Friday, March 2, 2012

Why Do They Hate Us?

The title of this column weighed heavily on the minds of some Americans immediately after the terrorist attacks of 911. I was involved in some Internet forum political debates at the time that looked at this question.  The question itself implies a lack of self analysis and misunderstanding of rhetoric and political strategy. Those same basic concepts can be applied to an analysis of psychiatry and the common political and rhetorical strategies that are used against us.

At this point some readers may suggest that this is quite a tangent for me to take given the fact that psychiatry after all is part of the medical establishment and as such should have very little to complain about.  Four or five decades of complaints from anti-psychiatry cults and about two decades of complaints from competing professionals has done little to diminish the influence of psychiatry.  If that is really the case, why has psychiatry been disproportionately affected in terms of resources available to treat patients and why are psychiatrists blamed for that?  I suggest that the discrimination against psychiatrists and their patients occurs at every level as the direct result of an antipsychiatry bias.

I first came directly in contact with hatred of psychiatrists in an unexpected setting – an academic team rounding on medical surgical patients.  It consisted of an attending, a senior resident, two interns and two medical students.  When the attending learned I was going to do a psychiatric residency, it was an opportunity for ridicule.  Didn’t I realize that psychiatrists were lazy and did not know what they were doing?  Didn’t I know that nobody with a mental health problem should consult with a psychiatrist?  The special attention focused on me peaked when this attending challenged me on the correct diagnosis of acute abdominal pain.  The patient was middle aged, obese and had acute abdominal pain with nonspecific exam findings.  What was my diagnosis?  When I said “appendicitis” – the attending said I was wrong and gave all of the reasons why the diagnosis was cholecystitis.  Several hours post op we had the diagnosis of acute appendicitis.  I learned more about what some physicians think of their psychiatric colleagues than the diagnosis of the acute abdomen during that rotation.

I came across an illuminating piece in the British Journal entitled Advances in Psychiatric Treatment. The author Claire Bithell of the Science Media Center in London showed that psychiatry was less likely to be reported on in the popular press and when it was, received treatment that was four times as negative as other medical specialties.  In an associated piece based on meetings with journalists, academics, clinicians and journalists she found problems at all levels in terms of engaging the media and one of the conclusions was that experts need to engage with breaking news stories to get important messages across to the public.
It is easy to prove to yourself that the same problem with the press exists in the US.  It is as easy as going to the New York Times web site and doing a quick search on psychiatry.  The search returns the articles and several commentaries on how psychiatrists are turning to medication management rather than psychotherapy,  an article on how the man accused of the mass shooting at Fort Hood was a psychiatrist, Radovan Karadzic was a psychiatrist, and an article about Carl Jung.  One of the central articles “Talk Doesn’t Pay So Psychiatry Turns Instead To Drug Therapy” gives the specific detail: “A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session”.  But at that point the author incorrectly concludes that competition from other mental health providers is the reason that psychotherapy is so poorly reimbursed.  He should have just applied his earlier conclusion that the dominance of large hospital groups and corporations in combination with the government essentially fixes insurance reimbursement to whatever the payers want to pay.  They do not want to pay for psychotherapy despite the fact that it is clearly an evidence based therapy.

The origins of bias against psychiatry are varied and include the continued misunderstanding of what we do and what our training is, fear of mental illness, and in many cases the pursuit of political goals.  We have seen attacks on psychiatrists by politicians, Hollywood stars, other psychiatrists, and of course anyone who wants to write an antipsychiatry book.  It can be very subtle such  as recognizing that there is no practical way that psychiatric services can be provided and shutting them down.  In this case it is common to blame psychiatrists for the “lack of access” rather than inconsistent and unrealistic reimbursement by payers.   I was talking to a highly reimbursed proceduralist one day who said that she didn’t mind that some of their margin was used to pay for psychiatry because it seemed like a needed service.

 At times the sheer amount of noise out there about psychiatry is deafening.  I don’t think we are alone when it comes to negative publicity.  Teachers and law enforcement come to mind.  I do not think that there is any doubt that public perception is affected by what is often false information about psychiatry. 

Apart from what is purely propaganda,  most people have an innate tendency to see themselves as armchair psychologists.  Artificial intelligence philosophers came up with the term folk psychology to discuss this tendency and its benefits.  If you are a folk psychologist you might conclude that it is so easy that a psychiatrist has nothing to add, especially when you watch other folk psychologists on television all day long.  Some of the people who have hated us the most have had their theories rejected by organized psychiatry.

From an organizational standpoint,  how do we respond to the hate?  Although it would serve us well,  I doubt the public is very familiar with the philosophical criticisms of folk psychology any more than they know the difference between a psychiatrist and a psychotherapist.  What can we do when we are being smeared on a routine basis?  Ignoring the attacks is a strategy that the APA has used for years.  From a strategic perspective – it is effective to a point.  That point is where some of our detractors gain either political advantage or there are sudden and unexpected changes.  Before that happens we need to be much more aggressive.

Since my early days of involvement with the Minnesota Psychiatric Society,  we have always believed that getting our message out to the public was a critical first step.  I was the Public Affairs Director in the 1990s and coordinated several of the initial National Depression Screening Days.  Today the majority of depressed people I see have been treated for at least 10 years by family physicians and although they were reluctant to see a psychiatrist , they really had no idea that I was a medical specialist.  MPS recently tried to get a letter published by local media on the mass shooting phenomenon.  We co-authored the letter with two mental health public service organizations and it was rejected at a time when there was peak speculation about whether or not the alleged perpetrator was mentally ill and others  were identifying heroes and suggesting that we move on.   Depending only on a biased press is a recipe for continued failure.

We need to start by recognizing that we all have a common interest here and it is called the psychiatric profession.  That is true if you are employed by a health care organization, the government or self employed.  That is true if your job is primarily research, patient care, or administration.  That is true if you are a medical student who has just been accepted to psychiatric residency.  When we are under constant attack – a short term solution is to cut and run.  That will not work in the long run.  We are currently the standard bearers for the kind of care that is possible and apart from our colleagues in other countries we are often shouting alone in the woods.  It is very clear that state and national governments and their allies in the business world do not care about reasonable standards of psychiatric care and in many cases have codified that.  Other advocates are often left to play one side against the other on an artificial playing field of constrained resources.  Psychiatrists have a common interest in making a stand against unfair treatment by both the government and the health care industry.

The other issue is how to make that stand.  We currently have political strategies with politicians and other groups with similar interests.  Those groups are not interested in our standards and we need to take those arguments directly to the public.  We have to let them know what inpatient units and state hospitals are capable of doing.  We need to let them know what state of the art community psychiatry looks like.  We have to let them know that outpatient psychotherapy for depression is actually more than a session or two and coming back every month or two to see somebody about medications.  We have to speak out on every topic of mental health interest in the media and presenting it ourselves rather than expecting the media to pick it up.  That is our job in the near future.

That is also in part what this blog is all about.


  1. The problem that psychiatrists will increasingly realise they have is that with time more psychiatric mental health issues including dementia will be recognised as the result of organic pathological brain disease. The need for doctors who have the capacity and training to understand and manage the manifestations of pathological processes, undertaking diagnosis and treatment with a range of tools and medications far outstretching the narrower view of psychiatrists will become more obvious in time.

  2. One of the reasons that many if not most of us go into psychiatry is our interest in the brain. Board certification in psychiatry requires examinees to pass a Neurology section. For 20 years I ordered brain imaging studies and reviewed them myself and taught this to medical students and residents. I was also the head if a Geriatric Psychiatry and Memory Disorder Clinic for many years. As a member of AAGP - I have routinely attended meetings where most of the content was on brain disease. I think that many people have a skewed image of psychiatrists sitting in an office and prescribing antidepressants when many of us are experts in organic brain problems and have produced some of the definitive works in that area (see Lishman's Organic Psychiatry).

  3. Hey there, I'm a med student from Europe. I'm not ashamed to admit that I love psychiatry because it is contrary to medical culture and that I'm a rebel by heart. I truly hate medical culture and medical people. I arrived there in a pretty random way, so I don't feel any sense of connection with these people. I find medical people to be despicable and I certainly don't want to become like them. I'm more of the philosophically inclined romantic and intellectual med student( understand, a medical misfit).

    I'm still hesitating between pediatrics and psychiatry...
    I must admit that psychiatry is more for the theoretical, open-ended, idealistic and more creative med student. I'm a musician and have always been attracted by the matters of the mind. I'm truly a misfit.

    I love the brain and the mind... more than the humans themselves.

    OK,I love psychiatry, so why Am I afraid to commit? Because of the perception.
    My family don't even know I'll be a psychiatrist... How are they gonna react once they find out their dear med students is about to get wasted and social suicide? Are they sill gonna love me? You must know that I fundamentally don't give a shit of what my family thinks.. I'm in the minority. Imagine how a more classical family person would feel?

    IN conclusion: Psychiatry is for unique people with a unique profile. I'm sorry but not everybody can become a psychiatrist. Just as not everybody can become a pediatrician or a surgeon. It's about a profile and sadly, the psychiatrist profile is a minority in the general population... and even more so in the medical field.
    Personally I don't care if people hate psychiatry... Minorities have always been hated anyways.

    1. Wow, I'm in the same boat as you, Anon above. Your situation is so similar to mine I almost teared up when I read your comment. I'm also a musician, and I see myself as a creative individual who has never been fully understood by others. I don't fit into the typical med student stereotype at all. I'm so tired of following expectations that have been pressured onto me since childhood, and now I want to find my own path. I'm also tossing up between paediatrics and psychiatry, although I'm more leaning towards psychiatry (or maybe i could combine into paediatric psychiatry?) Anyways, I know my family will not be happy if I make such a decision. I think I'm more of the "classical family person" you spoke of, because I know I would be deeply wounded if my family were upset. But I'm so done with rejecting my own happiness to make others happy. I think it's high time I live my life my way.