The Sanity of Survival – A Review of the Collected Papers of Carl Bell, MD

The Sanity of Survival: Reflections on Community Mental Health and Wellness (2004) collects the papers of psychiatrist, Carl Bell, MD. Dr. Bell was on faculty at University of Illinois – Chicago, where I did my psychiatric education 1993-1997. I had the opportunity to hear him speak in grand rounds and other educational lectures, but I did not know him personally. I remember him as outspoken, with a keen intellect, and a person who was not afraid to challenge paradigms. Given the recent events in the United States, the death of George Floyd, and the Black Lives Matter movement, I thought back to my training and career, looking for someone who worked on racism and human rights within psychiatry and I thought of Carl Bell. I have also been doing a lot of thinking about what I am calling medical activism: the professional responsibility to go beyond the four walls of the clinic to be a moral agent promoting health & wellness in the world. Dr. Bell surely qualifies as a medical activist!

Carl Compton Bell (October 28, 1947 – August 2, 2019) was born in the Bronzeville neighborhood in Chicago, attended University of Illinois for undergraduate, Meharry Medical College, Illinois State Psychiatric Institute for psychiatric residency and then served in the Navy 1974-1976. He dedicated his life to improving the survival and health of inner city African-Americans: looking at violence as a public health issue, the effects of racism on health, educating residents on cultural sensitivity for working with Black populations, innovating programs and systems (developing day hospitals, crisis beds, outreach programs), engaging in medical activism, and focusing on health and well-being. A true renaissance man, Dr. Bell was a public health researcher, a front-line clinician, a systems innovator, a health advocate who appeared on many TV, radio, and popular magazines, and a public health policy consultant for the Department of Health & Human Services and the Surgeon General.

Two guiding principles he mentions in his book are “bent nail research” and “getting rid of the rats.” He learned that a good doctor won’t just treat a rat bite, but will help to get rid of the rats in the neighborhood. He thus saw the role of the doctor and psychiatrist as not a technician in an office, but as an engaged professional intervening in the world. Robert Jay Lifton calls this a “witnessing professional,” (Lifton RJ, Losing Reality: On Cultism, and the Mindset of Political and Religious Zealotry, p. 190). This role of the physician as a moral agent having a moral role is consistent with Virchow’s statement in the 19^th Century, “Medicine is a social science, and politics is nothing else but medicine on a large scale,” (McNeely IF, Medicine on a Grand Scale: Rudolf Virchow, Liberalism, and the Public Health). Dr. Bell’s “bent nail research” developed when he was a kid and wanted to have a bookshelf and scavenged some boards and straightened out some bent nails.

“The completed bookcase leaned to one side and looked like hell! Yet it could always hold more than its share of books, and that was all that was important to me. The quality of research is very much like that bookcase. It may not be airtight scientifically because of limited resources and far-from-perfect methodology. However, our findings have been just as useful to as my bookcase was,” (xii).

These two guiding principles led to Dr. Bell’s “call for systemic interventions to address problems of the community rather than solving them on a case-by-case basis,” (xi). He describes other underlying principles of his life’s work as, “we’re all interdependent” and “states of consciousness…play a vital role in health and mental health,” (xii). This led to such things as developing a Wellness Institute, teaching Black Intrapsychic Survival Skills, researching states of consciousness in relationship to health, encouraging patients and trainees to learn martial arts, tai chi, and meditation. He expanded the concept of “combat fatigue” in veterans to “survival fatigue” in inner city African Americans exposed to daily stress of inner-city life (250-256). He sought to understand the effects of coma and brain injury on later violence, to understand and mitigate the effects of trauma on children and adults, and to understand and end inner city violence. He saw violence as a public health problem, presaging the recent move to consider gun violence as part of the “lane” or responsibility for doctors.

Violence is just one of the risks in the inner city, Dr. Bell saw the inequities in health between races in Chicago, as he wrote:

“As an African-American physician, I’ve always had a very different mission from most European-American physicians. European-American physicians are often concerned with trying to improve the ‘quality of life’ of their mainly European-American patients. Since leaving medical school, one of my major missions has been to save lives of my mainly African-American patients. Although I am interested in ‘wellness,’ until African-American life expectancy reaches that of European-Americans, I feel obligated to spend more time on ‘saving lives―making a difference’…There are very few people who value poor, mentally ill black people. As a result, resources allocated to help this population are scarce. This reality has always demanded the need to develop creative and innovative ways of effectively and efficiently serving the poor and underserved,” (50).

The title of his book, The Sanity of Survival, speaks to this focus on survival first and then sanity second – or perhaps it points out that without first dealing with the survival issues of the social (and moral) determinants of health, adverse childhood experiences, institutional racism, and violence, that there can be no sanity. Dr. Bell’s work developing programs such as day treatment and emergency housing (to help preserve community connections which can be disrupted by hospitalization), enhancing community support systems, assertive community treatment and case management, victim screening and support services, and a Wellness Institute, created an infrastructure (where there was none) to provide a spectrum of care for the whole person. He worked through Jackson Park Hospital and started the Community Mental Health Council. He also advocated for the use of “psychoanalytic theory in helping African-American patients cope with stress,” (91). He published papers on racism and narcissism and used psychoanalytic theory to understand racism, even considering whether racism, itself, should be considered a mental illness. (This is such important and relevant work that I will address it in a separate blog).

Dr. Bell’s concept of “survival fatigue” in inner city African-Americans compared the “high death rate, crime, unemployment, illness, and discrimination…inadequate housing, nutrition, education, and health and mental health care” to the stressors of combat and attendant combat fatigue, what we now call Posttraumatic Stress Disorder, (252). There is a growing awareness that another condition related to military service, moral injury, may also apply to systematic racism and Dr. Bell’s article, “Black Intrapsychic Survival Skills” could be seen as addressing moral injury. Through the cultural use of consciousness altering modalities in song and dancing in spiritual, ceremonial, and recreational settings, Dr. Bell saw resilience within the African-American community and culture. These consciousness altering techniques help to harmonize one with the environment, build community and help to process trauma and stress. These interests are part of Dr. Bell’s desire to “devise a true African-American-centered psychology,” (280). This was part of his shift to looking at “African-American strengths rather than deficits” for “cultivating resiliency” or even “resistance.” Through his clinical work and life, he concluded that, “there are two types of people when confronted with trauma: those who play funeral music deep inside and those who play adventure music,” (250-251).  Dr. Bell always tried to be a person playing adventure music for himself and his patients.

This is just scratching the surface of the life and work of Dr. Carl Bell, a psychiatrist whose holistic focus on body, mind, race, culture, society, disease, wellness, and advocacy is an outstanding example of medical activism and compassionate humanism. Dr. Stevan Weine calls him “a saint of service to African American patients, a saint of ‘bent nail’ research and ‘make it plain’ advocacy,” (Weine, “Dr. Carl Bell’s ‘Bent Nail Research,’” Psychology Today, November 5, 2019). Dr. Bell’s desire to heal the hurts of individuals and society went beyond the prescription pad and the hospital. We know that medical students tend to lose idealism during medical training and that burnout and compassion fatigue are more the norm than the exception these days. Somehow Carl Bell nurtured and developed resilience and idealism throughout his life and work. He closes his book telling us to listen to the words of the song, “Dream the Impossible Dream,” in order to develop kokoro “(indomitable fighting spirit, in Japanese),” (467). Let’s let Dr. Carl Bell have the last words and close with quotes from his afterword and I will soon write the next installment on his thoughts on racism and narcissism.

“I’ve recently realized that a major problem with psychiatry is that it’s too focused on what we were trained to do. It sometimes feels like psychiatry is stuck in a box that only recognizes diagnosis and treatment. Unfortunately, being in this box precludes psychiatrists from involving themselves with prevention and from focusing on strengths and characteristics of resilience and resistance. These are just as much a part of the human condition as is the psychopathology we were trained to identify and treat. Fortunately, some of us are blessed enough to be on the fringe, which allows us to occasionally leave the box and get a different perspective. This brings new paradigms and models that benefit the human condition.”

“I recall Dr. Boris Astrachan, former Chairman of Psychiatry at the University of Illinois at Chicago…telling me that I’m on the fringe. Psychiatrists are already on the fringe of society because we address the ills of those who are on the fringe by virtue of their psychopathology…Being on the fringe of the fringe, if you will, by virtue of being ahead of your time, is a lonely existence.”

“I also recall Dr. Astrachan telling me that the fringe was the best place to be because I could bring new ideas and have a great deal of innovative influence. I’ve often wondered why I find myself at the seat of power since I’m usually the ‘odd man out,’ and based on the depth and breadth of my work, haven’t really belonged in many rooms. With time and experience, I’ve learned that my being the ‘odd man out’ has contributed greatly to the creativity, humor, leadership, and productive dynamic tension in the room, and that we all have walked out more enriched. So, being on the fringe of the fringe has been a curse but also a huge blessing,” (466-467).

References:

Bell, Carl. The Sanity of Survival: Reflections on Community Mental Health and Wellness. Chicago: Third World Press, 2004.

Lifton, Robert Jay. Losing Reality: On Cults, Cultism, and the Mindset of Political and Religious Zealotry. New York: The New Press, 2019.

Martin, Michelle. “Can I Just Tell You: Remembering Dr. Carl Bell.” NPR, August 18, 2019, https://www.npr.org/2019/08/18/752221085/can-i-just-tell-you-remembering-dr-carl-bell

Moffic, Steven H, MD. “For Psychiatry, Our Bell Tolls for the Loss Of Carl Bell, MD.” Psychiatric Times, August 5, 2019, https://www.psychiatrictimes.com/view/psychiatry-our-bell-tolls-loss-carl-bell-md

McNeely Ian F, Medicine on a Grand Scale: Rudolf Virchow, Liberalism, and the Public Health. London: The Wellcome Trust Centre for the History of Medicine, University of London, 2002.

Weine, Stevan. “Dr. Carl Bell’s “Bent Nail Research,” Psychology Today, November 5, 2019, https://www.psychologytoday.com/us/blog/cafes-around-the-world/201911/dr-carl-bells-bent-nail-research

Wikipedia, “Carl Bell (Physician),” https://en.wikipedia.org/wiki/Carl_Bell_(physician)