The arbitrary and often absurd rhetorical attacks on psychiatry

 

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. 7^th 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.

More on Epistemic Injustice

 

I became aware of a paper on epistemic injustice (1) this morning and just finished reading the paper.  I wrote a blog on this topic with reference to one of the paper the authors discussed about 2 ½ years ago and I was interested in learning if the authors agreed or disagreed with my position. As suggested by the title – my position was that the concept of epistemic injustice was misapplied to psychiatry and further that it was misapplied in much the same way that other philosophical concepts have been. That misapplication typically begins with a false premise and the application of the concept is built upon that.

I took the original authors definitions of epistemic injustice in my original post.  The current paper defines epistemic injustice as occurring in two forms and once again I will quote the authors directly:

“Testimonial injustice arises when an individual’s factual report about some issue is ignored or taken to be unreliable because of individual characteristics that are not related to her epistemic (knowledge-having) ability.” (p. 1)

“Hermeneutic injustice… an individual’s knowledgeable reports fail to receive adequate attention because she, her listeners, or society as a whole lack the conceptual resources to interpret them.”

They give numerous examples both within and outside the field of psychiatry analyzing the arguments about why the epistemic injustice does or does not exist. I took the same steps in the previous blog post and my arguments were very similar to the authors of the current paper.  We basically agree that psychiatrists need to be focused on the subjective state of the patient.  That means we cannot arbitrarily discount what anybody says. We are also trained to not discount histories based on the demographic, social or interpersonal features of the patient.  In fact, we are the only physicians trained to recognize those tendencies and correct them.  The authors also agreed that all of the patient’s narrative need not be arbitrarily accepted and as an example they describe a patient who is at high risk for suicide and who is denying any risk in the emergency setting despite obvious evidence to the contrary.   They suggest just accepting the narrative for the sake of social justice may result in patients being placed at risk. I agree with that opinion.

I addressed this issue in my original post by describing what I consider to be the clinical method of psychiatry.  That involves listening carefully to the patient but at the same time deciding about the continuity and plausibility of the narrative.  This is a general process independent of any specific patient characteristic that recognizes all human informants make errors and that there are multiple reasons for these errors.  In other words, this general process needs to be applied to every patient professional encounter with a psychiatrist.  One of my mentors in residency also suggested that at some point it extends to everyone a psychiatrist talks with including informal contacts.  That means that psychiatrists may be analyzing many people that they encounter – but not in the psychoanalytic or mind reading sense.  

 The clinical process is important because it can refine the assessment and assist the patient in communicating the problems that brought them in to treatment. The goal of the interview is to establish a diagnosis and formulation and discuss them with the patient.  Agreement with the initial assessment forms the basis for treatment planning and the therapeutic alliance between the patient and the psychiatrist.  There are also therapeutic aspects to this communication.  Interventions like confrontation, clarification, and interpretation not only to improve the factual report but to assist the patient in recognizing active defenses that are limiting their insight into maladaptive behaviors and thought patterns.

The best way to counter any possibility of epistemic injustice is to keep teaching psychiatric methods exactly the way they are being taught right now.  Psychiatric trainees need to learn early on that analyzing the subjective communication is a rich source of information that cannot be denied, but may need to be clarified. There are never any clear reasons for rejecting this information – but like all psychiatric communication it all has to be seen through a critical lens and in some cases multiple hypotheses apply.

The authors have an interesting take as a footnote at the end of their paper on why some authors may be interested in applying a philosophical concept where it might not apply – especially if the critic is a psychiatrist.  There is after all an established pattern of some psychiatrists doing this.  From the paper:

“To the objection that psychiatrists are the ones writing some of these articles, we would suggest that being a psychiatrist does not protect one from misunderstandings – or more likely, misrepresentations – of one’s own field when in the grip of an idea. This should be no more surprising than the possibility of an anti-psychiatric psychiatrist, a familiar figure in the philosophy of psychiatry.”

The authors condense various motivations for misrepresentation as an intellectual idea.  That may be a possibility as a one off paper but what about a pattern over years and decades?  What about the associated self-promotion over those years? What about the inability to recognize the good work of hundreds of colleagues over that period or personal mistakes?  There are always many unasked and unanswered questions when it comes to an idea that criticizes an entire field of work.    

It is indisputable that no medical field has been mischaracterized more than psychiatry. Philosophy has been one of the vehicles used to do it. I hope that more papers are written to illustrate exactly how it happens. In the misapplication of epistemic injustice, it starts with a false premise and builds from there. Psychiatrists everywhere know that one of our best attributes is being able to talk to anyone and more specifically people that other physicians either do not want to talk with or are unable to. Most importantly – we are interested in talking with these people and can communicate with them in a productive manner. We do not get to that point by rejecting what people have to say or not paying attention to them.

The qualifier in my original post still applies:

“There is no doubt that people can be misdiagnosed. There is no doubt that things don’t always go well. There is a clear reason for that and that is everyone coming to see a psychiatrist has a unique conscious state. There is no catalog of every unique conscious state. The psychiatrist's job is to understand that unique conscious state and it happens through direct communication with that person.  That direct communication can happen only if the psychiatrist is an unbiased listener.”

There are plenty of external constraints that directly impact the time needed by a trained psychiatrist to interview and understand a person. That is probably a better focus for criticism than the continued misapplication of philosophical ideas.

George Dawson, MD, DFAPA

 

References:

1:  Kious BM, Lewis BR, Kim SY. Epistemic injustice and the psychiatrist. Psychological Medicine. 2023 Jan 5:1-5.

 

Waffling - A Rare Window Into Psychiatric Advocacy

 

Consider the following thought experiment:

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

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

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

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

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

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

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

We have seen this clearly play out in other medical fields during the current pandemic. Government scientists who have been long term public servants are attacked and attempts made to discredit them – not on the basis of science, but on the basis of rhetoric.  The attacks are not made by scientists but most frequently by people with no qualifications, attempting to rationalize their attacks by whatever information they can glean from the internet or just make up. In some cases – the conspiracy theories being advanced are the same ones that psychiatrists observed in the late 20^th 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 20^th 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:

Wikimedia: CC BY-SA 4.0 https://creativecommons.org/licenses/by-sa/, via Wikimedia Commons" https://commons.wikimedia.org/wiki/File:Waffles.png https://upload.wikimedia.org/wikipedia/commons/thumb/e/e8/Waffles.png/512px-Waffles.png

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.

Lancet Psychiatry's Inconsistent Look At Conflict Of Interest

The opening paragraphs of this editorial piece seemed promising, especially these lines:

It's not just about the money. In mental health, reputational interests exist alongside potential financial conflicts. There might also be deep-rooted interests based on professional identity. Our specialty sometimes resembles a field of conflict, or maybe some particularly ill-tempered football league—psychiatrists versus psychiatrists, psychiatrists versus psychologists, behavioural psychologists versus psychoanalysts, pill pushers versus therapists, and, as a forthcoming attraction, ICD versus DSM—a world of factionalism, rifts, ideology, personal philosophy, and ego (or should that be id?). (ref 1)

Unfortunately things rapidly fell apart after that point.  The above statements capture much of the position I have advocated on this blog from day one.  Anyone who is not aware of the purely political factors affecting some of the conflicts outlined in these sentences is extremely naive.  If anyone needs a more extensive scorecard, please refer to the graphic at this link.  On the other hand, the problem may be that I have a restrictive view of what the authors here refer to as "our specialty".  They seem to include a lot of other people than just psychiatrists.  Midwestern psychiatry may be a different culture than the rest of psychiatry.  I think we tend to view ourselves as physicians first and then psychiatrists.  We may be more comfortable talking with medical and surgical colleagues and medical knowledge is valued rather than denigrated.  We don't claim medical knowledge for the political advantage of seeming to be like other doctors.  We know a lot of medicine because we treat a lot of people with psychiatric and medical problems and consult in acute care settings.  Some of the conferences I see advertised and a few I have attended suggest to me that there are psychiatrists out there who do not have that interest in all things medical and neurological and may be more comfortable talking with non-physicians.   When I think about "our specialty",  I am thinking about those hundreds of medically oriented psychiatrists who I know who want to talk about taking care of people with severe illnesses.  People who are comfortable in hospitals and medical clinics.  People who know about the brain, labs, brain imaging, EEGs, and all things medical.

You might think that this is just another "faction" of a fractionated specialty, but it has been surprisingly seamless to me.  I trained in three major University settings in their core hospitals and affiliated Veteran's Hospitals.   When I got out, I practiced in community hospitals and clinics before coming back to a University affiliated tertiary care center.  The knowledge base of what needed to be diagnosed and treated was uniform across all of those settings.  I could expect highly competent psychiatrists available in those settings to consult with and for cross coverage.  The focus was always excellent clinical care and avoiding mistakes.  It did not resemble the confederacy of dunces described in this editorial and frequently in the popular press.  The practical issue is that practicing in acute care settings focuses the type of care that needs to be delivered.  People need to get better, and they need to get better in a hurry.   All of the debates wash out in the bright light of pragmatism.  If your plan cannot be enacted and result in clear improvements, you don't last long in that environment.  The potential complications alone will make you look bad.  The results of a clinical trial of a medication in completely healthy adults is irrelevant.

Turning the management of the world's most expensive health care system over to a for-profit industry capable of skimming hundreds of billions of dollars off the top for what amounts to a rationing scheme is a uniquely American solution, so I would not expect a lot of recognition in a British journal.  Medical journals make it seem like we are all practicing the same brand of medicine independent of cultural and political constraints.  I doubt that the editors in these situations will prove any more savvy than American editors who seem to ignore the fact that, managed care and everything that involves dwarfs the pharmaceutical industry in terms of conflicts of interest affecting the care of patients at least in the United States and that pro-managed care articles deserve at least as much scrutiny as papers written about pharmaceuticals.

The authors use about 1/3 of their space to criticize Rosenbaum's New England Journal of Medicine series on conflict of interest and the term pharmascolds.  They get one point correct, good research should not be ignored irrespective of who is funding it.  Like other critics of Rosenbaum, they wax rhetorical in their criticism and side step the numerous valid points that she makes.  They suggest that they should be focusing on a larger number of conflicts of interests ranging from the potential financial gains from various non-pharmacological innovations to "professional vendettas" but provide very little insight into how that might occur other than continuing to "question, query, probe, and interrogate" beyond the usual financial conflict disclosure.

On that procedure, I will say good luck to them and editors everywhere.  The Institute of Medicine inspired approach (2) of considering the appearance of conflict of interest and conflict of interest to be equivalent and unevenly applying that to one industry while completely ignoring the insidious effects of another has done very little to  "strike the right balance between addressing egregious cases and creating burdens that stifle relationships that advance the goals of professionalism and generate knowledge to benefit society."

There is no better example than a health care system that systematically discriminates against mental illness and addiction and does that on the basis of questionable research based on business rather than scientific principles.  The editors could start to expand their probing to spreadsheet research that looks at the purported "cost effectiveness" of managed care or collaborative care and question any associated reported quality measures.  It is always amazing how new research compares a relatively trivial case management intervention to "care as usual", when that terrible care was the product of early research on how care can be rationed.   A good starting point might be a requirement analogous to "refusing to publish non-research articles on depression from authors who have received unrelated funding from pharmaceutical companies that market antidepressant." by refusing to publish opinion pieces from opinion leaders in the business of rationing mental health services.  Refusing to publish research articles that compare rationed to less slightly rationed care would be another.

If medical research is really supposed to be generating knowledge that benefits society, where are the state-of-the-art models for psychiatric care that can set this standard?  That is what editors everywhere should be looking for.  

George Dawson, MD, DFAPA

Ref:

1:  Conflict Resolution.  The Lancet Psychiatry 2015, Volume 2, No. 7, p571, July 2015

2:  IOM (Institute of Medicine). 2009. Conflict of Interest in Medical Research, Education, and Practice. Washington, DC: The National Academies Press.

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.

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?

"Preventing Violence: Any Thoughts?"

The title of this post may look familiar because it was the title of a recent topic on the ShrinkRap blog.  That is why I put it in quotes.  I put in a post consistent with some the posts and articles I have written over the past couple of years on this topic.  I know that violence, especially violence associated with mental illness can be prevented.  It is one of the obvious jobs of psychiatrists and one of the dimensions that psychiatrists are supposed to assess on every one of their evaluations.  It was my job in acute care setting for over 25 years and during that time I have assessed and treated all forms of violence and suicidal behavior.  I have also talked with people after it was too late - after a homicide or suicide attempt had already occurred.

The responses to my post are instructive and I thought required a longer response than the brief back and forth on another blog.  The arguments against me are basically:

1.  You not only can't prevent violence but you are arrogant for suggesting it.
2.  You really aren't interested in violence prevention but you are a cog machine of the police state and inpatient care is basically an extension of that.
3.  You can treat aggressive people in an inpatient setting basically by oversedating them.
4.   People who are mentally ill who have problems with violence and aggression aren't stigmatized any more than people with mental illness who are not aggressive.

These are all common arguments that I will discuss in some detail, but there is also an overarching dynamic and that is basically that psychiatrists are arrogant, inept, unskilled, add very little to the solution of this problem and should just keep quiet.  All part of the zeitgeist that people get well in spite of psychiatrists not because of psychiatrists.  Nobody would suggest that a Cardiologist with 25 years experience in treating acute cardiac conditions should not be involved in discussing public health measures to prevent acute cardiac disorders.  Don't tell anyone that you are having chest pain?  Don't call 911?  Those are equivalent arguments.  We are left with the curious situation where the psychiatrist is held to same medical level of accountability as other physicians but his/her opinion is not wanted.  Instead we can listen to Presidential candidates and the talking heads all day long  who have no training, no experience, no ideas, and they all say the same thing: "Nothing can be done."

It is also very interesting that nobody wants to address the H-bomb - my suggestion that there should be direct discussion of homicidal ideation.  Homicidal ideation and behavior can be a symptom.  There should be public education about this.  Why no discussion?  Fear of contagion?  Where does my suggestion come from?  Is anyone interested?  I guess not.  It is far easier to continue saying that nothing can be done.  The media can talk about sexual behavior all day long.  They can in some circumstances talk about suicide.  But there is no discussion of violence and aggression other than to talk about what happened and who is to blame.  That is exactly the wrong discussion when aggression is a symptom related to mental illness.

So what about the level of aggression that psychiatrists typically contain and what is the evidence that they may be successful.  Any acute care psychiatric unit that sees patients who are taken involuntarily to an emergency department sees very high levels of aggression.  That includes, threats, assaults, violent confrontations with the police, and actual homicide.  The causes of this behavior are generally reversible because they are typically treatable mental illnesses or drug addiction or intoxication states. The news media likes to use the word "antisocial personality" as a cause and it can be, but people with that problem are typically not taken to a hospital.  The police recognize their behavior as more goal oriented and they do not have signs and symptoms of mental illness.  Once the psychiatric cause of the aggression is treated the threat of aggression is significantly diminished if not resolved.

In many cases people with severe psychiatric illnesses are treated on an involuntary basis.  They are acutely symptomatic and do not recognize that their judgment is impaired.  That places them at risk for ongoing aggression or self injury.  Every state has a legal procedure for involuntary treatment based on that principle.  The idea that involuntary treatment is necessary to preserve life has been established for a long time.  Civil commitment and guardianship proceedings are recognition that treatment and in some cases emergency placement can be life saving solutions.

The environment required to contain and treat these problems is critical.  It takes a cohesive treatment team that understands that the aggressive behavior that they are seeing is a symptom of mental illness.  The meaning is much different than dealing with directed aggression by people with antisocial personalities who are intending to harm or intimidate for their own personal gain.  That understanding is critical for every verbal and nonverbal interaction with aggressive patients.  Aggression cannot be contained if the hospital is run by administrators who are not aware of the cohesion necessary to run these units and who do not depend on staff who have special knowledge in treating aggression.  All of the staff working on these units have to be confident in their approach to aggression and comfortable being in these settings all day long.

Medication is frequently misunderstood in inpatient settings.  In 25 years of practice it is still very common to hear that medication turns people into "zombies".  Comments like: "I don't want to be turned into a zombie" or "You have turned everyone into zombies" are common.  I remember the last comment very well because it was made by an observer who was looking at people who were not taking any medication.  In fact, medication is used to treat acute symptoms and in this particular case symptoms that increase the risk of aggression.  The medications typically used are not sedating.  They cannot be because frequent discussions need to occur with the patient and a plan needs to be developed to reduce the risk of aggression in the future.  An approach developed by Kroll and MacKenzie many years ago is still a good blueprint for the problem.

There is no group of people stigmatized more than those with mental illness and aggression.  It is a Hollywood stereotype but I am not going to mention the movies.  This group is also disenfranchised by advocates who are concerned that any focus on this problem will add stigma to the majority of people with mental illness who are not aggressive or violent.  There are some organizations with an interest in preventing violence and aggression, but they are rare.

At some point in future generations there may be a more enlightened approach to the primitive thoughts about human consciousness, mental illness and aggression.  For now the collective consciousness seems to be operating from a perspective that is not useful for science or public health purposes.  There is no better example than aggression as a symptom needing treatment rather than incarceration and the need to identify that symptom as early as possible.

George Dawson, MD, DFAPA