Thursday, December 30, 2021

Waffling - A Rare Window Into Psychiatric Advocacy


Consider the following thought experiment:

[Ask yourself if you can think of a well-known proponent of psychiatry.  And if you can is there is a list of proponents as available to your thought process as the easily recalled list of detractors.]

First of all – Congratulations to the author for coming up with that thought experiment and wish I had thought of it myself.  Most psychiatrists are hard pressed to think of a single name.  The proponent  that came to my mind was Harold Eist, MD the only American Psychiatric Association (APA) President I recall who was a staunch advocate for front line psychiatrists, patient privacy, quality psychiatric care and the only outspoken critic of managed care.  But beyond that – nobody comes to mind. I have certainly worked with and become aware of first-rate clinicians, teachers, and researchers – but all of that seems to end when it comes to facing the withering attacks of many against the profession. At that level – the thought experiment is an immediate success.

This thought experiment was proposed by Daniel Morehead, MD in his article It’s Time for Us to Stop Waffling About Psychiatry in the December 2 edition of the Psychiatric Times.  He proposes the experiment after presenting a small sampling of the inappropriate and repetitive criticism against the field.  I started writing this blog with a similar intent and noted from the outset that responding to antipsychiatry rhetoric often resulted in attacks not from the originators of the diatribes – but often psychiatrists themselves. I was contacted by an expert in antipsychiatry philosophies who advised me that it was apparent that many psychiatrists seemed to have self-hatred and associated hatred of the specialty that they were practicing.  I viewed that as somewhat harsh – but did acknowledge a tendency towards self-flagellation as typically evidenced by acknowledging responsibility for criticisms that had no merit.

In Dr. Morehead’s paper – he reviews examples of attacks that nobody in the field seems to respond to and the resulting potential damage.  In his bullet points he lists the political arguments about biological versus psychosocial models of illness and treatment, the familiar identity crisis that only psychiatry seems to have, the accusations of corruption and conflicts of interest, books that describe psychiatry as either a completely failed medical specialty or one struggling for legitimacy as a medical specialty, psychiatric diagnosis is routinely attacked, and medications that have led to deinstitutionalization and have literally saved the lives of hundreds of thousands of people are vilified.  And that is a short list.

His conclusion that these criticisms “generate an image of psychiatry that is both wildly distorted and profoundly destructive” is as undeniable as his observation that there are rarely any responses to these diatribes from psychiatrists or other physicians. I would actually take it a step further and suggest that in many of these cases psychiatrists or other physicians are in the habit of piling on even in cases of the most extreme unfounded criticisms.  In fact, you can find many examples of this in the comments sections of my blog.  In the body of his paper Morehead takes on three common criticisms that are often viewed as definitive by people outside the field including the memes that psychiatric illnesses are somehow less real than physical illnesses, psychiatric medications make conditions worse, and psychiatrists are biological reductionists who are only interested in prescribing pills and some pharmaceutical company conflict of interest makes that bias even worse. I have addressed all of these fallacious arguments and many more on this blog. Morehead certainly provides adequate scientific refutations to these memes and concludes that:

“We live in an intellectual culture that has habituated the public to think of psychiatry as flawed, failed, corrupted, and lost.”

If only that were true. I think what most psychiatrists (and physicians in general) fail to grasp is that these endless arguments have nothing at all to do with science or an intellectual culture. In fact, the best characterization of these arguments is that they are anti-science, anti-intellectual, and rhetorical. Because this is a political and rhetorical process these fallacies give the appearance that they can’t be refuted. Those advancing these arguments seem to “win” – simply by repeating the same refuted positions over and over again.  In some cases the repetition goes on for decades - as long as 50 years! This tactic is a time honored propaganda technique and I would not expect it to go away by confronting it with science or the facts.

We have seen this clearly play out in other medical fields during the current pandemic. Government scientists who have been long term public servants are attacked and attempts made to discredit them – not on the basis of science, but on the basis of rhetoric.  The attacks are not made by scientists but most frequently by people with no qualifications, attempting to rationalize their attacks by whatever information they can glean from the internet or just make up. In some cases – the conspiracy theories being advanced are the same ones that psychiatrists observed in the late 20th century as applied to some clinical conditions.  Many of these attacks have gone from anti-science attacks to attacks on a personal level including threats against the scientist or his family. Financial conflict of interest can be significant as anti-science stars take on celebrity status floating for profit social media and mainstream media companies. Sponsors and believers in the anti-science message flock to these sites and generate significant revenues to maintain the message and the celebrities.  This discourse is the farthest possible from an intellectual endeavor.

This same anti-science and anti-intellectual posture is working against psychiatry and it has similar roots in the postmodernist movement.  Postmodernism was basically a movement against realism and in the case of science - facts.  Postmodernist discourse emphasizes relativism and an inability to construct reality.  One of the best examples is history. A postmodernist approach concludes that due to the limitations of language – actual history is not knowable.  The historian is merely telling one of many possible stories about what really may have happened. That has popular appeal as it is commonly acknowledged that history as taught in American schools clearly omitted a lot of what actually happened to and the contributions made by large populations who were marginalized by racist ideology.  That is as true in medicine as in any other field. But does that mean that the limitation of language and the application of current social constructs make the study and recording of history unknowable? Probably not and the problem with postmodernism is how radical the interpretation – can it be seen to encourage skepticism rather than outright rejection for example.

In the case of science as opposed to history, philosophy, and the arts – postmodernism does not have similar traction. The main features of science including an agreed upon set of facts irrespective of demographic or cultural features and science as a process does not lend itself to political or rhetorical criticism.  In the case of psychiatry, that is not for a lack of effort. The continuous denial that mental illness exists for example stands in contrast with the cross cultural and historical observations that severe mental illness clearly exists, that it cuts across all cultures, and that there is significant associated morbidity and mortality. It is however a classic example of postmodern criticism that it often suggests mental illness is really a social construct to maintain the power structure in society. The associated postmodern meme is psychiatry as an agency for social control over the eccentric defined as anyone who does not accept the predominate bourgeois narrative.

I first encountered this idea when I critiqued a New York Times article about the DSM-5 that suggested it was a blueprint for living (2).  That is an idea that is so foreign to any trained psychiatrist aware of the limitations of the DSM that it borders on bizarre.  And yet – here was a philosopher in the NYTimes making this claim along with several defenders in the comment section. At the time I was not really aware of this postmodernist distinction and responded just from the perspective that it was a statement that was not based in reality. Nonetheless, there were several defenders of the statement.  In retrospect all of this makes sense. Postmodernist critiques can amount to mere rhetorical statements. If you believe that reality is merely a battle of competing narratives – blueprint for living becomes as tenable as the reality of the DSM – a restricted publication with obvious limitations to be used only by trained individuals in a restricted portion of the population for clinical work and communication with other professionals. The large scientific and consensus effort is ignored – as well as the fact that societal control over anyone with a mental illness is the purview of law enforcement and the court system.

Similar repetitive postmodernist arguments are made about all of the examples given by Morehead in his paper.  For psychiatrists interested in responding to this repetitive and inappropriate criticism – it is important to respond at both the content level as Dr. Morehead has done but also the process level because the process level is pure post modernism and at that level realism or the facts on the ground may be irrelevant.

That brings me to what I would refer to as a second order criticism. Suppose you do respond to the criticism as suggested and suddenly find yourself being criticized by the same peers that you hoped to support?  Let me cite a recent example. Drapetomania is another criticism leveled at both psychiatry and the relationship that modern psychiatry has frequently claimed with Benjamin Rush, MD – a Revolutionary War era physician who has been described as the Father of American Psychiatry.  Of course, Rush was never trained as a psychiatrist because psychiatry was really not a medical specialty until the early 20th century.  He was really an asylum physician with an interest in mental illness and alcohol use problems.  He also advised Gen. Washington on smallpox vaccinations for his troops and treated people during Yellow Fever outbreaks. In other words he functioned as a primary care physician at the time.  Drapetomania and Dr. Rush are connected though a meme that suggests that the southern physician who coined the term also “apprenticed” with Rush.  Drapetomania was proposed as a diagnosis by Samuel Cartwright to explain why slaves running away was a sign of psychopathology rather than rational thinking. Cartwright himself was a slave owner and there was widespread interest among his peers in racial medicine. Despite this peer interest and the Civil War being fought around the issue of slavery – nobody ever used the diagnosis. It was openly ridiculed in some northern periodicals and largely ignored in the racial medicine publications. Rush was affiliated with the University of Pennsylvania Medical School over the course of his career and Cartwright graduated from a Kentucky medical school.  There is no evidence he ever matriculated at Penn or met Rush.  Despite that history drapetomania has been consistently marched out as a psychiatric “problem” and evidence of a failed psychiatric diagnosis for the last 40 years.  The implicit connection with Rush is also made – suggesting that as a mentor he may have had something to do with the racist pseudodiagnosis.

I did a considerable amount of research on drapetomania and connecting of Cartwright to Rush.  I was very fortunate to have definitive work available to me from Rush biographer Stephen Fried (4) and historian Christopher D. E. Willoughby (5).  The details of all of that research are available in this post that illustrates the lack of connections of drapetomania to Rush and psychiatry but also a very long period of time where it was not actively discussed.  Szasz (6) resuscitated the word when he published an article in 1971 that essentially concluded: 

“I have tried to call attention, by means of an article published in the New Orleans Medical and Surgical Journal for 1851, to some of the historical origins of the modern psychiatric rhetoric. In the article cited, conduct on the part of the Negro slave displeasing or offensive to his white master is defined as the manifestation of mental disease, and subjection and punishment are prescribed as treatments. By substituting involuntary mental patients for Negro slaves, institutional psychiatrists for white slave owners, and the rhetoric of mental health for that of white supremacy, we may learn a fresh lesson about the changing verbal patterns man uses to justify exploiting and oppressing his fellow man, in the name of helping him.” (4)

If you feel somewhat disoriented after reading that paragraph it is understandable. Szasz not only uses an example with no connection at all to psychiatry, but he creates a completely false narrative by using Cartwright’s racist work as a metaphor for psychiatry and then accuses psychiatrists of being rhetorical. This unbelievable screed was published in a psychiatric journal and the Szasz meme has continued in all forms of media since that time. It also happens to be a classic postmodernist technique of essentially making up a competing narrative and then writing about it like it is true.

Post-modernist memes like this invention by Szasz essentially cut across all of the inappropriate criticisms covered by Dr. Morehead and more. They are basically a vehicle for anyone with no knowledge of psychiatry to bash the field repeatedly over time and recruit like-minded postmodernists to do the same. The best examples of this process include the historical memes dating back to a time before there were any psychiatrists and the familiar themes of identity crisis, chemical imbalance, antidepressant withdrawal, epistemic injustice, psychiatric disorders as disease states, biological reductionism, the Rosenhan pseudo experiment, and more.

These memes are complicated by the fact that psychiatrists themselves are probably the only predominately liberal medical specialty and post modernism has an uneasy relationship with liberal or left-wing politics and overtly Marxism. This may leave many psychiatrists on the one hand feeling that their specialty is being inappropriately criticized, but on the other feeling like the criticism is justified on political grounds – even if it is grossly inaccurate or just made up. As long as it seems to be a liberal criticism, they support it. This may be the reason why the drapetomania meme was included as a legitimate topic in a recent American Journal of Psychiatry article on systemic racism (7).  It may also be why when I attempted to present my drapetomania idea another psychiatrist objected on the grounds of “social justice”.  How is a groundless accusation leveled against the profession a measure of social justice?  

In order to stop waffling, these complex relationships and the rhetoric of post modernism needs to be recognized. As I hope I pointed out – it is as unlikely that these memes will respond to factual refutation any more than I would expect antivaxxers or COVID conspiracy theorists to respond. A basic tenet of postmodernism is that the facts or actual history can never really be known with any degree of accuracy and it is always a matter of competing narratives. That may work to some degree in the case of disciplines where relativism exists, but it does not work well in medicine or science.

There needs to be a far more comprehensive strategy to counter postmodern rhetoric and its use against psychiatry. It needs to be limited in scope at first. It should be recognized in psychiatric publications so the memes are stopped at that level. Drapetomania is a prime example, but as noted above there are many others.   Trainees and residents in psychiatry need to be aware of this rhetoric in order to avoid confusion and demoralization. During an era when we are all more aware of our biases than at any other recent time, political biases that lead to acceptance of inaccurate rhetoric at the cost of the profession also needs to be recognized.

If that can be done – the waffling will be over.


George Dawson, MD, DFAPA



1: Daniel Morehead. It’s Time for Us to Stop Waffling About Psychiatry. Psychiatric Times December 2, 2021. Vol. 38, Issue 12.

2: Gary Gutting.  Depression and the Limits of Psychiatry.  New YorkTimes February 6, 2012.

3: Gutting, Gary and Johanna Oksala, "Michel Foucault", The Stanford Encyclopedia of Philosophy (Summer 2021 Edition), Edward N. Zalta (ed.),

4:  Fried S. Rush: Revolution, madness & the visionary doctor who became a founding father. Crown Publishing Group, a division of Random House LLC; New York, 2018

5:  Willoughby CDE.  Running Away from Drapetomania: Samuel A. Cartwright, Medicine, and Race in the Antebellum South. Journal of Southern History
The Southern Historical Association Volume 84, Number 3, August 2018 pp. 579-614; 10.1353/soh.2018.0164

6: Szasz TS. The sane slave. An historical note on the use of medical diagnosis as justificatory rhetoric. Am J Psychother. 1971 Apr;25(2):228-39. doi: 10.1176/appi.psychotherapy.1971.25.2.228. PMID: 5553257.

7: Shim RS. Dismantling Structural Racism in Psychiatry: A Path to Mental Health Equity. Am J Psychiatry. 2021 Jul;178(7):592-598. doi: 10.1176/appi.ajp.2021.21060558. PMID: 34270343

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