Why The Antipsychiatrists Have It All Wrong

Twitter is an odd place to read about antipsychiatry.  There are apparently some academics in the UK who are keeping it alive and well. I sent this Tweet about the continued mischaracterization of psychiatry by various antipsychiatry factions. Those factions certainly are varied ranging from cults to academics - but they all seem to have an agenda that they are promoting. I certainly don't hope to correct their various rants and obvious conflicts of interest - only to set the record straight from this psychiatrist's perspective.

In a previous post, I pointed out how some of the more famous antipsychiatrists characterize psychiatry as monolithic and fail to appreciate both the diversity in the field and the complexity of the field.  Examples of those errors abound and I included them in previous posts about the monolithic mischaracterization and another rhetorical attack on the DSM-5.

It comes down to power and that argument is a gross distortion of reality. Before I proceed, let me say that I am talking about the time frame that encompasses my training and clinical practice. At this time that is the last 32 years post residency. During that time I have lived and breathed psychiatry and know what really happens in the field.  I came in to this field with my eyes wide open since I had a family member with severe bipolar disorder who was treated for years by primary care physicians with benzodiazepines and antidepressants so that by the time she was able to see psychiatrists - she could be partially stabilized but continued to have significant comorbidity. That family member was my mother.  As her son, I experienced first hand the lack of concern and care by any responsible entity in the community.  When she was extremely agitated and ill to the point that the police were being called repeatedly, I know what it is like when you are a kid and an angry cop says to you: "Do you want us to lock her up like a chicken in a chicken coop?" The cop of course knew nothing about severe mental illness and just wanted to leave and not have to deal with my mother's illness and her 5 young kids (my father was deceased).  In addition to my mother's illness, I witnessed first hand the toll that psychiatric illness had on the neighborhood as I walked to school every day. My point here is that I am not the only kid who had these problems.  In fact, I am certain the general view that psychiatric illnesses and addictions are diseases begins with this experience.

As a clinical psychiatrist with a solid medical orientation, my method has always been one that tries to engage the patient in a detailed analysis and solution to their problem.  Like many physicians, as a resident there is always an emphasis on what you are doing to solve the person's problem, but it was fairly evident that medical interventions themselves were risky and that higher risk interventions should be reserved for high risk conditions. It was also obvious that medical treatment depended on informed consent.  In other words provide the information to the patient and they either consent or don't consent to treatment.  It is really no different than seeing any other physician.

Since antipsychiatrists are a diverse group, they advance diverse rhetoric to advance their agendas.  That typically includes making money or seeking to elevate their status over psychiatry.  I will focus on a single common agenda and that is power.  The last time I actually studied power it was in a physics class.  It certainly never came up in medical school.  Studying psychiatry was an identical process to studying medicine and surgery.  Recognize the problems, diagnose, and treat them.

Somewhere along the line I realized that people were using rhetoric based on Foucault and whatever Szasz adapted from that to suggest that psychiatry had a hidden agenda.  It is so well hidden that it is unknown to psychiatrists.  It is more or less of a conspiracy theory that psychiatry wants to medicalize the treatment of all human behaviors and treat those behaviors as an illness.  Of course along the way, psychiatrists will enrich themselves and inflict untold suffering on the people they misdiagnose and treat.  Take a look at this argument that the DSM-5 was supposed to be a manual about how to live as an example. Their supporting arguments range from the non-existence of all mental illness to the fact that there are no tests that prove there is such a thing as mental illness.  The underlying antipsychiatry theories are predominately from the 1960s and 1970s and they have been classified by philosophers (1).  There has been little change since then - just a long series of repetitive recycled arguments.  The rhetoric can range from the recycled arguments of Szasz to overt threats.  One uniform feature of antipsychiatrists is that they believe they are above any sort of criticism.

The table below contains some of the common rhetoric used by antipsychiatrists. It is not exhaustive, but it is a good example of the rhetoric I referred to in my Tweet.

Here is why their power arguments and all of the associated rhetoric are irrelevant. The reality is that psychiatrists represent only 5% of mental health providers in the US.  Primary care physicians and now nurse practitioners and physician assistants prescribe far more medications than psychiatrists do and they have for some time.  Even though psychiatrists are a little slow in picking up on it – health plans are replacing physicians with non-physician prescribers and that is also true of psychiatry.  In fact, in most cases if you are trying to see a psychiatrist about medications you will end up seeing a nurse practitioner. Does that sound like an all-powerful profession?

The second point that the detractors seem oblivious to is that physicians in general have not run the field of medicine for the past 35 years. Nobody cares what a psychiatrist or for that matter any physician has to say.  Businessmen and politicians determine who patients see, for how long, and what those physicians are paid.  The only exception is specialty groups (Radiology, Orthopedics, Neurology, Urology, Ophthalmology) that can avoid employment relationships with healthcare organizations.  Does that sound like an all powerful profession? Strange that the antipsychiatrists with guild issues don't get that since they are under the same constraints from these monopolies.  

More to the point – if you see any physician in the USA and you don’t like what you are hearing – you are free to walk away and see somebody else.  It is not a question of being a victim of medical or psychiatric treatment.  In fact, psychiatric treatment is just as straightforward as I have portrayed it.  Come in, sit down and we will talk about your problems. My job is to give you the best possible scientifically based advice.  Your job is to decide whether to take it or not.  There is no medical treatment known that does not involve some risk.  Accepting treatment involves risk. If you accept that risk and are injured that does not mean that you were intentionally victimized by that physician or the profession.  In fact, only antipsychiatrists seem to routinely use that argument. 

Consider an example very familiar to me. Let’s say you are diagnosed with a hormone secreting pituitary adenoma.  The neurosurgeon you are seeing recommends removal but also says there is a chance that the carotid artery may be cut and the result would be catastrophic and irreparable.  Your choices are an experimental procedure with an uncertain outcome that may lead to surgery or radiation therapy (gamma knife) or doing nothing and trying to manage symptoms that will lead to your eventual death by congestive heart failure.  The risks are clear and significant, but the majority of people who I have met who have had this conversation decided on surgery. Antipsychiatrists will say it is not the equivalent to a suicidal person deciding to take an antidepressant.  I would say the risk of no treatment is equivalent, but the actual risk of psychiatric treatment is much less.  I have not seen a catastrophic, irreversible event from taking antidepressants as prescribed.  As far as the power dynamic – there is no comparision.  Being unconscious under general anesthesia for hours while an ENT surgeon and a neurosurgeon drill through your sphenoid bone into your pituitary fossa doesn’t compare to consciously talking to a psychiatrist for an hour, picking up a prescription, and then deciding on a day to day basis to keep taking an antidepressant pill.  There is really no comparison at all.

The point of this example is not that patient injuries do not occur during patient care. The point is that they do occur but that is the risk people generally have to take to get well.  The notion that psychiatrists are somehow more likely to cause these injuries and that the entire profession should be blamed as a significant cause of injuries compared with other specialists is a dubious argument at best.   

Antipsychiatry rhetoric has really not changed much over the years.  There is just a question of how much distortion, overt paranoia, or conflict of interest it contains.  In the 50 years that the antipsychiatrists have been hard at work, they have had more than ample time to come up with an alternate way to help people with severe mental illness.  To my knowledge they have not come up with a single treatment for mental illness. Of course that is no problem if you don't believe mental illness exists or that there is any way to diagnose or treat it.

That would also mean that the antipsychiatrists would have to do something positive instead of just blaming psychiatrists.  I am not holding my breath for that day to come.

George Dawson, MD, DFAPA




References:


1:  Fulford KWM, Thornton T, Graham G.  Oxford Textbook of Philosophy and Psychiatry.  Oxford University Press, Oxford, 2006: 17.



Graphic Credit:

Samei Huda contributed 3 points on the graphic.

Marvel and Netflix Keep The Antipsychiatry Fake News Alive

I try to exercise an hour a day.  During that time I am either on a treadmill or an exercise bike.  If I am exercising in the house, I am watching television at the same time.  I watch a lot of television at the same time.  Entire series on Amazon, Netflix, or premium channels.  Some of this television can be motivating but even with all of that content bandwidth - I still find myself searching for the occasional independent film because there seems like there is nothing else out there.  About 80% of what I watch is on Netflix and a lot of that is science fiction.  The Marvel series on Netflix is a rich source of superhero type science fiction.  I noticed the latest addition The Iron Fist some time ago, but that name and the visuals were not all that inspiring.  At least until I stopped a very bad film dead in its tracks about 15 minutes in an switched over to Iron Fist.

In the opening moments we see a disheveled young man walking barefoot through New York City.  We find out that his name is Danny Rand.  He appears to be fairly naive.  At one point he announces that he is from a large family who owns a prominent building and the man he is talking to suggests that he should: "Sell the building an buy some shoes."  He tries to get in to the building to talk with Harold Meachum his father's former partner who is currently the head of Rand Enterprises.  He has to fight his way past security.  He encounters the adult Meachum children Ward and Joy.  They tell him that Harold is dead and they doubt his identity.  They say the Rands including Danny were all killed in a plane crash in the Himalayas 15 years ago.  He leaves but Ward Meachum dispatches his security forces to find Danny and beat him up or kill him.  After he dispatches the security guards he breaks into the Meachum home and eventually meets with Joy back at the company headquarters.

This is where several distinctly antipsychiatry themes start to kick in.  Joy drugs Danny and he is taken to what appears to be a small forensic psychiatric hospital.  He awakens there in five point restraints and is advised that he is on a 72 hour hold.  Over the course of that hold he is given many cups of what are supposedly psychiatric medications.  In some cases the orderly forces his mouth open with a tongue blade and pours the cup of capsules and tablets into his mouth.  On other occasions, the orderly comes  in with an absurdly large bottle of medication and draws the medication out of that bottle into a syringe and he is given an injection.  He is told that the medication is given to him so that he will "cooperate".  Cooperate is loosely defined as not becoming aggressive but also in some cases giving up the idea that he is Danny Rand.  In short, he is basically tortured on this inpatient unit.

To make  matters even worse, another patient disguised as a physician with a white coat is alone with him at one point when he is being restrained.  The viewer does not realize it at the time until this patient suggests that Danny kill himself and when that fails he sticks a fork under his chin and says he will kill him if he gives him the word.  The aggressive patient is eventually removed, but later reinstated as Danny's "tour guide" of the unit.  During that tour, he advises Danny of the folly of the 72 hour hold like this: "He was living under a bridge and came in here on a 72 hours hold.  Now he has paranoid personality disorder and he has been here for 5 years.  He was living on the street and came in on a 72 hour hold.  Now he has schizoaffective disorder and has been here for 3 years."  He simultaneously points out the folly of the 72 hour hold and suggests that people are just plucked off the street, labelled and stuck in a locked psychiatric facility for a long time.  In the span of 5 or 10 minutes we have seen a homicidal patient disguised as a doctor, threatening to kill the superhero, and then becoming a tour guide who is an expert commentator on psychiatric injustices!

Dr. Paul Edmonds is the psychiatrist on the floor.  He is pleasantly coercive at first.  He seems generally clueless about assessing acute care psychiatric patients and interacting with them.  He finally catches on that Danny Rand is who he really says that he is and acts professionally for a brief period of time.  He almost gets to the point where he will release Danny, but decides against it when he hears about how Danny is a Warrior Monk who is in possession of the power of the Iron Fist.  At that point Harold Meachum who has been watching all of the events in the psychiatric unit remotely and who has concluded that Danny is the real Danny Rand - sends in his security to take Danny out of the hospital.  In the finale to episode 2, Danny summons the Iron Fist power to dispatch the security guards who were beating him mercilessly and with a single punch - knocks down a large metal door confining him in the hospital.

There are numerous cliches about psychiatric treatment that are obvious in this episode.  The first is that psychiatric treatment is about social control.  In this case the Meachums have a problem when Danny shows up.  He owns 51% of the company stock.  They get him out of the picture by drugging him and taking him to a psychiatric hospital.  I have never seen that happen.  In real life, if a person in the emergency department shows up there drugged and points out that somebody did this to them, the police would be dispatched to pick them up for assault.  The associated dimension here is that the psychiatrist and the hospital are working for the Meachums and doing their bidding at least until Dr. Edmonds finally refuses to provide Joy confidential information on Danny.  In my 23 years of inpatient work, treatment was focused on the best interests of the patient, and confidential information was not provided without consent.  Forced treatment was portrayed in as heavy handed a manner as possible.  The patient was drugged to the point that he was "in control" and in one situation ready to cooperate by accepting a false identity.  Dr. Edmonds also appears to lack skill at two levels.  It takes him too long to find out who Danny really is and them it seems only by a bit of luck.  When he finally does that, he is unable to assess the patient's superhero story (trained warrior monk from the Mother of the Crane order in the mythical K'un-Lun that appears from another dimension once in every 14 years), see it for what it is and release him.  Any inpatient psychiatrist has seen and discharged their share of superheroes.  Delusional or not - treatment depends on local legal convention and the bias is heavily stacked toward no treatment by the courts and business systems.  Businesses don't want anybody spending any length of time in a psychiatric hospital whether they are stable enough for discharge or not.  But I suppose that is a far less dramatic premise than psychiatrists and psychiatric hospitals detaining people and torturing them.

At no point do we see legal representatives and representatives of the court to protect the civil rights of anyone who is on a legal hold or subject to involuntary treatment.  The viewers have to suffer through another skewed treatment of psychiatric care and an unenlightened view of the containment function of psychiatric units.

There is a clear mischaracterization of acute care or inpatient psychiatric units.  Anyone experienced with psychiatric disorders and severe addictions realizes that there are some mental disorders where the person's ability to self correct is gone.  That results in uncharacteristic behaviors that can include aggression, suicide, self-injury, and a long list of high risk behaviors that endanger health and life.  A common example is mania without psychosis.  The manic person can carry on a coherent conversation but may have been hospitalized because his or her judgment and decision-making was greatly impaired by the manic state.  A consistent treatment environment is required to assist that person in getting back to their stable mood and decision-making.  Having an appropriate treatment unit available can prevent life altering events that can be associated with severe mental disorders.  When I refer to a containment effect - it means providing a safe environment for these changes to occur and there are multiple pathways to stability.

I know a lot of people will say it's just a television show.  It is a television show with considerable viewership in a country with meager resources for psychiatric treatment.  It is a television show in a country that is a mill for antipsychiatry fake news.  It is also part of an ongoing process that stigmatizes people with mental illnesses and psychiatrists.  You only have to look as far as network television and Gotham or American Horror Story to find an equally grim depiction. It seems that the default horrifying and anxiety producing storyline is to go back to the old myth of the psychiatrist as bogeyman.

The treatment situation is so desperate that in current politically correct times - people with mental illnesses, their families, and doctors need to be treated realistically just like it would occur with any other disadvantaged minority.            

Get real with portrayals of mental  illnesses, psychiatric treatment, and psychiatrists and drop the unnecessary drama and distortion.  It deters people from seeking the safety and treatment that they need and keeps politicians and the businessmen in charge of medicine and cutting psychiatric services to the bone.

It's the 21st century and it is time to wake up and realize that there is an enlightened approach to these problems.



George Dawson, MD, DFAPA        

 

A Garage Door Lesson

I learned a valuable lesson from a garage door today that I thought I would pass along to some posters who think they know something about psychiatry and psychiatrists.....

I came home early this afternoon and hit my garage door remote, like I had done thousands of times in the past.  This time the door went up and seemed to hesitate and drop back about 2 inches, then it went all the way up.  I stepped out and noticed a bolt laying on the floor.  I picked it up and it was a 5/8 x 1 1/2 inch self-tapping bolt.  Looking around, I noticed that it has fallen out of the plate that fastens the garage door to the door itself.  The plate was bent and there was only one bolt left holding the door.  I grabbed a socket wrench and a ladder and headed up to where the door was suspended to fix it - about 5 or 6 feet off the floor.  It was immediately evident that the plate was bent at such an angle that I could not gain any purchase in the door with the free end of the bolt - or it was stripped.  Without thinking, I thought I would pull the emergency door release hanging just to my right to give me just enough slack to fasten the bolt.

In an instant, the arm assembly jerked my left hand very hard toward the door opening as the door crashed from fully open to fully closed in a less than a second.  I was propelled about ten feet through the air landing on the floor at the base of the door with some serious neck strain and a few sprains but otherwise, none the worse for wear.  I was somewhat stunned by all of this.  When I looked up I noticed the coil spring over the left side of the double garage door was snapped in half.  Directly in front of me was a warning that I had read many times before:

The universal "Don't turn your own wrench" sign.  I apparently ignored some pretty basic information that any professional garage door mechanic would not have.  It resulted in me getting knocked around pretty good and putting me at serious risk for a head injury, a spinal injury or death.  A few data points and I ignored them.  I also knew that garage doors were dangerous.  Just a few years ago, my brother showed me a healed scar across his palm that resulted when he attempted to repair a snapped garage door spring.  But where in all of this is the lesson for the inappropriate criticism of psychiatrists?

I should probably define at least part of what I consider inappropriate criticism and what a poster here has touched on as important dynamic.  On the sites where it is common for psychiatrists to post or sites that claim some legitimacy in the area of criticism, there are also some thoroughly hostile and malignant posts that are at the minimum inappropriate and at their worst pathological.  I have received a few directly here last week, but have decided that posts such as these will not appear on this blog.  I am aware that some people think that anyone should be allowed to criticize psychiatrists in any manner.  They are wrong.  People suggesting that I should "burn in the hottest part of hell" of course would be one example, but there are many more.

The garage door incident is instructive for at least some of them.  I recently saw a number of anonymous posts saying that psychiatrists can "just say anything" and that psychiatric credibility could be "shredded" in forensic settings.  Interspersing those arguments among supposedly legitimate critics takes the level of their arguments way down.  If these types of posts were always the case, it would be very easy to ignore a thread inhabited by barbarians.  I could certainly come up with a neat little definition of the barbarians but what is the point?   A related question is why those sites feel compelled to include this posts?  I don't think that is a passive or well thought out decision.  Once the discussion has headed into abusive, threatening, or irrational territory and it remains in fair play - that says a lot about the intent of the administrator.  At the very minimum, the intent is no longer a reasonable discussion.  Granted that it is often difficult to determine what is reasonable, given the overall tenor of the site.  For example, if I wrote a book bashing all psychiatrists and was promoting it on a site, why wouldn't I include every possible irrational post as evidence that I am correct?

It is much more instructive to look at the garage door example and what it implies for the basic argument that there is no such thing as mental illness and the closely related arguments - psychiatrists are not needed for the diagnosis and treatment of mental illness or that they have simply made up mental illness so that they can all be rich and drive expensive cars (another e-mail from one of the fans).  The garage door is a simple scenario with three critical points of information that any experienced person could observe - arm plate screw missing, arm plate bent, and left main garage door coiled spring snapped in half.  As an additional historical point I should add that in my experience these springs snap about every 15 years and this one was only 5 years old.   I observed 2/3 of the points thought I could make the repair and nearly had a catastrophic result.

In the case of a psychiatrist seeing a new patient, there are hundreds of relevant points that all have to be acquired and examined in the initial evaluation.  The total number of critical points is unknown, but to use just the example of a basic instrument for the assessment of suicide potential they number in at least the 20-30 range.  This assumes that the patient is able to respond appropriately to the questions.  There are at least another 20 or 30 points when it comes to the prescription of medications and coming up with a treatment plan.  As any affected family member can attest, severe mental illness or addiction is at least as serious as a crashing garage door that knocks you off a ladder.  It leads to trying to shake off the acute effects and prevent any long term harm.  In that event many people are seen and treated successfully by psychiatrists.  As I have posted here before, we are the people who are trained to see significant problems and the psychiatrists I know do a good job.

In practically all of the irrational criticism of psychiatry, none of these information points are covered.  People seem quite content to tar and feather psychiatrists with whatever seems fashionable at the time.  So this lesson is really one about the information content not typically being covered and how missing even a small point in any information set can be potentially problematic, and in my analogy, not just in terms of my own safety but the liability issue if anyone had been working with me.

I know that this lesson may be a stretch for some and in that case consider this a public service announcement for not trying to fix your own garage door.  Do not try it at home like I did.  Leave it to the professionals.

Oh - and I am not sorry to disappoint those who would have just as soon seen another psychiatrist bite the dust.

As far as I know - I am OK.



George Dawson,  MD, DFAPA

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

Heat Map of Psychiatric Criticism

On my drive home today I got the idea of a heat map of psychiatric criticism based on the principles outlined in my previous post.  I have started one as shown in the diagram below.  The heat zones on the map are general areas corresponding to the parameters outlined in the previous post on rhetoric.  In other words red and redder would correspond with more irrational and rhetorical criticism.  Green and greener would be more rational criticism and less rhetorical.  See the previous post for supporting arguments.

I have started out with a few examples in each zone.  I would like to be exhaustive here so send me your favorite one liners about the profession or your most hated psychiatrist and I will try to place it on the heat map.  Just a heads up, no personal attacks or identifiers will be tolerated.  It may be hard to believe but this is nothing personal.  I hope to provide a simple graphical solution to the question of what is and what is not appropriate psychiatric criticism.

I also thought about a couple of reasons why this is important.  Several years ago a friend of mine called me up and asked me a question about the American Board of Psychiatry and Neurology.   He wanted to know what year it was incorporated.  I told him I thought it was on my certificate and I would call him later.  When I got home I looked at the certificate and sure enough it read: "Incorporated 1934".   I called him with the information and asked him why that was important.  He is a social worker and told me that he was at a major DSM training course attended by social workers and the speaker (who was not a psychiatrist) suggested that psychiatry was such an illegitimate field that they were not even one of the original specialties and decided to form the ABPN later in order to seem more legitimate.  And this was a guy who was teaching a DSM course!  In another similar session, the presenter (also not a psychiatrist) compared the validity of psychiatric diagnoses referring to the Robins and Guze criteria to the validity of drapetomania.  For anyone not familiar with this definition, it refers to the idea by a 19th century quack that a slave running away is somehow a mental illness.  It really has no connection at all to the idea that there are valid mental illnesses that can be diagnosed and treated.  And yet here we have a professional making this comparison.  The term was also used in a periodical that is valued for its intellectual appeal, but the interview is embarrassing to read especially the tortured attempt to connect it to DSM-5.  My speculation is that the people who use this term have an additional agenda.  It is clear that there are are many uses of the loose application of this rhetoric and gaining political advantage is often an overlooked one.

As I look at my initial attempt, I am realizing that I need to figure out a way to group all of the statements at the top firmly in the red zone so that none of them touch the transition area to the green zone.

George Dawson, MD, DFAPA



Supplementary 1:

Here is a working list to consider (click to enlarge all graphics on this page).  This is the second version and as of today (2/16/2014) no outside suggestions.  The image below is formatted to print or store as a single 8.5 x 11 inch page:

The Jerk Store Called

In response to a number of posts to my last post, I decided to take an idea posted by Dr. Steven Reidbord and run with it - but at his request I used a different descriptor than the one he suggested.  From my early days as a psychiatrist the general idea in our culture is that you basically listen to all of the criticism of psychiatry no matter how nonsensical it is and put up with it.  Act as though it is true.  In fact, go ahead and make public policy based on it!

One of the most frequent rationalizations for that passive behavior is that there are always some imperfections and therefore just about any criticism is justified - shut up and take it.  At some point it becomes obvious that line of logic excludes most reality.  When Dr. Reidbord requested that I not use his brilliant metaphor, the only other thing I could think of was the term "jerk".  That reminded me of the Seinfeld episode "The Comeback" and George Costanza's failed retort about the Jerk Store so I thought I would include it here.  The following post has otherwise been vetted by a philosophy professor and it looked good to him.

So here goes:

The Jerk Argument

It is a given that the the class of psychiatrists like all major subgroups of people and workers contains some jerks.  In this case a jerk can be defined as whatever a hater of psychiatry likes it to be.

Possible conclusions:

1.  All psychiatrists are jerks.

2.  Psychiatrists are inherently evil whether they are jerks or not, jerks are not really any worse.

3.  All psychiatrists should be treated like jerks whether they are jerks or not.

4.  It is possible to distinguish jerks from psychiatrists and treat each class accordingly.

5.  It is inaccurate at best to generalize to the entire class of psychiatrists what is observed in the jerks.

1-> 3 are positions of the various psychiatry bashers whether they are antipsychiatrists or not, or formal antipsychiatry philosophies or not.  That encompasses a full range of cults, lone critics with an axe to grind, academics, competing professionals, critics with a book or column to sell, and scandal mongers.  It may even contain some critics with a legitimate criticism but they end up including these additional invalid arguments in the body of their work.  These positions contain various logical fallacies and are unsupported at that level.  It is also interesting to contemplate that these initial conclusions are never applied to any other medical specialty and ideally are not applied to any group of people.  Think about substituting any other societal group in those sentences as see what you come up with.  Since they are illogical arguments the only possible conclusion is that psychiatrists as a group are clearly discriminated against and the basis for that discrimination is irrational.

Jerk logic also has implications for the way that the government and healthcare organizations treat psychiatrists.  The government and managed care attitude toward psychiatrists is probably most accurately captured in 3.   Every regulation and interaction with a managed care company reinforces that idea.  It could also be argued that the managed care industry is in the business of converting psychiatrists into jerks.  That is true if they are employed by the managed care companies directly or indirectly working on the "medication management" assembly line.

My positions are best represented by 4 and 5.  That is the evidence I focus on in this blog.  I have debated with myself about whether I should fight the bashers head on, but they generally not really interested in debating logic, scientific evidence, or any evidence contrary to their argument.  Per my previous post they are engaged in sophistry and will post endless fallacious arguments and say that ain't so.  So fighting them by definition is futile and they can aggregate to any number of psychiatry bashing sites on the Internet where they can revel in their rhetoric.

So if the basis of your psychiatry bashing lies in arguments 1 - > 3.

The jerk store called and  ...........

George Dawson, MD, DFAPA

Supplementary 1:  As I was preparing this post I noticed this post popped up on the Shrink Rap blog entitled Are Psychiatrists Evil? and that dovetails nicely with my small study in rhetoric.  There are several previous posts here that examine this rhetoric in different ways like The Myth of the Psychiatrist as Bogeyman  and Why Do They Hate Us?

Supplementary 2:  Per this previous post - the  antipsychiatry philosophies follow per the reference below.  It is also a good example of a potential critic with something useful to say but using invalid arguments of the form given in the body of the above post.  A standard tactic is falsely claiming that psychiatrists hold a certain position and then attacking that position as though it is true.

Fulford KWM, Thornton T, Graham G.  Oxford Textbook of Philosophy and Psychiatry.  Oxford University Press, Oxford, 2006: 17.

"Some of the main models advanced by antipsychiatrists, mainly in the 1960s and 1970s, can be summarized thus:

1.  The psychological model...
2.  The labeling model...
3.  Hidden meaning models...
4.  Unconscious mind models...
5.  Political control models..." <-Foucault is located here. (p. 17)

Supplementary 3:  Of course it is always important to recognize the bullshitters - Is Bullshit A Better Term Than Antipsychiatry?