I Don't Need Your Vote

Apple’s CEO Tim Cook came up with quote last week and I thought it was a good one:

“I’m not running for office.  I don’t need your vote.  I have to feel myself doing what’s right. If I’m the arbiter of that instead of letting the guy on TV be that or someone who doesn’t know me at all, then I think that’s a much better way to live.”

The original article began with an introduction about how Steve Jobs took a lot of heat and a lot of praise to protect the executives focused on Apple’s business and products.  Observers also note the activities of so-called “activist investors” trying to influence the management of the company into buying back stock for a quick short-term gain.  Cook is clear that he is all about long-term results and he is accountable for those results.  The same logic applies to what I do and have done for the past 30 years.  On the financial message boards there is constant noise with news and analysis of whether the stock price is going up or down.  After watching those trends it is clear that nobody knows the trends and that far fewer people know anything about the technology.  Many of those posts are placed there to manipulate opinion.  The critics don't know Tim Cook and the critics don't know me and clearly seem to have never met the psychiatrists that I know and work with.  Let’s take a look at how the so-called critics of psychiatry compare with the critics that Cook is addressing.  They can be broken down into several classes:

1.  The professional critic – criticism generally takes the form that I have special knowledge that no other psychiatrist has.  That knowledge can vary from the totally absurd (there is no such thing as mental illness or I am the only person to keep psychiatry honest) to more plausible exaggerations (I am the only person who can do this therapy, detect this side effect, prescribe this medication, etc.).  There is some legitimate criticism but it tends to be very rare.  I think the sheer number of internet articles by the same author saying the same thing may be an indication of volume substituting for quality.  The obvious message in many of these articles is that I am unique and everyone else is either ignorant, crooked, or stupid.   There are varying levels of conflict of interest (books, speaking engagements, the hero worship of various hate groups).  These critics are magnets for the haters of psychiatry who see them as modern day heroes and generally ignore the conflict of interest issues that their heroes use to criticize others.

2.  The journalist looking for an angle – the overall bias of journalism against psychiatry is well documented and wide spread.  Looking to sell papers or in these days mouse clicks is an obvious motivator.  In some cases the journalists just jump to books and web sites as sources of revenues and fame.  Even the most charitable interpretation of their work will note the obvious flaws.  Considering the DSM-5 a treatment manual or overestimating the impact of the DSM-5 when in fact most primary care physicians never use it are good examples.   While telling psychiatrists what their problems are when they have completely ignored the biggest stories in mental health for the past three decades that really have nothing to do with psychiatrists.  Those stories are how managed care companies and state and local governments have decimated the care for people with severe mental illnesses and addictions.  They have only recently picked up on stories related to incarcerating the mentally ill and trying to provide them psychiatric services in jail.  Not a stellar job of mental health reporting over the past 30 years.  As in the first category, some rare legitimate criticism exists.   

3.  The injured patient – certainly the treatment of psychiatric patients has the potential to cause injury like any other medical treatment and injuries do occur.  As I have posted several times on this blog, anyone who takes a medication that is FDA approved is at risk for side effects up to and including death.   As I have pointed out here (where you will not see in many other places) – the FDA decision can be purely political rather than scientific.  As a result, any medical or psychiatric treatment should be entered into very cautiously.   I have also posted here (and you will not see this in many places) that nobody wants to take a non-addictive medication and that people are generally hopeful that it will provide relief from a miserable condition.  I do not believe that people take any medications, especially psychiatric medications lightly.  I have outlined my clinical method to minimize side effects and adverse events.  Even with that high level of caution, side effects and adverse events will occur.  There are no shortage of remedies that can be pursued at multiple levels.  Most people resolve the problem immediately with their physician.   In the case where medical organizations are involved there can be direct complaints to the medical administration, hospital authority, or patient advocates.  At the state and licensing level complaints to the state medical boards and in some cases complaints to a mental health ombudsman can be made.  There are obviously malpractice attorneys.  Injuries caused by medical treatment are legitimate reasons for complaints and criticism but at some point I would hope that it would lead to a solution to a real problem.  I would also hope that nobody is compelled to sacrifice their medical confidentiality for the purpose of a complaint.

4.  The severely personality disordered – there is no good way to say it, but there are people who are very hostile to other people.  In many cases they aggregate around psychiatrists because that is where everyone else tends to send them when they cannot be dealt with.  Like any group of people in contact with psychiatrists, the vast majority of people with personality disorders are able to work on their problems in a productive way and do not turn treatment into a series of personal attacks.  But there are also the small fraction that do.  In many cases they target psychiatrists (and others) and their anonymous criticism is frequently irrational, heated and in some cases threatening.  They can attract like-minded people.

5.  The professional critic who is not a psychiatrist.  I posted my earliest experience of an irrational response by an attending physician when he learned that I was going into psychiatry.  In today’s politically correct landscape it would be classified as harassment and abuse.  Practically all of the psychiatrists I know have similar stories.  In fact, I personally have several more.  The unexamined irrational hatred of psychiatrists is just a fact that any psychiatrist has to deal with.  But when I hear a medical professional come up with some blanket statement about psychiatrists that is what it is all about.  I have examined in a previous post the basis for these generalizations.  Most physicians are at least are circumspect about why they did not go into psychiatry.  Most of them tell me they don’t want to deal with lethal violence or deal with the severely personality disordered.  Unless somebody points out this unexamined irrational thought pattern for what it is – it will never be corrected.  See my previous comment about it.  Or as the kids say these days haters be hatin' and leave it at that.

6.  The people who bristle when psychiatrists speak out against irrational criticism or even offer an alternate explanation are an interesting lot.  Some blogs seems to attract a lot of them, but I don’t frequent the more hateful blogs.  They are a self- righteous lot that looks as far as their own information.  They generally ignore any contradictory information and stick to their story or accusations.  They will attempt to bury any psychiatrist pointing that out with righteous indignation and sophistry usually by invoking victimhood  ("Noooo we are not antipsychiatrists – stop calling us that name!"),  hero worship ("You just aren’t as good as the psychiatrists who we agree with!") or the usual appeals to emotion ("It is so pathetic that these psychiatrists are just so (ignorant, evil, etc) and they just can’t accept our “facts”").  You can apparently say anything and really believe it is true.  Just so nobody forgets – it is true that psychiatrists are bogeymen.

Boo!

I am an experienced psychiatrist with 30 years of experience.   I have specialized in treating the toughest problems and the problem of lethal violence and severe mental disorders, often with significant medical comorbidity.  Like a neurosurgeon said to me at a serious point: “You guys treat the toughest problems that nobody else in medicine wants to treat.”  I have treated many more people than are mentioned in “case reports” and at this point in entire clinical trials.  I have as much experience as anyone in the safe and effective treatment of these disorders.  I encourage people to not tolerate side effects, use psychotherapy, and to be comfortable with the idea that I should be able to answer any questions they might have about my assessment or treatment recommendations.  Like all physicians I have much higher levels of accountability than most other professionals.  Like all physicians there is a rare day where I am not being harassed by someone who thinks they know how to do my job better than I do usually because it suits their business interests.  And I am the one with no conflicts of interest.  This is a non-commercial blog.  I have no books to sell.  I have no financial connections to any industry.   I couldn't care less if anybody ever paid me for my opinion.  So it should not be too surprising when I say:

I don’t need your vote.  I know what I am doing and that has been substantiated time after time – tens of thousands of times.  Further, I know how to read research and interpret the findings as opposed to the general lack of scholarship from those who assume they know more about my job than I do.  There are a handful of psychiatric experts that I consider to be authoritative and none of them are the usual media critics.  In fact, some of the media critics aren’t even psychiatrists and it shows.  But the best part is I am no different from my other colleagues that I consult and collaborate with every day.

They don’t need your vote either.

George Dawson, MD, DFAPA