A CRITIC TAKES ON PSYCHIATRIC DOGMA, LOUDLY

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
"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."