Wednesday, February 12, 2014

The Jerk Store Called

In response to a number of posts to my last post, I decided to take an idea posted by Dr. Steven Reidbord and run with it - but at his request I used a different descriptor than the one he suggested.  From my early days as a psychiatrist the general idea in our culture is that you basically listen to all of the criticism of psychiatry no matter how nonsensical it is and put up with it.  Act as though it is true.  In fact, go ahead and make public policy based on it!

One of the most frequent rationalizations for that passive behavior is that there are always some imperfections and therefore just about any criticism is justified - shut up and take it.  At some point it becomes obvious that line of logic excludes most reality.  When Dr. Reidbord requested that I not use his brilliant metaphor, the only other thing I could think of was the term "jerk".  That reminded me of the Seinfeld episode "The Comeback" and George Costanza's failed retort about the Jerk Store so I thought I would include it here.  The following post has otherwise been vetted by a philosophy professor and it looked good to him.

So here goes:

The Jerk Argument

It is a given that the the class of psychiatrists like all major subgroups of people and workers contains some jerks.  In this case a jerk can be defined as whatever a hater of psychiatry likes it to be.

Possible conclusions:

1.  All psychiatrists are jerks.
2.  Psychiatrists are inherently evil whether they are jerks or not, jerks are not really any worse.
3.  All psychiatrists should be treated like jerks whether they are jerks or not.

4.  It is possible to distinguish jerks from psychiatrists and treat each class accordingly.
5.  It is inaccurate at best to generalize to the entire class of psychiatrists what is observed in the jerks.

1-> 3 are positions of the various psychiatry bashers whether they are antipsychiatrists or not, or formal antipsychiatry philosophies or not.  That encompasses a full range of cults, lone critics with an axe to grind, academics, competing professionals, critics with a book or column to sell, and scandal mongers.  It may even contain some critics with a legitimate criticism but they end up including these additional invalid arguments in the body of their work.  These positions contain various logical fallacies and are unsupported at that level.  It is also interesting to contemplate that these initial conclusions are never applied to any other medical specialty and ideally are not applied to any group of people.  Think about substituting any other societal group in those sentences as see what you come up with.  Since they are illogical arguments the only possible conclusion is that psychiatrists as a group are clearly discriminated against and the basis for that discrimination is irrational.

Jerk logic also has implications for the way that the government and healthcare organizations treat psychiatrists.  The government and managed care attitude toward psychiatrists is probably most accurately captured in 3.   Every regulation and interaction with a managed care company reinforces that idea.  It could also be argued that the managed care industry is in the business of converting psychiatrists into jerks.  That is true if they are employed by the managed care companies directly or indirectly working on the "medication management" assembly line.

My positions are best represented by 4 and 5.  That is the evidence I focus on in this blog.  I have debated with myself about whether I should fight the bashers head on, but they generally not really interested in debating logic, scientific evidence, or any evidence contrary to their argument.  Per my previous post they are engaged in sophistry and will post endless fallacious arguments and say that ain't so.  So fighting them by definition is futile and they can aggregate to any number of psychiatry bashing sites on the Internet where they can revel in their rhetoric.

So if the basis of your psychiatry bashing lies in arguments 1 - > 3.

The jerk store called and  ...........

George Dawson, MD, DFAPA

Supplementary 1:  As I was preparing this post I noticed this post popped up on the Shrink Rap blog entitled Are Psychiatrists Evil? and that dovetails nicely with my small study in rhetoric.  There are several previous posts here that examine this rhetoric in different ways like The Myth of the Psychiatrist as Bogeyman  and Why Do They Hate Us?

Supplementary 2:  Per this previous post - the  antipsychiatry philosophies follow per the reference below.  It is also a good example of a potential critic with something useful to say but using invalid arguments of the form given in the body of the above post.  A standard tactic is falsely claiming that psychiatrists hold a certain position and then attacking that position as though it is true.

Fulford KWM, Thornton T, Graham G.  Oxford Textbook of Philosophy and Psychiatry.  Oxford University Press, Oxford, 2006: 17.

"Some of the main models advanced by antipsychiatrists, mainly in the 1960s and 1970s, can be summarized thus:

1.  The psychological model...
2.  The labeling model...
3.  Hidden meaning models...
4.  Unconscious mind models...
5.  Political control models..." <-Foucault is located here. (p. 17)

Supplementary 3:  Of course it is always important to recognize the bullshitters - Is Bullshit A Better Term Than Antipsychiatry?




11 comments:

  1. You can be competent and be a jerk and incompetent and be a mensch. Not seeing your point...

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  2. Well "wart" is probably a more encompassing term, but Websters does say that it is "a contemptibly naive, stupid or insignificant person". So the contempt dimension is there, but I would stretch it even more generically to whatever negative connotation the detractors want to use.

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  3. "Never argue with an idiot. The best possible outcome is that you win an argument with an idiot" ~ Richard Dawkins

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  4. Thanks for the credit and praise, although I don't deserve it (and my name has no "g"). I didn't realize "wart" also means "an obnoxious or objectionable person." I was only using it in the common idiom "warts and all" to mean "entirely, including features or qualities that are not appealing or attractive". I guess you could have used "warts" after all...

    I agree that views #1-3 are prejudices that should not be applied to any group, and that views 4 and 5 represent my position regarding psychiatry. However, I anticipate an objection from an articulate anti-psychiatrist: that psychiatrists are not jerks, but that our discipline or general endeavor is irredeemably "jerky" instead. I don't agree with this, but it may escape your rhetorical analysis so far. Or is that encompassed by view #3?

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    1. Sorry about the misspelling and I corrected it. I think your modified argument is the equivalent of 3 but it also has elements of 1 and 2. I may ask for some additional philosophical analysis. I was thinking more along the lines of homogeneous groups of people without redeemable features. Just as a hypothetical let's say sociopaths. In other words it may be possible to select a group based on a trait common to what we would use to classify jerks (eg. highly aggressive to exploit others). In that special case some of the arguments will fit, but it would be easy to demonstrate that general classes of employees and people cannot be segregated into that type of group and still function as expected as a group member.

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  5. I think this is a deflection. Most of the critical posts have been psychiatrists against the conflicted and out of touch psychiatric establishment for good reason, supporting OCare, supporting mangled care, supporting MOC, promoting the DSM money machine, not disclosing indulgences and conflict of interest, and APA Presidents being completely out of touch (why does insurance parity even matter when half of psychiatrists don't take it?). It really has nothing to do with jerks or who is a nice guy, but who is best for the field. Martin Luther was a jerk by all accounts but he was right about the Catholic Church. I could care less if the nice guy wins, I want the right guy to win.

    By the way, it isn't just the APA, the AMA is just as bad. The (once) major association for doctors supporting a 2700 page health care reform that made no mention of medical malpractice limitations (which are severe in all those idealized European countries).

    And just to be clear I am not singling out psychiatry, I would say acupuncture is the least scientific medical discipline (see sham acupuncture studies). And either pain management or back surgery (depending on the practitioner) to be the most potentially damaging to patients.

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    1. James,

      I think that we talking about different things. My analysis is of the rhetoric has to do with attacks like the 10 points in “Psychiatry Gone Astray”, the drapetomania rhetoric, the repeated accusations that the average psychiatrist out there is basically on the take, all of the rhetoric about how psychiatry is an inferior branch of medicine and how psychiatrist are interested in harming people by loading them up on useless drugs for the sake of Big Pharma profits.

      That differs quite a bit from criticizing the APA and AMA for being politically inept organizations that have repeatedly caved in to managed care and the government. I would call that legitimate and historically correct criticism.

      But I would also suggest that there is a gray zone. In that gray zone I would place the “appearance of conflict of interest” or ApCOI. I think that has become somewhat of witch hunt in psychiatry these days, especially in the context of personality conflicts and other issues at the national level. It is quite easy to look at many university professors and their personal employment arrangement with their employers and find something out of order. That is the nature of conspiracy theories. Accepting all of this innuendo and speculation, becoming indignant and condemning these people are totally unacceptable to me. Trying to turn that into some collective guilt that everyone in the profession has to share is even more unacceptable to me. Suggesting that psychiatrists need to be handled in a certain way because of the ApCOI is particularly egregious to me, especially when it is coming from a Congress that is fuled by whitewashed COI. It is the exact reason we find our profession run into the ground by the pencil pushers working for managed care and the government.

      The other problem with all of this rhetoric is that it creates a certain dynamic for professional critics. It allows them to identify with the aggressors against psychiatry and appear to have authority over the rest of the field. The implicit message is that the rest of us are just too damned dumb to realize that mental illness is a myth or that people can fake their way into a psychiatric hospital.

      Any reasonable person would be offended by these tactics. Only a beaten down specialty that sees no hope for the future would put up with this kind of bullshit. If the APA and AMA won’t get off their asses and take care of this business, we need to start doing it post by post in the blogosphere. I am certainly not waiting to hear anything about psychiatry in the New York Times.

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  6. I agree that the ApCOI thing is overblown and is now destructive and is killing innovation in pharma. See Stephen Stahl's 2011 editorial on the subject. However, in this atmosphere, Kupfer was inviting trouble by not disclosing the link to the testing company. As a student of human behavior, he should have understood what the reaction would be. BTW, I have no problem with dimensional models myself. Better than most of the categorical garbage in DSM-5.

    Certainly there is no creature more compromised than a congresscritter but for some reason we don't care. Actually the decline of the country through this corruption is not hard to understand, lobbyists are intense and focused and the taxpayer isn't individually affected enough to scream. This will change when the money finally runs out on the kleptocracy. Having Congressmen sit in judgment of KOLs is absurd, but again, some of them clearly let pharma influence their better judgment. The fiasco in opioid pain management is the best example of this.

    BTW having all the research money coming from government instead of the private sector won't stop the problem of influence either. Look at how corrupted climate science has become.

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  7. From the following reference:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3767378/pdf/nihms503098.pdf

    “The second major contribution of this study is documenting the prevalence of GIRs (government-industry relationships) at the NIH, before and after the implementation of the 2005 ethics rules. While previous studies have shown the pervasiveness of corporate affiliations within academia, this is the first empirical study to document a strikingly similar proportion of GIRs among NIH faculty. A comparable survey of 3080 academics from the top 50 grant-receiving institutions in 2006–2007 suggested that 52.8% of academic research faculty maintained some form of relationship with industry, while the data presented above show that 51.8% of all NIH research faculty were linked with industry before the introduction of 2005 ethics rules….”

    This was survey research of 900 NIH faculty. After the introduction of the “ethics rules” there were decreased self-reported government-industry relationships among NIH faculty (from 51.8% to 33.2%, P < .01), including significant drops in consulting (33.1% to 7.8%, P < .01) and scientific advisory board membership (31.5% to 16.0%, P < .01. This was a survey and the authors also conclude that morale and the perceived progress of research was lower even though the rate of publishing stayed the same.

    The numbers are interesting because as I have maintained all along GIRs among psychiatrists are trivial as a group compared to these rates or most major university engineering and science departments. Dr. Stahl is correct that drug development will and has suffered. And the critics are still using the old ApCOI argument continue to irrationally bash the entire profession.

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  8. You have made an interesting step here, because you look a bit like you are saying "All anti-psychiatry advocates are jerks"
    ... which implies that...
    "the only possible conclusion is that [anti-]psychiatrists as a group are clearly discriminated against and the basis for that discrimination is irrational."

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    1. You can only come to that conclusion by applying the extreme rhetoric of antipsychiatrists to themselves. One of my points is explicitly that kind of extreme rhetoric doesn't really apply to anybody - including psychiatrists.

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