I drew the above graphic (click on it to enlarge) to highlight a few things about popular psychiatric criticism, but mainly that it is absurd. I have commented on antipsychiatry rhetoric many times in the past and how it has a predictable pattern. But this goes beyond antipsychiatry to include critics in the press, authors selling books (or being paid for lectures or appearances), and even critics in the field. I thought it might be useful to try to crowd as much of this rhetoric into one diagram as possible for easy reference.
Why is rhetoric so important? Rhetoric is all about winning an
argument. The strategies are all well
documented and you can read about them and the common fallacious arguments in
any standard rhetoric or logic text. My
goal is not to teach rhetoric. For the
purpose of this post, I want the reader to understand that there is more
rhetoric leveled at psychiatry than any other medical specialty. There is
always a lot of speculation about why that might be – but nobody ever seems to
come out and say the most obvious reasons – gaining political advantage or financial
renumeration. There is also dead silence on the questions of facts and
expertise - since practically all of the literature out there including much of
the rhetoric advanced by psychiatrists is an overreach in terms of psychiatric
knowledge and expertise. When absurd
rhetoric about psychiatry makes the New York Times or even prominent
medical journals it is simply accepted as a fact. There is no marketplace of
ideas approach or even a single alternating viewpoint. Some of the
statements in the graphic are taken directly out of newspaper articles and they
are absurd.
I happen to believe that the best critiques of the field
come from people who are experts and usually do not deteriorate into ad
hominem attacks against the field or other experts in the field. I was
trained by many of those experts who consistently demonstrated that a lot of
thought and work goes into becoming a psychiatrist and practicing psychiatry. I
have known that for 35 years and continue to impressed by psychiatrists from
around the world who contact me every day.
I sought feedback from psychiatrists through several venues
about absurd psychiatric criticism, by showing them a partially completed table
and asking for suggestions. One
suggestion was making a grid to evaluate plausible, implausible, and
unproveable. I do not think that is the best way to analyze these remarks.
There seems to be a lot of confusion about rhetoric versus philosophy and a
tendency to engage in lengthy philosophical analysis and discourse. It turns
out that a lot of what passes for philosophical critique of psychiatry is
really rhetoric. That rhetoric generally
hinges on controlling the premise and arguing from there. For example – the
statement that the DSM is a “blueprint for living” is taken directly out of a New
York Times article where the author – a philosophy professor was critiquing
the 2015 release of the DSM-5 on that basis. Never mind that no psychiatrist
ever made that claim or even had that fantasy – there it was in the paper
written like the truth. A reading of the first
25 pages of the manual would dispel that notion but it is clear
nobody ever seems to do that.
I seriously considered modifying the diagram based on a
division proposed by Ron Pies, MD (1). That
would have involved dividing the area of the graph into a zone of “legitimate
criticisms focused on problematic areas in psychiatry” versus “fallacious
and baseless attacks ... aimed at delegitimizing and ultimately destroying
psychiatry.” As I attempted to draw
that graph – I realized that I could not include any of the current statements
in a legitimate criticism zone. In order
to do that I will need to find an equivalent amount of legitimate criticism and
include it in a new graph.
This rhetoric has much in common with misinformation, except
it has been around for decades. It is not an invention of the Internet or
social media. An important aspect of rhetoric is that since it does not depend
on facts it can be continuously repeated. That is the difference between the
truth and facts versus rhetoric. The classic modern-day example is the Big
Lie of the last Presidential campaign. Former President Trump stated
innumerable times that the election was stolen by election fraud and at one
point suggested that there was enough proof that it allowed the Constitution to
be suspended. All that rhetoric despite no independent corroboration by any
judiciary or election officials from his own party. Major news services began reporting his claim
as a lie. Recent news reports revealed
that the stars of the news outlet that Trump was most closely affiliated with -
did not believe the election was stolen. Many of the statements leveled at
psychiatry in the table are equivalent to the Big Lie.
Rhetoric typically dies very hard and that is why it is an
integral part of political strategy. A current popular strategy is to use the
term woke as a more pejorative description of politically correct.
It creates an emotional response in people “You may be politically correct but
I am not.” The term is used frequently
to describe many things including the teaching of Critical Race Theory
(CRT) in public schools. Repetition alone has many Americans believe that CRT
is being taught in public schools and that is something that they should
actively resist. The fact is – CRT is not taught in public schools and yet the
effect of the rhetoric has been enough to leave many people outraged and
susceptible to political manipulation. The rhetoric itself is difficult to
correct by a long explanation about CRT.
That approach will not win any arguments. The best approach is to
characterize it for what it is at the outset – absurd rhetoric that is not reality
based. But there is a good chance that will also not have much impact.
When I talk with psychiatrists about the problem of not
responding to rhetoric – I typically encounter either blank stares, the
rejoinder that “there might be a grain of truth there”, or the suggestion that we should just ignore it
and it will go away. Physicians in general seem to be clueless about the effect
of politics and rhetoric on medicine and psychiatrists are no exception. When you are trained in science and medicine,
there seems to be an assumption that the scientific method and rational
discourse will carry the day. That may
be why we were all shocked when the American people seemed to be responding in
an ideological way to public health advice during the pandemic and they were so
easily affected by misinformation.
Rhetoric in science predates the pandemic by at least a
century. It has been suggested that
Charles Darwin used natural selection as a metaphor for domestic animal
breeding (1) in order to convince the predominately religious people and
scientists of the day. He had to argue
the position that unpleasant natural states were intermediate steps leading to
a more advanced organic state. Without
that convincing argument Darwin’s theory may not have received such widespread
acceptance in the scientific community. It is useful to keep in mind that just
presenting the facts is not necessarily enough to win an argument especially in
the post truth environment that exists in the US today.
The “grain of truth” rhetoric is typically used to
classify, generalize, and stereotype and may be more difficult to decipher than
straightforward ad hominem attacks. A typical “grain of truth” argument in the
graphic concerns pharmaceutical money being paid to psychiatrists and other
physicians. Some psychiatrists are employed by pharmaceutical companies to
conduct clinical trials and other business, some provide educational lectures,
and more are passive recipients of free continuing medical education
courses. All of this activity is
reported to a database where anyone can search how much reimbursement is
occurring. From this activity it is typical to hear that psychiatrists are on
the pay roll of, get kickbacks from, or are brainwashed by Big Pharma and KOLs
(Key Opinion Leaders). The reality is
most psychiatrists have no financial conflict of interest and they are not free
to prescribe new expensive medications because those prescriptions are
controlled by for-profit PBMs (pharmacy benefit managers). Further – the entire
issue was highlighted by a No Free Lunch movement that provided
essentially rhetorical information about conflict of interest and how it
affected prescription patterns. Those
arguments have a very weak empirical basis.
What about just ignoring this rhetoric? Ignoring it has
clearly not been a successful strategy.
Any quantitative look at antipsychiatry rhetoric and literature would
clearly show that it has increased significantly over the past 20 years – to
the point that papers written from this standpoint are now included in
psychiatric journals and you can make money doing it. Recent cultural phenomena including the Big
Lie rhetoric of the last Presidential election, the partial recognition of
climate change (despite firsthand experience with increasingly severe weather
most do not believe it is due to human activity), and the multilayered
problematic response to the coronavirus pandemic sends a clear signal that
rhetoric must be responded to and not ignored.
The American public has been fed a steady diet of absurd
criticisms about psychiatry for decades. If you do not believe that – study the
table and compare it to what you see in the papers and across the Internet. And never take anything you read about
psychiatry at face value.
George Dawson, MD, DFAPA
Supplementary 1: As noted in the above post I am interested in graphing legitimate psychiatric criticism in the same format used in the above graphic. If you have critiques and references - feel free to post them here. I have some favorites from Kendler, Ghaemi, and others.
References:
1: Pies R. Four dogmas of antipsychiatry. Psychiatric Times May 5, 2022: https://www.psychiatrictimes.com/view/four-dogmas-of-antipsychiatry
2: Herrick JA. The
History and Theory of Rhetoric. 7th ed. New York, NY: Taylor
and Francis, 2021: 221-223. – I highly
recommend this book on the historical and current importance of rhetoric. A lot
of what passes for philosophical criticism of psychiatry is really rhetoric.
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