A Critic Takes On Psychiatric Dogma, Loudly

The New York Times, March 6, 2001

By Erica Goode

Sometimes people buttonhole Dr. Charles H. Clark Jr. at professional meetings and hint that he might do well to muzzle his most high-profile employee, Dr. Sally Satel.

“Can’t you control Sally?” they ask.

The subtext, Dr. Clark said, is clear. His colleagues would like it if Dr. Satel, who works 12 hours a week as a psychiatrist at Dr. Clark’s methadone clinic in northeast Washington, did not voice her provocative views on addiction, mental health policy, minority health issues and other sensitive topics quite so loudly, writing about them in the Op-Ed pages of The New York Times and The Wall Street Journal, in magazines like Commentary and The New Republic or in her book, “PC, M.D.: How Political Correctness Is Corrupting Medicine,” published in December.

They wish, for example, that Dr. Satel would not insist that addiction is fundamentally a problem of behavior, over which addicts have voluntary control, rather than a “chronic, relapsing brain disease,” as the National Institute on Drug Abuse asserts.

They cringe when she calls well-known public health researchers “quot;indoctrinologists,” as she does in her book, and accuses them of promulgating a “social justice agenda” by focusing on racism and poverty rather than health education and disease-fighting strategies.

They would prefer that she did not criticize feminists for construing wife-battering as a symptom of a patriarchal society.

Or argue that psychiatry is being co-opted by a culture of “victimology,” which undermines personal responsibility and ultimately damages patients.

They do not, in short, agree with the way Dr. Satel, who one critic dubbed the “most dangerous psychiatrist in America,” sees the world.

Dr. Clark, who described himself as coming “from a long line of black Republicans,” has a simple response:

“You want me to sit on Sally?” he asks. “Is this Germany in 1941?”

“Sally is Sally,” he tells them. “She has some things to say. Whether you agree with them or not is not my issue.”

Sally L. Satel has always had some things to say, and she has almost always said them.

In first grade, she got impatient when the teacher kept ignoring her eagerly raised hand. “Well, it’s about time!” she snapped, when her name was finally called.

Angry at first, the teacher eventually relented, and offered her bright and outspoken young pupil a bag of Fritos after class.

Four decades later, Dr. Satel, Yale-trained psychiatrist, sharp-penned essayist, conservative pundit and book author, is still bright and still outspoken. And both the anger and the Fritos are still coming her way.

Her Op-Ed pieces, which mine a theme of individual accountability and often play off current events, inspire bitter complaints, furious letters and indignant cries from those she singles out for censure.

“I think she represents a point of view that’s been very destructive in terms of public health and mental health policy,” said Michael M. Faenza, the president of the National Mental Health Association, who was berated by Dr. Satel in a 1999 essay that criticized the surgeon general’s report on mental illness for saying that one-fifth of Americans are in need mental health care.

Yet Dr. Satel’s relentless questioning of psychiatric dogma—weighing in with contrarian views on topics from drug addiction and involuntary commitment to fad therapies and the usefulness of grief counseling—has drawn the praise of other colleagues, and opened up public debate.

“She is somebody who makes one think, and re-examine some cherished ideas,” said Dr. Steven S. Sharfstein, the president and chief executive officer of Sheppard and Enoch Pratt psychiatric hospital just outside Baltimore.

Dr. Satel’s critics are as blunt as she is. They call her opinions “harsh” and “lacking in compassion”; they claim that she simplifies and selects. Several researchers, for example, complained that in the chapter of her book attacking studies that link racial bias to inequities in health care for blacks and whites, Dr. Satel ignored a wealth of other research supporting such a connection.

“If she’s looking for indoctrinologists in public health, she need look no farther than the mirror,” said Dr. Nancy Krieger, an associate professor of health and social behavior in Harvard’s School of Public Health, whose study on racial bias and health was one of those Dr. Satel lambasted.

Dr. Krieger countered with her own opinion of Dr. Satel’s work: “What she presents is a completely slanted, woefully incomplete and misleading overview of the literature.”

Dr. Satel’s tenure at the American Enterprise Institute—where as a scholar she shares office suites with such conservative luminaries as Newt Gingrich, Jeane J. Kirkpatrick and Robert H. Bork—is proof, her critics insist, that her opinions are based in ideology.

Dr. Satel’s supporters, on the other hand, are equally vocal in praising her bravery and independence, the complexity of her thought and her meticulous research.

Dr. Sherwin Nuland, the author of “How We Die,” deemed her book “a clarion call” in a favorable review in The New Republic. Dr. Satel is “the conservative I most like to debate,” wrote Dr. Peter D. Kramer, the author of “Listening to Prozac,” who taught Dr. Satel at Brown medical school before her residency at Yale.

Controversial or not, her views have earned her a solid niche in the world of Republican politics. President Bush sought her counsel on drug policy during his campaign, and she has received feelers about a role in the new administration, she said, declining to specify what positions, if any, were discussed.

Yet for anyone who looks beyond the surface, Dr. Satel, 45, is not easy to pigeonhole, her 5-foot-1 frame a package of unexpected twists and apparent contradictions.

She reads the usual intellectual fare, The New Yorker and The Atlantic, Slate and Salon, but she lists “Babe” among her three favorite movies (the others are “The Silence of the Lambs” and “All About Eve”), and she prefers chocolate doughnuts over more health-conscious breakfast cuisine.

Though she gave up riding horses after suffering a minor injury, she hopes to learn to race her B.M.W. She compares smoking cigarettes to placing one’s head in a bucket of asbestos, but is disappointed when a visitor has none for her to bum.

Politics is for Dr. Satel now a comfortable stomping ground. But although she reached voting age in the early 70’s, she did not cast a ballot until 1992, when she voted for Bill Clinton. (She liked the idea of “ending welfare as we know it.”) Before then, she said, “I never read the paper. I didn’t have a political thought in my head.”

And while this time she voted for President Bush, her background makes her an unlikely Republican.

The product of a Jewish middle-class upbringing, she was the first in her family to go to college. Her parents were both Democrats, her father a graphic artist, her mother a homemaker who died of leukemia when Sally Satel was 18. An only child, she shared a three-room apartment in Queens with her parents and a parakeet—the only pet they would allow their animal-crazy daughter to keep in such cramped quarters.

It was a world far removed from the culture of the conservative right. And when, in 1994, she went to work for Senator Nancy Landon Kassebaum, a Republican of Kansas, she said, she hardly knew what a Republican was.

Indeed, though Dr. Satel is often characterized as “conservative,” she resists the label. She supports abortion rights, she points out, and does not feel strongly about gay marriage—”Be a good person. Live the life you want,” she says. She would be “profoundly distraught” if the government banned fetal tissue research, and she could not care less about school prayer.

Her concern, Dr. Satel said, is for patients. “I think there is always that tension between nurture and discipline,” she said, “but from the standpoint of patients, it really is apolitical. You want to maximize the best interests of the patients so that eventually they can discipline themselves. Get out, get a life. Just let them go. That’s considered conservative. I don’t understand it.”

Working with people struggling with dependence on illegal drugs, she said, she became convinced that excusing them from responsibility for their actions did them no service.

“I reject the notion that addicts become a zombie and so are not responsible for anything they do,” she said.

And to label addiction a “chronic, relapsing brain disease,” she argued, “is pessimistic.”

“It gives everybody a pass,” she said. “When the treatment system doesn’t do a good job, you just fall back on that.”

Yet if Dr. Satel does not neatly fit conservative stereotypes, she has a striking knack for choosing issues identified with the starboard wing.

And she appears content as a clam speaking to the Manhattan Institute, a conservative research group. “Isn’t it the liberal impulse to get people dependent on you?” she asks the nodding audience.

There are other conundrums. In person, Dr. Satel is soft-spoken and impish, wry and sensitive, doe-eyed and quietly elegant.

Her one-bedroom apartment in downtown Washington is simply furnished. She allows that she almost got married once, but she turns away other such questions with a line borrowed from Senator Kassebaum, “Your personal life is personal.”

Friends describe her as caring and supportive, a baker of cookies, a giver of spontaneous compliments.

“She’s utterly reliable and delightful and completely there,” said Dr. Deborah Fried, a psychiatrist and friend from Dr. Satel’s days at Yale.

Dr. Satel’s patients at the methadone clinic, where she is affectionately known as Mustang Sally, also like and trust her.

“She is a good psychiatrist, clinically,” Dr. Clark said. “She’s compassionate and she sets boundaries and she works with patients and they respond.”

Joseph Smith, a longtime patient at the clinic, lights up with pride when he talks about his therapist.

“Dr. Satel is on my A list,” he says.

Yet her tone can turn suddenly sharp, and some who have felt the pointed end of her pen said they were surprised at the vehemence of her attack.

Mr. Faenza, of the mental health association, for example, her target in the essay on the surgeon general’s report, bristles at the mention of Dr. Satel’s name.

“I’d really never met her before that piece,” he said. “I thought it was odd in every way. I guess she’s getting media attention.”

For her part, Dr. Satel said she was often baffled by how incensed people become.

“I can’t quite get used to the fact that some people take this as personal wounding, and won’t even be cordial or shake hands,” she said.

The point, she contends, is to have a debate, to talk about things that have not been talked about before.

“All I can say is that I feel I’m motivated out of what I see as problems in the system,” she said. “There are no villains here, just, I think, more enlightened ways to proceed.”