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
References:
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.), https://plato.stanford.edu/archives/sum2021/entries/foucault/
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
Graphic Credit:
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