Why Finger-Pointing and Self Flagellation Don't Work

This post is an effort to address some of the rhetoric that is focused on psychiatrists by other psychiatrists. It can be traced back to some of the replies posted here on this blog. But the real impetus today is a thread on Twitter. Twitter is an interesting format for studying dynamics during discussions. It has significant limitations but some of the highlights are interesting. The thread of interest started out as an exchange between myself and another clinical psychiatrist on the issue of the intensive treatment of patients with psychotic disorders specifically early intervention. My responses noted below.

In my experience two groups are overlooked that result in chronicity:
-post partum psychosis
-bipolar disorder with psychosis

Have seen both groups poorly stabilized and rediagnosed as schizoaffective and then schizophrenia.

Both need very intense effort at first diagnosis.

— George Dawson (@dawso007) July 26, 2019

What followed was a fairly rapid deterioration in this exchange. There were the usual comments about how diagnoses are really “labels” and wouldn’t it be nice if we had a different name for the label. From there things progressed to talk about stigma and how it was a significant problem that we need to address. There was also the question about the “dark past” of psychiatry and how there needs to be some kind of atonement for that. I made the basic point that I don’t come from a dark past of psychiatry and there are more positive ways to proceed. From there, one of the posters who was a psychiatrist put up references to what he meant about a “dark past”.  His references were both highly problematic. For example, in the first reference he discusses drapetomania as one of the dark chapters in psychiatry without realizing that the term has nothing to do with psychiatrists. The term is straight out of the anti-psychiatry playbook.  In a second reference (1) there is a chapter from the Schizophrenia Bulletin on the political abuses of psychiatry. There are no references to the political abuses psychiatry in the United States. I might be concerned if I was practicing psychiatry in Russia or China.  It seems that if more countries had the patient safety and civil rights safeguards in place like the United States has - the political abuse of psychiatry would be far less likely.  The arguments about atoning for the “dark past” on the basis of the provided references appear to not apply to my statement about not needing to atone for anything.

As a person who understands rhetoric and who knows psychiatry, there are plenty of historical problems that can be characterized as problematic. That is true of any medical specialty. What is difficult to understand is why a person who is practicing psychiatry is criticizing the field using anti-psychiatry rhetoric. I criticize the drapetomania reference in this post that was written by a psychiatrist defining the field of critical psychiatry (par 10).  I will attempt to summarize the arguments and illustrate my approach.

1. Everyone is biased including psychiatrists- 

My position has always been that psychiatrists receive more extensive training in recognizing and eliminating bias than anyone. That is not a popular position to take in today’s political climate where the fastest way to win an argument is to suggest than someone has an unconscious bias that only you can recognize. The overwhelming evidence that what I am saying is true is basically the training of current and previous generations of psychiatrists. Psychiatrists learn how to talk to people from all backgrounds and cultures. They learn how to communicate with people who have difficulty communicating with other doctors or even their family members. They are trained in aspects of the interpersonal relationship that allow them to analyze that relationship both diagnostically and from a therapeutic standpoint. Beyond that it should be very clear that this communication process happens every day and multiple times a day. Psychiatrists are consulted for difficult analyze problems and they make medical diagnoses - in addition to psychiatric diagnoses - based on these communication techniques.  This is the the work of psychiatry and everybody I know in the field is there because they know it and they are interested in it.

2. Psychiatrists are biased against patients with particular diagnoses-

 One of the concerns that came up was that there are certain diagnoses specifically personality disorders that psychiatrists would prefer not to treat. In clinical practice no matter what your specialty, one of the professional goals is to find a certain niche. I preferred to treat patients who were very ill and many of them had significant personality disorders. There are different approaches to personality disorders and treatment can occur without using that diagnosis as long as there is a specific problem list. The other factor is the number of resources necessary to provide treatment. It is common these days for people to be referred for dialectical behavior therapy (DBT) whether they have the requisite diagnosis or not. That explanation will not suffice for people who believe that personality disorder diagnoses are inappropriate labels that should be eliminated and that they have a problem that has no specific treatment. The reality is that current treatments work and that is what psychiatrists are focused on.

I have had other physicians tell me that they wanted to go into psychiatry, but they experienced intense emotional reactions when talking with people who had certain diagnoses. That could be a specific personality disorder diagnosis or extreme affects associated with other conditions. It highlights the fact that psychiatrists want to be able to communicate with people that others avoid and they are successful at doing so.

3. Psychiatrists should listen to people who are critical or in some cases abusive because there needs to be an “atonement” with the past-

I got a reaction from some people because of my matter-of-fact statement that there is nothing for me to atone for. Interestingly, most of the psychiatrists holding this opinion are all from the United Kingdom. Irrelevant rhetoric aside, additional analysis might be useful. The first has to do with the way the criticism is presented. In a public forum it is common for people to attack psychiatrists and suggest that they are “arrogant” because they refuse to listen to a long list of complaints. At one point, a reference was made to problematic treatment in some institution. The poster referred to the fact that a patient had died from a bowel obstruction and alluded to gross mistreatment. The problem with that type of argument is - were psychiatrists involved? What were the specifics? Where are the authorities?

Whenever people have anonymously complained about psychiatrists and mistreatment I typically ask them why they have not filed a complaint with regulatory authorities. At least I used to do that until I realized they really don’t want an answer or solution. They just want to make psychiatrists look bad. I realize that I was dealing with a lot of people from the UK, but let me discuss how things go in the United States. There are federal and state regulations on the practice of medicine. The ultimate authority and whether a physician is disciplined up to and including loss of license is the state medical board. In the state where I practice, any complaint is thoroughly investigated. That means the complaint does not have to be accurate or even coherent. If any complaint is filed against a physician, the medical board contacts them and requests all of the relevant records and a response from that physician within two weeks. A failure to respond results in disciplinary measures that may include loss of license and the ability to practice medicine. There are independent entities that report on how many physicians are disciplined in every state and encourages people to file complaints. They have rating systems that suggest whether or not enough complaints are filed against physicians. That is a very low threshold for dealing with complaints about physicians.

All physicians must apply for a new medical license every year. On that medical license physicians must attest to the fact that they do not have any substance use problems, medical problems that impair their ability to practice, and have not committed any crimes. They also have to attest that they are not under investigation by any hospital, clinic, professional organization or the board of medical practice. All controlled substance prescriptions are tracked by physician and patient. In the state where I work there is also an Ombudsman who is located in the Governor’s office and is charged with investigating complaints against the vulnerable adults. Vulnerable adults by definition include people with mental disorders, addictions, and developmental disabilities. An Ombudsman investigation is totally independent from the medical board.

I can’t say what happens in the UK, but patient safety is a priority in the US rather than the reputation of any doctor. With all the safeguards in place,  I don’t know why anyone would post information on social media about being injured or abused by any physician without going through this process.

Since most physicians in the US are employees, that is another area of oversight. Practically all medical organizations solicit physician ratings from patients being seen and aggregate those ratings around each physician. They are used to “incentivize” physicians to get more optimal ratings. They are also used to intimidate physicians into doing what their administrators want them to do. Any significant complaint from a patient or a fellow healthcare professional would result in a physician needing to meet with an administrator.  That internal employer investigation must be reported to the medical board and credentialing agencies.

In the extreme, malpractice litigation is another source of oversight but there is an admittedly a mixed agenda. Malpractice litigation occurs both in the United States and the UK, suggesting to me that with some of the extreme scenarios described in social media this litigation would be an obvious approach.

These levels of physician oversight, suggests that the complaints leveled against psychiatrists in social media have either not been brought to the responsible authorities or they don’t exist. These processes also suggest that there is no room for a “dark” present at least not without discipline or loss of license. Physicians have a fiduciary responsibility to their patients and very clear accountability. Specific responsibility is a much clearer way to approach the problem than suggesting that everyone atone for some vague injustices.

 4. There are no unique psychiatrists and you don't have to be unique to do good work –

 The final bit of rhetoric that I encountered was in the form of a hashtag #NotAllPsychiatrists. The discussant in this case was another psychiatrist from the UK who suggested that using that hashtag as an argument to counter the blanket condemnation of psychiatrists “gets us nowhere”. He was suggesting that psychiatrists should listen to all possible complaints and that by using this hashtag “it suggests we are interested in listening”.  Unless you believe that most or all psychiatrists harm patients this is an argument based on a false premise.  The hashtag itself is as rhetorical as well as the statement that all complaints should be listened to by all psychiatrists.  Each psychiatrist listens to  the patient sitting directly in front of them. They have responsibility to that person.  The psychiatrists I know are preoccupied with not making mistakes and they generally do a good job of that.   A more appropriate hashtag to counter the blanket condemnations might be #PracticallyNoPsychiatrists.

This idea is not productive in other ways.  Direct observation of my colleagues suggests that we are all uniformly trained and the idea that one psychiatrist is “better” than another is a convenient illusion subject to context. I have seen more than one mistake made when a psychiatrist was blamed for something beyond their control and their colleagues were not supportive. That seems to be the dynamic operating here when discussions among colleagues suddenly become forums for complaints against psychiatrists. It is also a convenient way to just win an argument. In other words, there is no good reason for a psychiatrist to not want to listen to complaints about the profession in a conversation that started as a professional discussion about psychiatry. Case closed!

This is some of the rhetoric used against psychiatrists in social media and unfortunately much of the finger-pointing and self-flagellation is from psychiatrists themselves. I pointed out clear reasons why it is unnecessary. There are currently plenty of more functional avenues for complaints against physicians and they should be utilized.

And no psychiatrist out there should be suggesting that they have a superior position when it comes to caring for patients or endorsing blanket criticism of the field.



George Dawson, MD, DFAPA


References:

1:   van Voren R. Political abuse of psychiatry--an historical overview. Schizophr Bull. 2010 Jan;36(1):33-5. doi: 10.1093/schbul/sbp119. Epub 2009 Nov 5. PubMed PMID: 19892821
.

Supplementary:

One of the qualifiers for this post is that psychiatric practice is being compared between the US and the UK.  Reading literature written by psychiatrists from the UK for decades I can't imagine the practice there is much different.


Graphic Credit:

The "words have power" graphic is from Shutterstock per their standard user agreement.  The artist is gerasimov_foto_174.  I thought it was very appropo for this post because many of the intense critics and in many cases maligners of psychiatry have power as their predominate focus. Most psychiatrists don't see the world that way and in fact realize that in most cases we are lucky to be able to secure the most appropriate treatment for our patients.

Turning the United States Into Radioactive Dust

I don't know if you noticed, but it appears that the post cold war era is over.  The Putin appointed head of a Russian news agency Dmitry Kiselyov went on Russian television this morning and stated that Russia is "the only country in the world capable of turning the USA into radioactive dust."  In case anyone wanted to dismiss that as being short of a threat, he went on to say the President Obama's hair was turning gray because he was worried about Russia's nuclear arsenal.  We have not heard that kind of serious rhetoric since the actual Cold War.  As a survivor of the Cold War, I went back and looked at what time period it ran for and although it is apparently controversial the dates 1947 to 1991 are commonly cited.  I can remember writing a paper in middle school on the doctrine of mutually assured destruction as the driving force behind the Cold War.  In the time I have thought about it since, some of the cool heads that prevented nuclear war were in the military and in many if not most cases Russian.  We probably need to hope that they are still out there rather than an irresponsible broadcaster who may not realize that if the US is dust, irrespective of what happens to Russia as a result of weapons, the planet will be unlivable.

I am by nature a survivalist of sorts.  And when I detect the Cold War heating up again I start to plan for the worst.  The survivalist credo is that we are all 9 meals away from total chaos.  So I start to think about how much food, water, and medicines I will have to stockpile.  What king of power generation system will I need?  What about heating, ventilation and air filtration?  And what about access?  There are currently condominiums being sold in old hardened missile silos, but what are the odds that you will be able to travel hundreds of miles after a nuclear attack?  If you are close to the explosion there will be fallout and the EMP burst will probably knock out the ignition of your vehicle unless you have the foresight and resources to store it inside a Faraday cage every night.  There is also the question of what happens to the psychology of your fellow survivors.  In the post apocalyptic book The Road - a man and his son are surviving in the bleakest of circumstances on the road.  We learn through a series of flashbacks that their wife and mother could not adapt to the survivalist atmosphere and ended her life.  In one scene, they meet an old man on the road and the man gets into the following exchange with him after the old man says he knew the apocalyptic event was coming.  It captures the paradox of being a survivalist (pp 168-169):

Man:  "Did you try to get ready for it?"
Old Man:  "No.  What would you do?"
Man:  "I don't know"
Old Man:  "People always getting ready for tomorrow.  I didn't believe in that.  Tomorrow wasn't getting ready for them.  It didn't even know they were there."
Man:  "I guess not."
Old Man:  "Even if you knew what to do you wouldn't know what to do.  You wouldn't know if you wanted to do it or not.  Suppose your were the last one left?  Suppose you did that to yourself?"

By my own informal polling there are very few people who want to unconditionally survive - either a man-made or natural disaster.  Many have told me that they could not stand to be in their basement for more than a few hours, much less days or months or years.

For the purpose of this post, I want to hone in on the rhetoric or more specifically the threats.  I have had previous posts on this blog that look at how this rhetoric flows from the history of warfare and dates back to a typical situation with primitive man.  In those days, the goal of warfare was the annihilation of your neighbors.  In many cases, the precipitants were trivial like the theft of a small number of livestock or liaisons between men and women of opposing tribes.  In tribes of small numbers of people, even when there were survivors if enough were killed it could mean the extinction of a certain people.  Primitive man seemed to think: "My adversaries are gone and the problem is solved."

Over time, the fighting was given to professional soldiers and it seemed more formalized.  There were still millions of civilian casualties.  I think at least part of the extreme rhetoric of Kielyov is rooted in that dynamic.  Many will say that is is propaganda or statements being made for political advantage and in this case there are the possible factors of nationalism  or just anger at the US for some primitive rhetoric of its own.  But I do not think that a statement like this can be dismissed without merit.  There were for example two incidents where Russian military officers exercised a degree of restraint that in all probability prevented a nuclear war.  In one of those cases the officer was penalized for exercising restraint even though he probably avoided a full scale nuclear war.  In both cases the officers looked into the abyss and realized that they did not want to be responsible for the end of civilization as we know it.

I don't think extreme rhetoric is limited to international politics.  It certainly happens with every form of intolerance at one point or another if that intolerance is rooted in race, religions or sexual preference.  That is especially true if there are physical threats and physical aggression.  Intolerant rhetoric can also occur at a more symbolic level.  We have seen extreme rhetoric on psychiatry blogs recently.  Rather than the annihilation of the United States, the posters would prefer the annihilation of psychiatry.  I would say it is a symbolic annihilation but it is clear that many of them want more than that.  It still flows from the sense of loyalty to tribe, the need to annihilate the opponents, the necessary rigid intolerance and the resulting distortion of rational thought.  Certainly self serving bias exists to some extent in everyone, and it may not be that apparent to the biased person.  It took Ioannidis to open everyone's eyes to that fact in the more rational scientific world.  It can serve a purpose in science where the active process often requires a vigorous dialogue and debate.  Sometimes people mistake science for the truth when science is a process.  In order for that dialogue and debate to occur in an academic field there has to be a basic level of scholarship in the area being debated.  Without it there is a digression to tribal annihilation dynamics and complete intolerance.  That is counterproductive and negates any legitimate points that the proponents might otherwise have.

In science, the risks are lower.  At the minimum it adds nothing to the scientific debate.  An irrational bias with no basis in reality is the most primitive level of analysis.  In the 21st century, nobody needs to be annihilated in reality or at the symbolic level.

George Dawson, MD, DFAPA

Cormac McCarthy.  The Road.  Vintage Books.  New York, 2006.