease model for understanding the psychiatric consequences of social injustice and political violence.

This may sound like catastrophizing, but there is evidence that the public has begun to accept this view. For example, a prominent mental health consumer group proclaims on its Web site that “mental illnesses are biologically based brain disorders.”4 I reflected on this idea as I walked past pits that held the ashes of incinerated prisoners, hastily buried before advancing liberation forces arrived. I remembered some elderly Holocaust survivors I had seen as a medical student rotating through psychiatry. Some suffered from depression, others from posttraumatic stress disorder; all suffered from memories of the Holocaust, and there were many others like them in the clinic where I worked. How would they react if they were told that their painful memories were the result of brain disease?

I understand that describing mental illness as brain disease may reflect a well-intentioned effort to de-stigmatize mental disorder and legitimize its treatment as a medical illness. However, it also suggests that biological explanations are the final word on psychiatric illness. Walking among the ash pits, this would be a difficult claim to believe. No doubt that anxiety has biological correlates, but in a concentration camp it is worth asking whether biology is the most appropriate explanatory principle. If a prisoner at Auschwitz were shot in the head, one could accurately describe the victim’s injury in terms of “genes plus environment”—but to do so would be worse than insensitive and rather beside the point.

This example may seem absurd, but it suggests that there are moral consequences to placing biomedicine on an ideological pedestal—some researchers have suggested that biomedical approaches to trauma have the potential to systematically disenfranchise victims of social injustice and political violence.5 It would be easy to argue that a biological model of mental illness cannot furnish moral judgments, but models are employed by human beings who possess moral agency. In this example, adherence to the biomedical model reflects a choice to avoid engaging in moral questions concerning the person who pulled the trigger. The connection between political violence and its psychiatric consequences may be more nebulous than a gunshot, but if I chose to describe those consequences in biological terms then I believe this is no less an abdication of my ethical duty of beneficence.

I place a special emphasis on choosing one model over another, because no doctor is limited to the biomedical model. In fact, although the biomedical model informs all medical specialties, no medical specialty could function without equally relying on other models of illness.6 Chief among these is the clinical model, which emphasizes the patient-doctor dyad and lies at the heart of the therapeutic relationship. One of its essential functions is to ensure that patients are not blamed for their illnesses, even when their own genes or behaviors adversely affect their health. This does not always mean there is no one to blame, however, and in my view the Holocaust represents a situation in which the perpetrators of social injustice are to blame. In this context, emphasizing biological causes removes the focus from social injustice and may become an insidious form of blaming the victim.

Advocates of pure biological psychiatry counter that social problems lie beyond the purview of medicine. However, this argument ignores another key paradigm that is intrinsic to medical practice: public health.6 The public health model is essential for translating biomedical knowledge into social policies that reduce the burden of illness on society. To illustrate this, consider the example of coronary artery disease. In treating patients with myocardial infarction, physicians discovered that smoking was a risk factor for heart attack. Although coronary artery disease is a medical illness, this did not release doctors from their ethical obligation to help initiate anti-smoking campaigns to reduce the toll of tobacco on cardiovascular health.

As I wandered near the silent ruins of Auschwitz’s infamous crematoria, I could not escape the moral import of the Holocaust: what happened there was wrong. But by simple analogy to smoking, genocide—whatever else it may be—is a risk factor for mental illness. Unfortunately, this recognition has not led to widespread public information campaigns aimed at reducing the incidence of political violence in the present day. Focusing public attention on the plight of genocide victims is perhaps asking too much of psychiatry, but as a medical specialty we still have a duty to inform public policy in a world that is increasingly globalized. It does not seem unreasonable that we should carry out this duty in a way that—at the very least—does not offer a view of mental illness that discourages policymakers and their constituents from trying to address nonbiological causes of mental illness.

The biomedical model is unequivocally useful—my patients at the Holocaust survivor clinic were grateful for the somatic treatment they received, and many benefited from it. But is that the end of the story? If I closed my eyes, it would be easy to imagine that treating survivors was all psychiatrists had to do, and that we had no obligation to fight the conditions that made our patients ill. But my eyes are open, and I am not convinced.


1. Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet. 2005; 365:1309-1314.

2. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129-136.

3. Erickson SK. The myth of mental disorder: transsubstantive behavior and taxometric psychiatry. Akron Law Rev. 2008;42:67.

4. National Alliance on Mental Illness (NAMI). What is mental illness: mental illness facts. 1996-2009. Accessed June 24, 2009.

5. Zarowsky C, Pedersen D. Rethinking trauma in a transnational world. Transcult Psychiatry. 2000;37: 291-293.

6. Adler DA. The medical model and psychiatry’s tasks. Hosp Community Psychiatry. 1981;32:387-392.

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