key: cord-0926905-1g46coht
authors: Ratner, Austin; Gandhi, Nisarg
title: Psychoanalysis in combatting mass non-adherence to medical advice
date: 2020-10-19
journal: Lancet
DOI: 10.1016/s0140-6736(20)32172-3
sha: a3771ae1f3889ecaee8299710e446ac87dbceca8
doc_id: 926905
cord_uid: 1g46coht

nan

The USA's failure to contain COVID-19 has been spectacular from every angle. Looked at as a case of mass non-adherence to medical advice, however, it's unique in modern history. Never before have so many citizens had so much access to information and simultaneously protested public health recommendations with such full-throated denial of the medical facts. The media has covered psychological denial as a cause of non-adherence to public health recommendations for COVID-19, climate change, and other risks, 1 but public health officials have not, to date, employed the concept in a systematic way, if at all. We propose it is time that public health officials add the study and treatment of psychological denial to their toolkit for combatting medical nonadherence. To do that, we suggest a new partnership between the fields of experimental psychology, public health, and psychoanalysis-the field that first postulated defence mechanisms like denial, and still the only field that attempts to treat them.

While psychoanalysts have historically resisted collaborations with experimental psychologists and epidemiologists, 2 the time is ripe for change. After decades of insularity, the American Psychoanalytic Association has begun opening its doors and empowered constituents who have long sought more integration with experimental science and more involvement in public health. This is critically valuable at a time when psychological denial has thrust itself into the spotlight on multiple fronts as a genuine public health crisis.

Many cognitive scientists have documented denial 3 and related phenomena, like anxiety's power to compromise rational thought, 4 but they generally have not considered their findings vis-à-vis the psychoanalytic model of defence mechanisms, which might have helped explain the findings and suggested remedies. Insular-minded psychoanalysts of the past helped bring about this disconnect, but it would be a mistake to assume because of it that psychoanalysts have no help to offer. Denial surrounds us at present; to ignore psychoanalytic wisdom under the circumstances could justly be construed as another instance of denial.

How might psychoanalysts help to treat mass denial and mass nonadherence? Both epidemiologists and psychoanalysts solve problems by raising awareness; epidemiologists raise awareness of public health dangers, while psychoanalysts raise people's awareness of their own psychological defences, which work to push danger and anxiety out of consciousness, precisely because they are hard to contemplate. Although psychoanalysts cannot treat every case of denial individually, they can educate health-care workers and government leaders about denial, and work with them on effective messaging that helps dispel and delimit this serpentine psychological force.

In the best of times, medical nonadherence costs untold numbers of lives and hundreds of billions of dollars annually. 5 Commentators on non-adherence call for better communication. Since communication around unconscious defences is what psychoanalysts do, it makes sense to add them to the care team. We believe they are ready to join. AR participates as an unpaid, outside advisor on an advocacy, public information, messaging, and branding task force organised by the American Psychoanalytic Association. NG declares no competing interests. 

Covid, climate, and denial

The psychoanalyst's resistance to the task of proof

Denial makes the world go round

Anxiety and working memory capacity: a meta-analysis and narrative review

Adherence and health care costs