This murmuration with artist, psychiatrist, and ethicist Jacob Appel (www.jacobmappel.com) is an apt resurrection for Scry Magazine, which is emerging from a refiner’s fire and incubation of two years. Scry is a site for contemplation of experiential data – a forum where latent conundrums can be examined by those for whom they are day-to-day predicaments, rather than abstracted cocktail party topics for reductivist conjecture. We aren’t humorless here, the minds of Scry have simply inhabited cultural capitals where substantive dialectic has been marginalized in between superficiality and avoidance of discomfort.
How can the margin be in between? Doesn’t that indicate that the margin is at the center? Yes. And that is Scry.
Scry is a site for n-dimensional, non-didactic exploration. Yet as much as the armchair can be seductive, to many of us it is a luxury, and we live in a realm of direct, personal experience in which our primal responses – as well as deliberate decisions – are often made on the fly, perhaps under duress. SCRY likes to conceive of this as “resting” or “theoretical” or “passive” ethics, versus “pressurized ethics.” Kicking people into our amygdala is not an armchair activity. It involves a forensic analysis of how our fight flee faun freeze bypass that frontal cortex where things like ethics reside.
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This murmuration with Jacob Appel traverses his experiences as a triage emergency room psychiatrist, a playright and novelist, and an existential interlocutor. Jacob M. Appel is the author of four literary novels, nine short story collections, an essay collection, a cozy mystery, a thriller and a volume of poetry. Jacob is currently an Assistant Professor of Psychiatry and Medical Education at the Mount Sinai School of Medicine and an attending physician at Mount Sinai Hospital, Beth Israel Hospital, and St. Luke’s-Roosevelt Hospital in New York City. At Mount Sinai, he designed and teaches the ethics curriculum for the first and second year medical students, lectures in the psychiatric clerkship, and runs the ethics courses for the psychiatry residents. He also established and supervises a creative writing elective for the medical students. His books can be accessed through www.workman.com/products/who-says-youre-dead and www.blacklawrencepress.com/authors/jacob-m-appel. He invites you to email him at j a c o b m a p p e l at gmail dot com.
This murmuration commences…
– Quintan Ana Wikswo
SCRY: Welcome to our flight paths here at SCRY, where your contributions to our knowledge of the skies and its tides are very much appreciated. Shall we begin?
APPEL: As a bioethicist who writes about ethics in both fiction and nonfiction, I figured I’d mention five ethics topics that fascinate me but don’t interest many others.
SCRY: Your list is compelling. Being obsessive ethicists ourselves here at Scry, we often start at the most identifiable end and work backwards. Perhaps the conundrum that incites interest is the climax, the catastrophe, the juncture at which ethical infractions have occurred? It is intriguing to start an analysis before the apex (gorilla saves cat from tree), but often the early indicators of ethical rubrics in an individual don’t show up – or gain attention – until after pressure has been applied and the crisis point is reached.
All that aside, we are quite taken by your interest in malingering, which was the fifth topic in your list.
APPEL: My academic work focuses on the subject of people who feign medical or psychiatric illness, a subject that I find fascinating, but that most other people are not interested in.
SCRY: What do you find fascinating about feigning illness?
APPEL: Malingering appears to be a universal phenomenon in all societies. Odysseus does it to avoid service in Troy and the Biblical David to avoid the wrath of King Saul. At the same time, it comes in almost infinite varieties, as varied as human illness itself. But detecting malingering is part public service, part game-like challenge. It is one of the few opportunities for the modern physician to play Sherlock Holmes on a daily basis.
SCRY: Do you have a working theory on why the ethics of malingering is sidelined in your field? And we’re curious whether it has a history of being dismissed or centered depending on cultural needs. For example, malingering has been a consuming trope during slavery in the United States, and any time there has been a military draft.
APPEL: The major current causes are economic ones: No pharmaceutical company has an incentive to fund research on malingering, no investigator gets promoted for studying it and hospitals get paid just as much if they treat malingerers as if they treat real patients; sometimes they even save money. Everybody comes out ahead—except the taxpayers and people with genuine illnesses.
SCRY: So you have an interest in sorting out the real from the passing. Those who are truly ill, and those who make illness a kind of drag performance. Do you think you are, as a professional, capable of knowing anyone’s psyche sufficiently to conduct that sorting process? So many human urges are a tangle of conscious, subconscious, and utterly unconscious drives.
APPEL: There are definitely cases that straddle the line between malingering and factitious disorder, as well as patient who malinger some symptoms but are truly sick with others. For instance, I have encountered patients with schizophrenia who are hearing disturbing voices, but lie and claim to be suicidal, because they fear the doctors won’t take them as seriously unless they appear to be a danger to themselves or others. But many cases of malingering are very clear cut; once one discovers the outside motive, the entire story seems to write itself.
SCRY: Can you elaborate on how a malingerer is diagnosed? To me, the figure is a trickster one. I think of malingerers within Nazi-occupied Europe, who used it as a means to undermine the Reich without directly committing a crime of disloyalty. Or malingering in an exploitative worksite, or in any site/situation where rapid progress towards stated goals would advance the success rate of something objectionable to that individual.
In one example, someone is told to round up all the wolves for cattle companies and eliminate them. This person decides to drive slowly, forget to bring enough traps or poisons or weapons, and so forth. To the cattle rancher, this person is a malingerer and ethically abominable. To those who are attempting to reintroduce biodiversity, that person is heroic and engaging in ethics-based civil disobedience. Ethically admirable.
APPEL: Malingering can be adaptive or maladaptive, ethical or unethical. Prisoners-of-war who malinger in an effort to secure better rations are the quintessential example of ethical malingering. Many children feign sickness to avoid school; sometimes romantic partners do so to avoid sex.
There are two common ways to diagnose malingering: one is to ask the subject a series of questions that could be signs of illness and one that is not. So in psychiatry, I might ask a sequence that includes: Do you hear voices? Do you see visions? Do you believe any of your relatives to be automobiles. The latter is not a symptom of any known mental illness, so the patient who says, Oh yes, Uncle Fred was a Buick is lying. Similarly, I often administer games of memory in which someone with no memory should score random change (50%); if the subject scores significantly below chance or even 0%, it means they know they right answers and are intentionally choosing the wrong answers to appear impaired. You’d be surprised how many malingerers fall for that trick.
SCRY: That’s an enlightening and surprising basic diagnostic process, and one of which I was totally unaware. I have PTSD and temporal lobe epilepsy, and I have found myself in the psych ER on multiple occasions. I was never asked questions like that – there was rather a sense of whether I was an addict (bad player) or an earnest type who needed to be diverted to either neurology triage or psych triage. It’s always seemed a toss of the coin where I ended up. I never faked any responses – since these are “legitimate” diagnoses, but I always sensed deep skepticism, and I wonder what diagnostics I missed while in an impaired state. Now I have a medic alert bracelet that sends me to neurology.
There is a spiritual aspect to distress, and one that can be one of the most sublime of the human condition: purity of existential survival. Legitimate distress can result in many kinds of violence – towards the self, often, in the case of suicide. But faking distress is honestly something I’ve never considered, and my first – perhaps primitive response – is to feel angry that anyone in a fully legitimate, self-aware state of full sanity would perform this. Because that’s a bit of a luxury, and disrespectful at bet. If I decide to engage my empathy, I question, is the faking of illness in itself an illness? Perhaps of sociopathy?
APPEL: What exactly constitutes an illness is sociologically defined—as is how society chooses to address it. We view alcoholism as a disease now, but we still punish drunk drivers. Is pedophilia a disease? No sane person, I assume, would choose to have sexual desire toward children, yet we tend to view such individuals as evil rather than sick. So depending on one’s vantage point, malingering may be a form of antisocial behavior, and one might classify antisocial behavior and sociopathy, in turn, as pathology.
SCRY: You have written a great deal about malingerers in several of your novels. First of all, could you offer us a reading list of your works that you would like to be elevated? I am often frustrated that readers select my work by the algorithm of a search engine, rather than the texts that I feel are the cornerstones of my creative expression.
APPEL: My favorite works include several of my short story collections (Miracles and Conundrums of the Secondary Planets, Einstein’s Beach House, Amazing Things Are Happening Here) and my ethics essays in Phoning Home and Who Says You’re Dead? I will gladly send samples of my work for free in PDF to anyone who requests them via email to jacobmappel @ gmail dot com
SCRY: Now we have a good reading list. So, the second question. As writers, we live with our characters in a very intimate manner, in most instances. What role does malingering have in your literary work? As characters? As devices? As sites for exploration? Or…
APPEL: Malingering plays a role in my novel, Millard Salter’s Last Day. Several of my story collections deal with dishonesty in medicine and healthcare more broadly, including those in Einstein’s Beach House. My thriller, Mask of Sanity, is about sociopathy.
SCRY: As we delve into malingering, you question how society “should or could address the problem — which is probably the most expensive problem in the country that nobody is talking about.” I ask whether you have proposed strategies and tactics for this. But what overshadows that is the word “expensive.”
This is an n-dimensional matrix of questions for you. I’m intrigued that you cite fiscal impact as a core detriment of harboring malingerers. I don’t dispute the point – it’s critical to the analysis. Why do you privilege economic impact? Is there an impact cluster? Is it hierarchical? For instance, malingering can impact authority/power, humanitarian/safety (someone dies because the EMT decides to clean his ears before administering triage care), and dozens of other factors.
APPEL: Healthcare dollars are finite. I think it’s important to remember that each malingering patient we treat or hospitalize is money not spent of a real patient, dollars not devoted to someone’s mammogram or flu shot. And often the goals of the malingerers could be addressed much more cheaply as well. Why admit a patient to the hospital for $4000 a night when you can rent them a room at a luxury hotel for 10% of that?
SCRY: I initially interpreted your selection process as somewhat more sinister. But now I understand that eliminating hustlers and con artists is a form of human rights application. What a bitter task falls to the triage agent. Do you feel any concern, as a diagnostician, that you have made serious errors when you have approved or denied service?
APPEL: We always give patients the benefit of the doubt. If I’m sure you’re malingering but I can’t prove it, I still provide care. Only when I can prove fairly convincingly that a patient is malingering (I know the motive, have evidence of lying, often a previous history of malingering, implausible symptoms, etc.) do I confront them. Many malingerers then confess, which makes discharging them much easier…
SCRY: You told SCRY about your curiosity surrounding subjectively, what does it feel like to be a malingerer?
APPEL: Malingerers, like real patients, come in all shapes and sizes. Many are desperate—but in my thinking, there is a difference between being desperate for a meal or a place to sleep and being desperate to avoid one’s loan shark or child support payments or armed robbery trial. Every malingerer has a story to tell; unfortunately, many doctors never dig deep enough to reach the real story.
SCRY: Intriguing. Yes. There is a predatory, quite abusive element to those examples. Within my professional specialization in human rights work, outsiders can often see me as callous in my assessment of a case. But there are red flags that are probably only visible to me, and those indicate a degree of pathology, a wolf trying to seem a sheep.
APPEL: When I started out in psychiatry, I was very hesitant to diagnose malingering and was fooled many times. Over the years, it becomes second nature—just like any other skillset. I often can sense whether they patient is feigning long before I establish this with empirical evidence.
SCRY: Have there been assessment analyses of identified malingerers? Is there a diagnostic taxonomy of malingerers? Offering “Quintan” as a subject, she was in 2008 accurately accused of malingering on preparing an annual report for a large human rights nonprofit.
The reason “Quintan” cited for malingering was that gathering core data for the annual report involved close, extended interaction with a fellow vice president who was a rampant sexual harasser. Laziness was not a factor – the root source of the malingering dwelt in the amygdala “freeze” instinct. Rather than confront the ethical violations by a predatory colleague (fight), or quit the job (flee), or just try to make nice (faun), malingering was a primitive but moderately effective survival tactic.
As for what it felt like, “Quintan” felt anxiety, fear, joy, guilt, shame, and rage as primary emotions. It’s important to note that “Quintan’s” freeze response was only partly conscious. It was not until they were accused of malingering and threatened with disciplinary action that the subconscious or unconscious mind conveyed to the conscious mind “hey, I’m not doing this report because I don’t want to be assaulted and then have to deal with the human resources repercussions and safety issues of retaliation.”
APPEL: There are many different technical classification schemes, and I have published academic work on the subject, but I prefer a much simpler one in practice. There are “soft” malingerers who represent failures of the social service system or some other duty that we have to our fellow human beings, and there are “hard” malingerers who feign illness for a nefarious purpose, such as their legal obligations or to steal equipment from the hospital. For the former, we should have compassion—although we should not provide unnecessary medical care. The latter are basically engaged in stealing from the sick and should be treated accordingly.
SCRY: I have another subjective question about feelings, while we’re on the wire. I’ll return to your comment about malingering and sexual or intimate relationships. For example, a case study in which a spouse neglects celebrating the partner’s birthday. The assumption may be that this spouse was a simple case of malingering – too lazy, disorganized, selfish, and inconsiderate to go to the effort to remember something of value. But after a decade, the spouse confesses to a therapist that it was an intentional act of harm and retribution. The malingering spouse had been quite content to take shelter under the umbrella of “malingering” rather than express uncomfortable feelings. The question for you is, this kind of everyday malingering can either be questioned or accepted. Which do you recommend?
APPEL: The key to relationships is to approach each set of facts individually. Each human dyad is unique. Sometimes, questioning will be in order. Other times, the circumstances will call for acceptance. That is the “art” in the art and science of medicine.
SCRY: Would a viable strategy for reducing malingering in our society be a mass education campaign about how to navigate complex emotion without being driven by the more primitive survival instincts of the amygdala? In other words, to move society towards a healthier toolkit for managing uncomfortable emotions?
APPEL: The best solution would be to offer people the resources they need (food, shelter, human connection) outside the medical system.
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SCRY: Indeed. Moving backwards, let’s murmurate a bit about your fourth preoccupation: social disconnection.
APPEL: We are increasingly an alienated society afflicted with an epidemic of loneliness, a culture that bowls alone, so to speak, and then brands the consequences of that disconnection to be mental illness. As a psychiatrist who writes about mental health in both fiction and nonfiction, I am distressed at how we have created such structures and continue to perpetuate them, even though they render many people miserable and benefit almost no one.
SCRY: The degree of human misery is limitless, and perhaps its complexity and scope is only visible to first responders such as yourself, myself, and others who inhabit the field of responding to abject distress.
I will approach this by beginning at the end – as I mentioned, the very best place to start, contrary to Fraulein Maria in The Sound of Music, who advocates that starting at the very beginning is the very best place to start. She sings this because the Von Trapp children are confused by the complexity of learning to sing, and so they refuse to sing at all until she simplifies the process.
I’ve always been intrigued by Julie Andrews’ body language in this scene – the children are frozen and unresponsive, she tosses up her hands in a gesture of frustration and cannot conceal a sigh of disappointment. Fine, the body language suggests, this won’t be as fun for me, but let’s just get things really simple for you kids. Upon saying, Doe, A Deer, A Female Deer, the Austrian county gentry become comfortable, and everyone sings together. Community! An end to the bilateral alienation!
APPEL: If only the world were like a Rogers & Hammerstein musical!
SCRY: Rogers & Hammerstein are rather sinister figures in my opinion. I think they are more than a bit reductivist, and very fertile mass graves for naïve performances of simplified ethics. So to restate the question without musical theater analogies, do you think the complexity of human connection is simply too overwhelming and nuanced and discomforting than most people can navigate?
APPEL: Rogers and Hammerstein can indeed prove sinister. The plot of “Oklahoma!,” for instance, rest upon mocking a mentally ill farmhand. As for human connecting, I think the vast majority of people desire to connect and have the capacity to do so. Often what they lack is simply the environment to fulfill these goals.
SCRY: Could social alienation and loneliness be a factor of disconnection caused by being overwhelmed by how to socialize? How to locate and cohabit complex sites? Perhaps it is a mental health problem – a lack in our society to administer basic effective training in simple social interactions that are mutually rewarding. I never talked to any white people when I grew up in the South because I was afraid they were in the Klan. Perhaps if we had all had a picnic…if we all just learned to get along…wait, that’s a joke. Sort of. In something of an aside, my disconnection was absolutely considered a mental illness. In fact, I was trying to avoid being harmed.
Later, when my psychiatrist forced me to socialize, I was beaten up. I found this to be most unfair. When I expressed the associated feelings, I was given a prescription for Risperdal. And the Klan boys who beat me up went out for hamburgers or something fun like that.
APPEL: I can’t argue with the suggestion that people should learn how to socialize and connect better. But I fear the deeper problem is structural: we have systematically eliminated the institutions that help people connect and the pathways for connection. The urban block of neighbors who know each other, the homogenous church or synagogue, the job that is a lifetime guarantee, the village pump. Of course, there were downsides to these institutions as well. In the shtetl, my family had lots of connection, but the cost was rigid social order and xenophobia. I would like to think there could be a path toward a healthy balance.
SCRY: The downsides were and are often fatal for social outliers. I longed to join a kibbutz when I was a child, but after living in a dormitory and in the queer ghetto of Sydney, Australia, I became a skeptic of intentional communities. I am interested in movements like The Nap Ministry, that simply provides sites for people to nap in public spaces. Is it possible to create sites for interaction in which people can commune without cohesiveness? That was specifically my intention in creating this magazine. As a site for substantive interaction without an overarching policed ideology.
As artists, our works can form these sites. I had an exhibition in the Berlin Jewish Museum where, I was told, there was an unprecedented number of repeat visitors. When the docents asked return visitors why they kept coming back, the answer was that it served as a site for them to think about the topic of the exhibition with others who were also preoccupied by the subject. In collaboration with the architects and designers, had created – with intention – an exhibit with softer lighting, and extra benches, and chair clusters. I think books can work that way, yet we often read in isolation.
You write plays, you write books, and you are a tangible figure in an emergency room. All of these are potential sites for communion.
APPEL: Yes, I confess I am probably more dependent on human connection than most. Literature and theater are two powerful ways to connect with people, both as a creator and as reader or spectator. Many of my stories and plays, in fact, are about the struggle for connection.
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SCRY: Your third fascination is “incorruptible people” which is very high up on my list of fascinations so here it is our hinge point in a set of five.
APPEL: There is good evidence at a certain subset of people simply cannot be compelled, no matter how strong the duress, into violating their core principles. For instance, in the famed Milgram experiment, some participants backed out at the onset. This is also a theme of many major works of fiction. We spend lots of time studying the moral transgressors, but much less figuring out what makes incorruptible people incorruptible.
SCRY: Could you murmurate a bit about the Milgram experiment?
APPEL: I imagine many of your readers are familiar with the Milgram experiment. Yet the take home messages is generally that “people follow orders”; I think the take-home message is the opposite. A subject of people don’t follow orders if they view them as unethical. If we could figure out who those people are, and why, that would be a major step toward improving life for all of us.
SCRY: I believe the data is there, but it is not easily accessible to most people. The military has long made this a priority. There is a large body of classified data from the psych experiments of ethics conducted upon concentration camp prisoners by psychiatrists from the Charité Hospital in Berlin.
APPEL: I will trust you on the specifics. More generally, I have no doubt that there is much more psychological data in the world that the average person—myself included—as access to.
SCRY: You mention duress. It’s hardly worth advocating for anyone’s character until one has witnessed their behavior during distress. How strong is the duress? In Dialectical Behavioral Therapy, there is the scale of Subjective Units of Distress (0-100) paired with the Scale of Distress Tolerance (0-100). If someone had a 90 sense of distress, and a 95 of distress tolerance, they would be able to withstand most pressures. But the two scales work in concert. And that model is one in which distress tolerance is a trained tool. Similar to SERE training for Special Services or Special Forces training.
You may recall a scene in Lawrence of Arabia where Peter O’Toole is bored as a junior analyst in Cairo and passes the time extinguishing matches between his thumb and forefinger. A rather jolly fellow British operative enters the room and tries the same thing, yells, and says something like, Golly, Larry, Doesn’t That Hurt? To which Lawrence/O’Toole – sanguine and desultory – says, Of Course It Hurts. The Trick Is Not To Mind.
APPEL: Most people have a breaking point, but history is populated with those who do not. Joan of Arc. Nathan Hale. The early Christian Martyrs. How much duress would break the majority of people has not been studied. It’s hard to imagine an IRB approving a controlled trial.
SCRY: Again, I invoke the research conducted by the Charité Hospital – later declared war crimes, but by the standards of the Nazi psychiatrists, it was perfectly reasonable scientifically sound research. And it has been studied, but the results are considered classified material to civilians.
APPEL: I fear one doesn’t have to go to Germany to discover unsettling research that investigators believed to be ethical. I highly recommend Harriet Washington’s Medical Apartheid for those who would like a powerful primer.
SCRY: Do you have working theories on what makes incorruptible people incorruptible? Or is all that locked away in the classified files at Fort Bragg and Nuremberg and the back offices of Peron, Pinochet, and Salazar. Joking. Sort of. Not really.
APPEL: The answer is that nobody knows.
SCRY: I just can’t help but disagree with you there.
APPEL: Presumably some combination of genetics and upbringing, but precisely which combination of gene and what particular formative experiences remain unclear.
SCRY: A short story and performance work of mine published in Tin House surrounds the case of Gerhart Kretchmar, an infant whose parents decided to have a Nazi doctor inject a fatal overdose due to the infant’s physical and developmental disabilities. There was extensive research and discussion within the eugenicists of that era – conversations that continue today – about whether those were parents who were corrupted by the purity ideals of the Third Reich, or whether the parents were incorruptible in their belief in compassionate euthanasia.
As someone who would have, as a child with epilepsy, been executed under Aktion T4, I have little capacity for objectivity on this. My immediate thoughts are that I would on the whole prefer to retain the agency for assisted suicide later on, if I decided my life was unworthy of life, rather than surrender that unilateral authority to others.
APPEL: Assisted suicide or aid in dying is a valuable tool that offers comfort to many terminally-ill patients as a last resort, whether or not they use it. Pediatric euthanasia is a distinctive phenomenon.
I have been a strong defender of the Groningen Protocol, a Dutch policy that permits such terminations in extreme cases. But these cases should be limited to those infants and young children who are so sick that they have no prospect of reaching adulthood to make their own decisions and will suffer terribly in the days or weeks they have remaining. No mainstream ethicist today would ever endorse euthanizing a child with epilepsy.
SCRY: I think that in certain cultures, mainstream ethicists would. I had a consultation regarding a potential pregnancy, and the Swiss gynecologist as explicit in her rage at me even possibly being pregnant, because it was not my right to introduce a child with epilepsy into society.
This has become something of a countdown, which was absolutely not my intention. Therefore, instead of moving to your second obsession, let’s skip to your first and then backtrack.
APPEL: You are the boss. I just work here.
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SCRY: Your first sacrificial lamb on the altar of SCRY was scientific fraud.
APPEL: Much attention has been paid recently to the reproducibility crisis in science and scientific fraud, but nobody seems to be asking what about our scientific culture creates the environment for this to occur.
SCRY: Yes. And you also pondered, “has science always been afflicted with this level of fraud or did something change?” I have more than a few toes in research science, and was at a physics conference as a mole and overheard a few conversations. I pressed the participants on their theories, and one of them emailed me a rather satisfyingly imposing link-list to studies that said much of the fraud in US-based scientific research is because “American science” has been corrupted over time by the influx of scientists – especially junior scientists – from Communist, Nazi, and Authoritarian regimes in which there was no training about separating “politics” and “ideology” from “the truth” or “data.” And that furthermore, these ethically-untethered refugees in the field of science were so frightened of negative repercussions that they felt faking results to survive was a necessary evil, and perhaps not evil at all.
I offer no commentary here, but ask for yours.
APPEL: I am doubtful of that theory. There certainly have been scientists of all different authoritarian persuasions in our laboratories over the years, but never the majority. And the major figures in these scandals from Bettelheim to Rosenhan tended to be anti-authoritarian in their outlooks. I fear the driving force is not ideology, but laziness and greed. Not sure which is worse.
SCRY: You also wondered whether it is “a selection effect or a treatment effect (ie. are we attracting the wrong people to science or are we doing something to make them go awry.)” The studies suggested that authoritarian regimes with state-sponsored scientific programs probably argues that it’s a treatment effect. I think of the mass arrests at the Physics Institute in Moscow this autumn. For undisclosed reasons, the intelligence agencies of Russia decided to both eliminate and intimidate a group of physicists.
Presuming they are freed, it may well be possible that they would attempt to emigrate or seek asylum outside of Russia. They might be very attractive in terms of other nations who would have the opportunity to select them. This suggests a selection effect – a scientific community in a different nation might find their skills enticing, but be comprehensively unprepared for complex PTSD, trauma-rooted behaviors, and other quite human phenomena in these scientists that could impact the research.
APPEL: That suggests a treatment affect in that particular case. But I think the overall verdict remains unclear.
SCRY: You return often to a certain opacity, and I question whether the opacity is by social design. Yet – moving on. You also asked how we can “change the culture of science to reduce the desire to cheat?” Like malingering, is there a diagnostic model to pull apart the taxonomies within the broadly-labeled term, “cheat”?
Is cheating a rather clear cut, condemnable urge, or is there also an underlying or adjacent system of survival urges that make cheating “more bad” or “less bad.”
APPEL: I don’t know if this has been studied, but my guess is there are people who set out to commit fraud and people who start off merely cutting corners and soon find themselves sliding down a slippery slope. I am reminded of the wisdom that one cannot lie to one’s spouse only once; similarly, fraud begets more fraud.
SCRY: Now we get to the juicy stuff – discipline and punishment. You asked, “What can we do to fix this beyond simply more detection and punitive measures?” One theory might be a series of mandatory certification trainings designed to weed out narcissists and so-called sociopaths, and simply unify the workers at all levels of the scientific community into a single official ideology – a code of conduct. Rules of engagement. Ethics courses are taught in nearly every doctoral program, but I wonder about that curriculum and methodology. It certainly isn’t working.
APPEL: Our system is not working in this regard. It may even be counterproductive, weeding out the wheat and promoting the chaff. What is needed now is some deep soul searching…..
SCRY: Deep soul searching does not typically receive research funding sufficient to satisfy a tenure committee. Perhaps this should change. I digress. But I am passionate about soul searching being a prioritized site, which it is not. Taking time for grief, for ethical conundrums, for existential perplexities is an indicator of social malfunction, rather than a crucial journey of the human condition.
I’m going to launch DOD, DARPA, DTRA (military income streams) and corporate income streams into the conversation as perhaps having a distortion effect on research. I’ll keep it easy by offering climate change research sponsored by non-renewable energy conglomerates. Violence and aggression research supported by the NRA. Gender-specific healthcare research sponsored by religious ideologies inside charitable foundation. Is the money not clean enough? Does it contaminate the data?
APPEL: I think it’s certainly true that various forces bias research. That being said, I think the influence on the content of studies is much less of a problem than the influence upon which topics are studied in the first place. The organizations and entities you mention help set the agenda. That is where their true power lies.
SCRY: Agency is not, therefore, driven by a legitimate needs assessment, but rather warped by tertiary agendae.
APPEL: In many instances. Sometime with the best of intentions, other times less so. All research reflects the agenda of a series of players – the investigator, the funding entity, etc. Even a needs assessment is the product of biased perspectives. I fear there are no easy solutions here.
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SCRY: Our climax is your second point. That’s sufficiently byzantine to satisfy my dislike for predictable structure. Your second overlooked obsession is, as you say, “the boundary between sanity and madness.”
APPEL: I am always struck by how close we all walk to the edge, a theme in my fiction, and how only a small push — a minor setback — can topple a person down a mountainside into a state of irrationality or desperation. I deal with this every day in my work in the psychiatric emergency room and it provides the basic for a number of my stories including the most well-known, La Tristesse des Herissons, about a man driven to the brink of madness by a depressed hedgehog.
SCRY: That’s eerie, because one of the childhood anecdotes I pull out in dull moments is the psychological counseling I had because our neighbors mistook my pet hedgehog for a pest, shot it, froze it, and later served it to me in a stew while my mother was hospitalized. Starving due to my father’s ability to only reconstitute dehydrated mashed potatoes from the navy surplus store, I gobbled it up before I was told the source of meat. Now I’m having flashbacks, and I can’t recall our larger point. Let me gather myself. Okay. How only a small push can topple a person into an impaired state of being.
APPEL: We are all very vulnerable. That is the human condition.
SCRY: Yet we can push others. I was a visiting professor in ethics at Yeshiva University, and a topic of several workshops was a project I made (performance, essay, poem, photographic series) about the women who were held prisoner in the rape brothels of concentration camps. The interrogating faculty posited that those women should have been urged to commit suicide rather than be defiled. To me, that represents a series of nested pushes over the edge. Both as a sexual assault survivor, and as someone who knew some of these female survivors personally during my work with them – it felt callous that a theoretical ethicist could tell me – and them – that they should have made the superior ethical choice of suicide.
APPEL: Yes, I don’t see how anyone can reasonably urge such a choice upon others under such circumstances. At the same time, I would certainly not judge these women if they did choose to take their own lives. Some situations are so horrific that they justify a wide range of human response.
SCRY: Can you murmurate a bit about this hedgehog story of yours, and others that surround this vulnerability to leaping or being pushed off into the typically fatal abyss?
APPEL: I figured you would ask about the hedgehog story (La Tristesse des Herissons). Almost everybody does.
SCRY: Scry is indeed almost everybody. Almost. Here, we consider the body a rhizome. But please, do carry on.
APPEL: It is one of a number of my stories in which characters operate on the brink of chaos. My favorite of them is “The Topless Widow of Herkimer Street” in which a middle-aged lawyer is driven to the edge by his widowed mother’s insistence upon sunbathing in her yard without a shirt.
SCRY: As lured as I am by the politics of public breast exposure, I will keep focused. What drew you to psych triage in a hospital setting?
APPEL: I love my job. It’s fascinating and I meet extremely interesting people with amazing stories. The frustrating part is that, because I’m a psychiatrist, I can’t share their stories.
SCRY: What keeps you there? Could you walk away without survivor guilt?
APPEL: They keep the doors locked. It’s hard to escape.
SCRY: That is so true. I have always been mesmerized by the double paned glass in between which is a venetian blind – this is common in psych units. And so often, I found dead flies in between the layers of glass. It’s quite confusing.
I was psych hospitalized as a teenager for PTSD after a sexual assault. The unit was really quite helpful, and kind, and helpful, and I was not in a hurry to leave. This is perhaps rather rare. But I did want to see if I could escape the locked ward and stole the key to the elevator that released access to the lobby. I called the unit from the lobby, quite pleased with myself, but requesting that they take me back. I just wanted to prove to everyone that I could leave whenever I wanted, and was there by choice. Could you leave if you wanted?
APPEL: In the short term, I could manage to leave the locked unit. But just like you, I’d be back sooner or later. I think I’m wedded forever to the psychiatric ER, for better or worse,
SCRY: Do we truly all walk that close to the edge? Are we all equal in that regard?
APPEL: Sort of like Orwell’s animals in Animal Farm, we all walk equally close to the edge, and yet some of us walk closer than others.
SCRY: Ad infinitum, fellow traveler.
BIOGRAPHY:
Jacob Appel’s first novel, The Man Who Wouldn’t Stand Up, won the 2012 Dundee International Book Award and was published by Cargo. His short story collection, Scouting for the Reaper, won the 2012 Hudson Prize and was published by Black Lawrence Press in 2014. His essay collection, Phoning Home (University of South Carolina Press, 2015) won the Eric Hoffer Book Award. Other recent volumes include Einstein’s Beach House (Butler University/Pressgang, 2014), Miracles and Conundrums of the Secondary Planets (Black Lawrence, 2015), The Magic Laundry (Snake Nation, 2015), Coulrophobia & Fata Morgana (Black Lawrence, 2016), The Topless Widow of Herkimer Street (Augsburg College/Howling Bird, 2016), The Mask of Sanity (Permanent Press, 2017), Millard Salter’s Last Day (Simon & Schuster, 2017), The Liar’s Asylum (Black Lawrence, 2017), The Amazing Mr. Morality (Vandalia/West Virginia University, 2018) and Amazing Things Are Happening Here (Black Lawrence, 2019). Four of these collections received starred reviews from Kirkus. Both Scouting for the Reaper and Miracles and Conundrums were on Small Press Distribution’s best seller list for over a year. A volume of ethics dilemmas for laypeople, Who Says You’re Dead?, is forthcoming with Algonquin.
Jacob’s short fiction has appeared in more than two hundred literary journals including Agni, Colorado Review, Gettysburg Review, Michigan Quarterly Review, Prairie Schooner, Southwest Review, Subtropics, Threepenny Review, Virginia Quarterly Review and West Branch. His prose has won the Boston Review Short Fiction Competition, the Arts & Letters Prize for Fiction, the Greensboro Review’s Robert Watson Prize, the North American Review’s Kurt Vonnegut Prize, the Missouri Review’s Editor’s Prize, the Sycamore Review’s Wabash Prize, the Briar Cliff Review’s Short Fiction Prize, the Salem College Center for Women Writers’ Reynolds Price Short Fiction Award, the Dana Award, the H. E. Francis Prize, the Devil’s Kitchen Reading Award for Fiction, an Elizabeth George Fellowship, a Sherwood Anderson Foundation Writers Grant, residencies at Yaddo and the Vermont Studio Center, and the New Millennium Writings Fiction Award on four separate occasions. He has been awarded first prize in the annual William Faulkner-William Wisdom competition in four distinct categories—essay, short story, novella and novel—making him the only author ever to achieve such honors. His writing has been short-listed for the O. Henry Award (2001), Best American Short Stories (2007, 2008, 2013), Best American Nonrequired Reading (2007, 2008), Best American Mystery Stories (2009, 2013), Best American Essays (2011, 2012, 2013, 2015, 2017), and the Pushcart Prize anthology (2005, 2006, 2011, 2014, 2015, 2018, 2019). Jacob’s stage plays have been performed at New York’s Theatre Row, Manhattan Repertory Theatre, Adrienne Theatre (Philadelphia), Detroit Repertory Theatre, Heller Theater (Tulsa), Curtain Players (Columbus), Epilogue Players (Indianapolis), Open State Theatre (Pittsburgh), Intentional Theatre (New London), Little Theatre of Alexandria and elsewhere.
He serves on the medical school’s admissions committee and the hospital’s institutional review board. In 2018, he was appointed Director of Ethics Education in Psychiatry. Prior to joining the faculty at Mount Sinai, Jacob taught most recently at Brown University in Providence, Rhode Island, at the Gotham Writers’ Workshop in New York City, and at Yeshiva College, where he was the writer-in-residence. He was honored with Brown’s Undergraduate Council of Students Award for Excellence in Teaching in 2003. He formerly held academic appointments at Pace University, Hunter College, William Paterson University, Manhattan College, Columbia University and New York University. Jacob holds a B.A. and an M.A. from Brown, an M.S. in bioethics from Albany Medical College, an M.A. and an M.Phil. from Columbia, an M.D. from Columbia University’s College of Physicians and Surgeons, an M.F.A. from N.Y.U. and a J.D. from Harvard Law School. He also publishes in the field of bioethics and contributes regularly to such publications as the Journal of Clinical Ethics, the Journal of Law, Medicine & Ethics, the Hastings Center Report and the Bulletin of the History of Medicine. His essays on the nexus of law and medicine have appeared in The New York Times, New York Post, New York Daily News, The Chicago Tribune, San Francisco Chronicle, Detroit Free Press, Orlando Sentinel, The Providence Journal and many regional newspapers.