One of the best physicians I’ve ever worked with was a doctor who had previously lost his medical license. I met him during my first job out of fellowship, when I was medical director of a crisis center in Durham, North Carolina. A mentor of mine called me to ask if I’d help this doctor who was trying to get his full license back. He needed a job where he was supervised to satisfy the next step required by the medical board. Because our crisis center needed another physician to help evaluate patients, a salubrious match was made.
We started by seeing patients together so I could teach him the basics of our psychiatric mental health assessments. It didn’t take long for me to realize that he was an extraordinary physician. He was quirky, yes, as he had a slightly formal bearing in all his interactions that was oddly charming. But even though he was not trained as a psychiatrist, he quickly mastered the basics of prescribing psychiatric medications for patients in crisis. And when he applied his own specialty to the patients, I was awestruck with his knowledge (he later told me that, when he retook his specialty boards, he was disappointed he had missed a question).
I was most impressed, however, with his humility. He was gentle and kind to patients and staff. He was dedicated to the point that he would spend long hours at work, even with some of our most difficult patients. This brilliant and experienced physician, facing the consequences of an unfortunate series of events and decisions, could be forgiven for being impatient, short, or bitter. Instead, despite having to do the most basic work in psychiatry, treating a marginalized and under-resourced patient population under close supervision by a junior colleague just out of training, he was calm, friendly, curious, and open to feedback.
I felt a little embarrassed by his humility sometimes when I would give him feedback. He would make direct eye contact, nod, and very seriously and sincerely thank me for giving him even negative feedback. It was a very powerful and humble demonstration of his professionalism.
Later, when we started to have more personal conversations, he talked about being a Taoist (follower of the Chinese philosophy). When I asked more questions, he encouraged me to read The Tao of Pooh by Benjamin Hoff as an introduction to Taoism. I read that, and since then, I haven’t stopped reading and thinking about the Tao.
“Tao” in Chinese means “road/way/path/doctrine.” The central text in Taoism is the Tao Te Ching1 (“The Way and Its Power”), which was written or compiled around 250 BCE. The text contains about 5,400 Chinese characters organized in 81 chapters of laconic poems. These poems describe the central idea of the Tao: there is a powerful, mysterious, and hidden force in the universe (the Tao) that is both the root of all existence and a force that pushes life forward in a natural state of harmony.
According to Taoist thought, our human desires, strivings, and efforts to change things only bring things out of balance. The Tao Te Ching encourages us to be intuitive, not logical, and often uses metaphors and paradoxes.The Way never does anything
and everything gets done (Ref. 1, p 44).
Taoism emphasizes humility and simplicity and finding a way to “go with the flow” of the Tao. This is summarized in the Chinese term “Wu Wei,” which literally means “nonaction” or “not acting,” but can be also understood as “not forcing” or “flowing with the moment.”Who knows
doesn’t talk.
Who talks
doesn’t know.
Closing the openings,
shutting doors,
blunting edge,
dimming light,
be one with the dust of the way.
So you come to the deep sameness.
There you can’t be controlled by love
or by rejection.
You can’t be controlled by profit
or by loss.
You can’t be controlled by praise
or by humiliation.
Then you have honor under heaven (Ref. 1, p 67).
Following the Tao has encouraged me to be more passive and measured in my forensic psychiatry administrative roles.So a wise leader might say:
I practice inaction, and the people look after
themselves.
I love to be quiet, and the people themselves find
justice.
I don’t do business, and the people prosper on their
own.
I don’t have wants, and the people themselves are
uncut wood (Ref. 1, p 68).
The concept of inaction as a conscious choice is an interesting one in the world of forensic psychiatry. We live in a culture that glorifies individuals taking charge, taking action, and making changes. But how often do our actions end up working against ourselves? I can think of some situations where I took action in a difficult situation or with a difficult patient and ended up regretting my own intervention.
I can also think of how, in many administrative situations or evaluations I conducted, I just relaxed and allowed the situation to unfold. This enabled the situation to become clear, and I got the information I needed without forcing. I think if I had tried to strive, or push, or force an outcome in these situations, the result would not have been as good.
I am not arguing for complete passivity, and I acknowledge finding the right balance of action versus inaction can be difficult. I had a situation at work unfold over some years where a senior employee in another department with an important work function for the psychiatry department was being deliberately rude and difficult to me and my staff. This person was in a role where direct confrontation of the situation was challenging. We’ve all probably encountered these types of situations with people in various gatekeeping roles. A certain person has a role with limited but important authority over how you do part of your job. In this sort of situation, I’ve found you must weigh carefully the pros and cons of a confrontation.
When the problem started years ago, I chose not to directly confront the person in the beginning of their bad behavior. I later regretted this decision as it became clear this person had the type of personality that enjoyed wielding power and pushing boundaries. Things came to a head right before the person retired in a confrontation with a clinician from another department.
After this difficult person retired, I asked myself, did the Tao, and inaction, lead me down the wrong path? Did my inaction make things worse for my department and others? My conclusion from this situation is not that inaction is always the right choice and action is always the wrong choice, or vice versa. I’ve realized it would have been far better to address the problematic behavior immediately rather than waiting. It is when you choose to apply action, the timing of action, that is crucial.It’s easy to keep hold of what hasn’t stirred,
easy to plan what hasn’t occurred.
It’s easy to shatter delicate things,
easy to scatter little things.
Do things before they happen.
Get them straight before they get mixed up (Ref. 1, p 76).
I think Taoism holds wisdom for the practice of forensic psychiatry. There have been ethics debates for over 40 years outlining some of the paradoxes in our field, where we have one foot in the ethics system of medicine and one foot in the ethics system of the law. It has been personally enriching to attend recent American Academy of Psychiatry and the Law (AAPL) meetings and learn more about how AAPL members have wrestled with, and continue to wrestle with, the dilemmas and paradoxes that exist when we evaluate, diagnose, and treat patients.
I have even gotten to know some of these thinkers, and it makes it even more rewarding to look at some of the papers and arguments that the different leaders in our field have put forward. I had a chance recently to reread Glancy et al.,2 which summarizes well some of the different ethics schemas that have been put forward for forensic psychiatry.
It is interesting especially to think about these ethics dilemmas in our field as we weigh the changes in society and mental health treatment that have occurred during the last 40 years. For better or worse, it has never been more important to have well-trained and ethical forensic psychiatrists. Current trends and policies, and the well-documented worsening of mental health and substance abuse problems by justice-involved populations, point toward more, not fewer, patients encountering forensic psychiatrists.
The field of forensic psychiatry is considering whether to be more inclusive toward psychiatrists that function in correctional settings, where the ethics lines can be even more blurred. I think we will and should continue to consider this as part of the ethics dimensions of our field. On a practical level for myself, I think new papers or perspectives are less likely to measurably change my practice with patients, colleagues, and staff. In our own lives, we each must find our lodestones toward strength and professionalism.
I have mine:True goodness
is like water.
Water’s good
for everything.
It doesn’t compete.
It goes right
to the low loathsome places,
and so finds the way.
For a house,
the good thing is level ground.
In thinking,
depth is good.
The good of giving is magnanimity;
of speaking, honesty;
of government, order.
The good of work is skill,
and of action, timing.
No competition,
so no blame (Ref. 1, p 11).
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2025 American Academy of Psychiatry and the Law
References
