Why A Diagnosis Is Not Stigmatizing and What Is...

 

 

The topic came up last week and it happens on a recurrent basis – diagnoses especially psychiatric diagnoses are not good because they are stigmatizing.  I addressed this fairly comprehensively in a post on this blog 10 years ago, but the persistent antipsychiatry rhetoric out there keeps repeating inaccuracies.  Since then there has been a comprehensive academic definition of stigma that makes things clearer.

Before that academic definition the standard dictionary definition was “a stain or reproach, as on one’s reputation” (1).  There is also a medical definition that is used to designate obvious pathognomonic findings: “visible evidence of disease” (2) and a long list of signs that apply.  There are additional definitions that do not apply to the specific situation of how mental illness is stigmatizing. The American Psychiatric Association has a web page on stigma and the adverse effects.  The web page does a good job of breaking it down to the public, personal, and structural levels.  Specific evidence-based interventions are suggested. They typically involve first-hand experience of persons with mental illnesses.

More sophisticated definitions of stigma are available today.  For the purpose of this post I am using one by Andersen, et al (3) that modifies previous work done by Link and Phelan (4).  According to the authors, stigma is a social process that involves “labelling, negative stereotyping, separation, and power asymmetry.” (p. 852).  They state further that stigma is not present unless all these criteria are met – specifically stigma exists “if and only if” all these criteria are present. 

Labelling in this case is defined as “social selection of human differences”.  The authors give an example of associating alcohol use with homelessness and whether it is a matter of “cognitive efficiency” based on personal experience and probabilities. The labelling that occurs is a result of these socially observed differences. Although these labelled associations can be positive, for the definition of stigma only negative associations are relevant for stigma.  That results in the negative stereotyping.

Separation creates a false barrier between the negatively stereotyped and everyone else.   It suggests that there cannot possibly be any overlap between the characteristics of the stereotyped and everyone else.  Earlier in their paper, the authors use the example of obesity, where it is obvious that there are several almost universal stereotypical qualities and overt discrimination. The same thing is true of ageism, where it is often assumed that elderly people are universally frail, cognitively impaired, and have negative personality traits. It is an us versus them mentality that is currently popular in right wing politics in the US.

Power asymmetry is attributed to the fact that is takes social, economic, and political power to label and negatively stereotype. This is inconsistent with the idea that it happens at an individual level and those individuals together can form a power structure. 

The authors cite an example from Link and Phelan: “They notice that mentally ill patients might label clinicians as e.g. “pill pushers” and link them to the stereotypes of being cold, paternalistic, and arrogant. But the clinicians will not, therefore, be a stigmatized group, because this group of patients simply do not possess the sufficient power to “(…) imbue their cognitions about staff with serious discriminatory consequences.”   

The social and pollical dimensions of the pill pusher characterization ignores history and the prevalence factor.  On a historical basis, Osler suggested that medications being used over a century ago were either worthless or cause more harm than good.  At the turn of the century "dope doctors" ran large practices by keeping people addicted to opiates. On the prevalence side, does the number of people with that characterization equal or exceed the number of people with other common important stigmatizing biases like obesity or ageism?  I doubt it. We do see an excessive amount of rhetoric directed at psychiatrists that is largely inaccurate and contrived and it is not without professional, social, and pollical fallout (5,6).  Very few reasonable people seem willing to discuss that.  The other reality that is rarely discussed is the fact that doctors are not powerful and certainly are not trained to use or exert power.  Today they are ordered around by middle level managers with no training in medicine exerting whatever form of administrative power that they choose.

There are much better examples of stigmatizing processes that are obvious but never discussed in today’s world.  I come back to the entertainment industry at the top of the list.  Apart from movie reviews psychiatrists have been curiously silent about this process that has gone on unabated for decades.  To cite a recent obvious example, I would refer anyone to the most recent episode of The Penguin an HBO series.  In season 1 Episode 4, we see one of the protagonists falsely diagnosed with mental illness to keep her from disclosing several homicides committed by her father.  She is placed in a medieval Arkham asylum where the patients are shackled by the neck and treated inhumanely.  She is eventually baited into committing a very violent homicide against another patient who is trying to befriend her.  The psychiatrists there are portrayed as indifferent at best and of course using electroconvulsive therapy as a punishment (there has not been any progress on that issue since One Flew Over the Cuckoo’s nest in 1975).  There may be people who argue these problems may have existed in 18^th and 19^th century asylums – but the problem is this is set in modern times.  The Penguin is driving a 2013 Maserati Quattroporte VI.  This episode plays the familiar stigma as the mentally ill being excessively violent and psychiatrists as agents of the state conspiring against people, using psychiatric treatments as punishments, and not caring at all about individual patients.

Right wing politics is a second source of stigmatization on almost a daily basis.  Trump and affiliated MAGA politicians routinely suggest that mass shooting and gun violence are attributable to mental illness – even though it clearly correlates with firearm availability and density.  In the case of undocumented immigrants, they are triply stigmatized as criminals, mentally ill, and invaders of the country when there is no evidence for it.

A final source is a carry over from my previous post.  Businesses and healthcare companies actively discriminate against mental illness despite parity legislation.  That should be obvious by the lack of resources that people face when trying to find treatment for a severe mental illness. It is easy to find state-of-the-art care and subspeciality care for any other bodily symptom – but not psychiatric care.  Getting an appointment to see a psychiatrist even in large metropolitan areas is often impossible.  Inpatient bed capacity in the United States is somewhere below the bed capacity of developing countries in the world. The majority of people with mental illnesses are not treated.

That is my update on stigma.  The only thing that has changed in the last 10 years is the current spin that a psychiatric diagnosis or treatment is stigma or stigmatizing and of course it is not at all.  As a reminder, a diagnosis is for the information of the patient and other treating professionals, it is confidential, and it is used by people who are professionally obligated to act in the best interest of the patient and incorporate that person's preferences.       

 

George Dawson, MD, DFAPA

 

1:  Random House.  Webster’s College Dictionary.  Random House, New York, 1996: p. 1314.

2:   Steadman’s Medical Dictionary.  The Williams and Wilkins Company, Baltimore1976: p.1338

3:  Andersen MM, Varga S, Folker AP. On the definition of stigma. J Eval Clin Pract. 2022 Oct;28(5):847-853. doi: 10.1111/jep.13684. Epub 2022 Apr 23. PMID: 35462457; PMCID: PMC9790447.

4:  Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001; 27(1):363‐385.

5:  Perlis RH, Jones DS. High-Impact Medical Journals Reflect Negative Sentiment Toward Psychiatry. NEJM AI. 2023 Dec 11;1(1):AIcs2300066.

6:  Bithell C. Why psychiatry should engage with the media. Advances in psychiatric treatment. 2011 Mar;17(2):82-4.

Photo Credit:

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Lessons In Political Violence

 

I got tired of waiting for the American free press to provide an analysis of political violence in the country.  It is a huge omission in day-to-day discussions of the coarsening of American politics.  I was prompted to think about it as I was out driving around today listening to stories of election officials being threatened and manipulated as the federal election approaches, some to the point that they will no longer do the work that they have been doing for years. In a long-standing democracy why is this not front-page news?  Where is the analysis of the problem?  Who has an interest in suppressing the vote and why are they continuing to do this?  At the same time, I heard about a poll today saying that most Americans will not trust the election results – even though they are the most secure at any time in history and there is no evidence of suspicious activity.

Elections are not the only places where political violence is acted out in the US.  Abortion clinics – even during the days of Roe were places where women were harassed and doctors were shot and killed. Schools, teachers, librarians, and school board members are targets for similar politics with threats, work exhaustion, and ultimately moral injury when they are shouted down and threatened for doing the work that they are trained and licensed to do.  Public health officials are attacked for providing the best possible public health advice just because some politicians don’t like it or need to cover their own incompetence.  Since when is it acceptable for politicians to be inciting this level of violence against competent citizens with high levels of competence – who are just doing their jobs?   

Before proceeding I will define what I mean about violence.  The same people who incite it frequently minimize it after the fact using the rhetorical sleight of hand: “It is free speech and I can say whatever I want to say.”  Without invoking the famous Supreme Court quote – let me provide a little detail about definitions.  First, violence or aggression does not require physical act.  Aggression has components that occur on a strictly verbal level and aggression toward property or inanimate objects as well as self (2).  If you have ever witnessed any of those forms of aggression, you know why it is important.  It has a direct impact on you that can be long-lasting. Threats alone can significantly affect your sense of physical and mental well-being. Many states have terroristic threat statutes that can result in legal action before any physical contact occurs (see Minnesota statute below). Threats alone are a signal that physical aggression may occur and in many states it can result in visits from the police, orders for protection, and in the case of mental illness – involuntary holds and civil commitment. Interestingly, the political violence I described typically results in the victims trying to protect themselves.

What does interpersonal violence look like?  On a verbal basis it can be angry shouting like we have seen many times in televised school board meetings.  That can include name calling, personal insults, and profanities.  As the verbal aggression increases the insults gets worse to the point of threatening physical violence. That is evident in routinely televised road and customer rage incidents.  Whether it culminates in physical violence or not is not the point. For years the police tended to ignore verbal aggression and operated on the basis that the only type of aggression that counts is physical aggression.  Over the past 20 years there has been a more enlightened approach since verbal aggression is harmful and predicts physical aggression.  That has been associated with domestic violence and terroristic threat statutes.  In the main areas I have discussed the violence has increased to the point that the Department of Justice is aware of it and successfully prosecutes cases (3,4,5).

Social media has become another source of aggression and interpersonal violence. The popular press documents an explosion of hate speech on X (formerly known as Twitter) while the new owner Elon Musk denies it and claims to have reinstated both right wing and left wing posters as a "centrist".  In the meantime academics debate the definition of hate speech (6) but were still able to find 91 papers written about it on Twitter alone.  Violence and hate speech are probably best analyzed on a case by case basis and in my estimation there is no better example than the last two chapters of Anthony Fauci's book On Call (7).  In it, Fauci clearly describes how providing the best possible public health advice to the White House angered President Trump and the non-experts he hired to manage the pandemic. Fauci was politically scapegoated, derided by other Republicans and MAGA, terrorized at work and home, and ultimately threatened with incarceration for providing historically outstanding public health service to the American people.  MAGA politicians are still threatening to incarcerate him even though he is retired.  I encounter people to this day who "hate" Dr. Fauci - not based on any semblance of reality but the gross misinformation provided to them by MAGA.  That entire sequence of events flowed from Trump's anger that the scientific facts (masking, herd immunity, immunization) did not fit with what he wanted to tell the public.  This is exactly how political violence occurs.  

From a political standpoint, this violence and aggression is often rationalized as “free speech” and it is not.  Violence is often rationalized as the absence of physical contact.  That really minimizes the impact of significant unprovoked threats that can include threats to bodily integrity.   The current elimination of gun laws makes some of these situations even more dangerous.  To cite one example, there was an armed protest in front of a director of public health’s home and in this case the police did nothing.  How would anyone feel about have a group armed with assault rifles outside of your home saying there will be no violence “for now” because you are doing your legal job.

What I find missing from most of these discussions is the overall cause.  I do not think there is any doubt that it originates with one party or more specifically movement and their aggressive rhetoric essentially because they have no useful policy. That is as obvious as the continued denials of the 2020 Presidential election results and the high percentages of people polled within that party (88%) that have doubts about the current election.  We have seen the effects of their propaganda, repeated lies, and political violence on these systems and it is completely unnecessary.  It also causes significant degradation of these systems when long time competent professionals leave because of the threats and harassment.  

Political violence in the US is quite literally the elephant in the room.  And it is time to start talking about it that way. Where is the press with this analysis?

 George Dawson, MD, DFAPA

Supplementary 1:

I decided to include the current Minnesota terroristic threat statute as an example. Note that physical violence is not necessary.  I am no attorney but carrying assault rifle and saying that you are not going to commit violence "yet" would seem to be an indirect threat of violence.  

Supplementary 2:  My wife and I voted at City Hall today.  It was technically an "in-person absentee" ballot.  The process was identical to the one 4 years ago.  We provided several levels of ID including - Driver's License number, address, phone numbers, email address, and Social Security Number. The election official was separated from us in a separate room and all discussion occurred through a heavy glass window with a portal.  We presented an identification form.  When that information was confirmed the election official printed a label with verification that was affixed to the top of our ballots. We were advised to complete the ballot - seal it inside 2 envelopes using tape provided at the voting stations and then return it to her.  When we returned the ballot she personally signed each ballot with her name and address.  There was no public access to a ballot box or voting machine and the entire process was airtight.  I did notice that Robert F. Kennedy, Jr. is still on the Minnesota ballot along with several other third party candidates.

Supplementary 3:  Former President Trump's ad in 1989 directed at the Central Park 5 is another good example of political rhetoric obscuring the facts.   In this ad he discusses hating the suspects and wanting them executed.  They were subsequently exonerated based on DNA evidence and won a $41 M lawsuit against the city of New York for malicious prosecution.  

https://www.documentcloud.org/documents/6131533-trumpdeathpenaltyad05011989

Supplementary 4:  Updated graphic to include a number of false attacks on the Biden Harris administration and their handling of hurricane emergencies.   Many were ultimately refuted by Republicans including Republican Governors.  First responders and aid workers were described as demoralized.  This occurs two weeks after Elon Musk commented that  "no one is even trying to assassinate Biden/Kamala"  Musk subsequently said he was joking and removed the comment from Twitter but said he would not retract it.  The White House condemned it for condoning political violence.  In an age where you can not joke about bombs or terrorists on airplanes "jokes" about assassination should obviously be out of bounds.  I have seen people interrogated by the Secret Service for similar comments.   

  

Addendum:  There are so many of these incidents of violence out there I decided not to try to reference them all.  They can easily be found by Google searching the main heading like "election worker violence" and secondary elements.  You will get a lot of references and very little attribution to the political cause other than "divisiveness".   That word in itself should be telling because it is one of the main strategies of one party. 

References:

1:  Meghna Chakrabarti.  On Point.  "Elections officials endure protests, death threats. Here are their stories."  https://www.npr.org/podcasts/510053/on-point

This is the radio program I heard this afternoon.

2:  Yudofsky SC, Silver JM, Jackson W, Endicott J, Williams D. The Overt Aggression Scale for the objective rating of verbal and physical aggression. Am J Psychiatry. 1986 Jan;143(1):35-9

3:  USDOJ Election Threats Task Force:  https://www.justice.gov/voting/election-threats

4:  USDOJ.  Justice Department Addresses Violent Threats Against School Officials and Teachers

https://www.justice.gov/opa/pr/justice-department-addresses-violent-threats-against-school-officials-and-teachers

5:  Fraser MR. Harassment of Health Officials: A Significant Threat to the Public's Health. Am J Public Health. 2022 May;112(5):728-730. doi: 10.2105/AJPH.2022.306797

6:  Mansur Z, Omar N, Tiun S. Twitter hate speech detection: A systematic review of methods, taxonomy analysis, challenges, and opportunities. IEEE Access. 2023 Jan 25;11:16226-49.

7:  Fauci A.  On Call: A Doctor's Journey in Public Service.  New York, New York: Viking, 2024: 374-455.

The Circular Logic Argument

 

I thought I would do a quick post on this because I am interested in rhetoric and this is mind-numbingly simple rhetoric.  It goes like this:

Being depressed means that you have major depression and you are depressed because you have major depression…..

Having motor restlessness means that you have attention-deficit hyperactivity disorder (ADHD) and having ADHD means that you have motor restlessness

This has been presented as though it is an indictment of psychiatric descriptive diagnosis – but you don’t have to think about it too long to figure out why this is a fallacy.  By analogy

Having a cough means that you have COVID and having COVID means that you have a cough.

The circular logic fallacy obviously does not consider the biological complexity of medical and psychiatric diagnoses.  We can rewrite them more accurately using that knowledge.  For example:

Being depressed means that you may have one of hundreds of medical, neurological or psychiatric conditions causing depression or that you may have completely normal mood reactivity or you may have one of thousands of pluralistic causes and having any one of hundreds of medical, neurological and psychiatric conditions or normal mood reactivity or one of thousands of pluralistic causes means that you have depression.

In other words – there is no 1:1 mapping of clinical depression onto the symptom of depression.  The diagnostic process returns a hypothesis about a condition that may be responsible for depressive symptoms.  I hope that illustrates how fallacious this argument is. The problem with rhetorical arguments like this is that they are generally advanced by people who have not gone to psychiatry school or who may have done it but poorly. It is reinforced by business practices and what I would call the necessity of low-quality research.

Starting with the research issue first.  Practically all studies of depression in the literature do not consist of psychiatric diagnoses of depression. Large GWAS studies typically use a ratings scale like the PHQ-9 as the depressive phenotype of interest.  There is no assurance that the patient would be diagnosed with depression by a psychiatrist or have had any of the other thousands of causes of depression considered.  In some of those studies there is a more general diagnostic screen administered to research subjects by non-psychiatrists and if screening criteria are met – the inclusion criteria for the study are met. None of this is assurance that the subjects’ studied would be diagnosed with depression (and not something else) by a psychiatrist.  The low-quality diagnosis in this case is necessitated by massive databases.  For example, the UK Biobank has data on a half million individuals and that would require at least a million hours of interviews by research psychiatrists to make a clinical diagnosis of depression.  That would probably require several hundred full-time psychiatrists working their entire 35 year career to complete.

The business practice of treating depression has similar problems.  It is almost a universal experience today to take anxiety and depression rating scales in primary care clinics.  The primary care experience may be even more crude than the research experience because the PHQ-2 may be administered instead of the PHQ-9.   The PHQ-2 consists of the following 2 ratings over the past 2 weeks:

1:  Little interest or pleasure in doing things

2:  Feeling down, depressed, or hopeless

These screening methods were initiated to show that managed care plans were interested in treating depression.  Since there will never be enough psychiatrists to assess and treat depression, these proxy screenings were felt to be an adequate replacement for psychiatry and they generally result in a diagnosis and treatment of depression even though (once again) there is no guarantee that a psychiatrist would have made that diagnosis.  Just from a purely rhetorical standpoint – it is a syllogistic fallacy to conclude that 1 and 2 above are adequate premises to establish a diagnosis of depression.  The debate at that point may be: “Well the clinician seeing the score will engage in a more elaborate diagnostic interview to make the diagnosis.”  If that is the case – what prevented them from doing that in the first place?  There is an expected paucity of data related to this practice – but I suspect there are many cases of antidepressant overprescription and “treatment resistant depression” based on the wrong diagnosis.  I recently offered to analyze the data from a large health plan for free and they were not interested in looking at it.

The most recent commentary on circular reasoning apparently came from a paper (1) claiming that causal language about psychiatric disorders is the result of a logical error and leads to a confused public and intellectual dishonesty.  The authors make several errors along the way as they develop this argument including:    

Ideally, a medical diagnosis both provides a precise term for a given condition and identifies its etiological mechanism

This is a rhetorical construct that ignores what has been known for decades and that is according to Merskey (2): “Medical classification lacks the rigor of either the telephone directory or the periodic table.  It is exceptionally untidy but it is taken to reflect in some way “the absolute truth” or at least the wonderful truth as it is known to its best practitioners.”  Merskey elaborates on how the medical classification system has several conceptual parameters – most independent of etiological mechanism. In fact, if etiological mechanisms were known – all categories would be mutually exclusive and that is another property that does not exist in medical classifications.  The medical terms "diagnosis" and "disease" are anything but precise and that leaves them open to attack by anyone providing a restricted definition.

“By contrast, diagnostic categories in psychiatry are currently defined only by symptoms.”

The DSM classification has a significant number of disorders where the precipitating and etiological factors are known. The hundreds of causes of organic mental disorders are a case in point as well as an entire section of neurocognitive disorders where the pathology is at least as precise as examples that the authors give.  There is a universe of medical and neurological disorders that are polygenic quantitative disorders with no specific etiology like psychiatric disorders.  Psychiatric disorders are also comprised of clear reproducible signs including sleep and appetite disorders and motor disorders that produce measurable results.  

“While it would be entirely correct to say that the human experiences that the diagnostic criteria describe can feel like an illness, it is different from claiming that an identified external biomedical pathological entity is really causing the symptoms.”

The authors trivialize depression as a mere feeling. I have never seen a person who came in for an assessment based on a mere feeling. They are typically experiencing a disruption in many aspects of their life and have difficulty functioning on a day-to-day basis.  Most patients seeing psychiatrists also have considerable medical comorbidity.

“By contrast, psychiatric diagnoses are not conceptually independent of their respective symptom lists.”

 The authors contrast psychiatric disorders and their symptoms with a lung tumor and a cough and suggest that because psychiatric diagnoses “cannot exist” without symptoms and this is proof that a purely descriptive syndrome cannot be a “cause” of the symptoms.  They also make the error in suggesting that a person must “meet criteria” for depression to be diagnosed with depression.  The problem is that depression, mania, and psychosis existed for centuries before there was a DSM.  These conditions existed long before there were psychiatrists.  They are obvious to non-psychiatrists (the authors apparently excepted).  The only reason psychiatry exists today is to treat syndromes that have been systematically observed and recorded by both psychiatrists and non-psychiatrists.  The medical side of things is described well by DeGowin and DeGowin in their physical diagnosis text (3).

"For several thousand years physicians have recorded observations and studies about their patients.  In the accumulating facts they have recognized patterns of disordered bodily functions and structures as well as forms of mental aberration.  When such categories were sufficiently distinctive, they were termed diseases and given specific names.”

To this day – medical practice is largely based on recognizing sufficiently distinctive categories and not pathophysiology.  There is always a lot of speculative pathophysiology and I have witnessed that all changing over the course of my career.  The pathophysiology learned in medical school – even if based on Nobel Prize work – is not the pathophysiology that applies today.  These diagnoses were independent of symptom lists for centuries and to this day they still are - in that no experienced psychiatrist is treating depression based on symptom lists or “meeting criteria”.

“Some authors therefore emphasize that depression can be described as an adaptive response or a functional signal to adverse circumstances.  Contrary to the erroneous causal beliefs that circular claims promote, this approach underlines that low mood and/or loss of pleasure are often meaningful reactions to life events, and that they can be meaningfully understood.”

This is a potentially erroneous causal belief and the authors apparently have no problem with circularity in this case or the potential lack of investigation of associated causes.  They also seem to misunderstand the idea that to have a disorder – there has to be some form of altered functioning beyond what would be expected.  Most people have that knowledge.  This is also a naive statement from the perspective of assessment and treatment of suicide risk. Can suicidal thinking associated with loss be explained away as a “meaningful reaction to life events” or does something more definitive need to be done?  Before anyone dismisses the idea as rhetorical - some of these same authors have suggested that psychosis is an adaptive response.  Finally – they include a quote from authors on the adaptive response theory as if psychiatrists have not been involved in theories, clinical observations, and developing therapies of these phenomena for decades (4-11).  

Rather than continuing a point-by-point analysis – a look at the rhetoric is probably a better summary.  From the diagram, the authors argue using a typical biomedical psychiatry conflation combined with controlling the premise. The top of the diagram illustrates that when all of psychiatry (in this case depression) is condensed or conflated into a monolithic nondescript biomedical model  - it is easy to demonstrate not only circularity but also how clueless psychiatrists are.  This should come as a surprise to no psychiatrist since this is really a longstanding rhetorical approach to the deconstructive criticism of the field.

A more realistic assessment can be seen in the lower graphic. I labelled it clinical depression since in this case the authors’ use of biomedical psychiatry is largely pejorative.  Every psychiatrist I worked with in acute care would not consider it to be a problem – since we were confronted with hundreds of conditions that had depressive symptoms that we had to figure out.  We were good at it and looked forward to it.  The emphasis is on multiple etiologies.  Numerous psychiatric disorders have depressive symptoms as well as medical and neurological disorders that psychiatrists need to be able to diagnose.  There are known biological causes as noted in the DSM, but many psychiatric disorders are complex polygenic disorders with no specific etiology.  With rule out diagnoses – that means that depression can cause depressive symptoms that can be addressed at the pluralistic level.  The authors suggest that “guild issues” may be a reason that biomedical psychiatry is defended as causal of depressive symptoms. Psychiatry in fact has produced a solid literature (4-11) of various etiologies of depression and how to treat them that easily encompass the authors’ suggestion that meaningful events may have a role to play. That theme has been present in psychiatry for decades prior to this paper.

Anyone reading a paper like this one needs to have an awareness of biology and human biology as a subset.  As I tried to point out in previous posts – for many reasons biological classifications will be imperfect.  That is true for biology without human constraints like speciation in all living organisms.  It is also true for disease classifications and I hope to have more on this soon. Any argument that there exists a standard for categories, diagnoses, or disorders in medicine or psychiatry that is perfect or even unidimensional should be considered rhetorical.

 

George Dawson, MD, DFAPA

 

1:  Kajanoja J, Valtonen J. A Descriptive Diagnosis or a Causal Explanation? Accuracy of Depictions of Depression on Authoritative Health Organization Websites. Psychopathology. 2024 Jun 12:1-10. doi: 10.1159/000538458. Epub ahead of print. PMID: 38865990.

2:  Merskey H. The taxonomy of pain. Med Clin North Am. 2007 Jan;91(1):13-20, vii. doi: 10.1016/j.mcna.2006.10.009. PMID: 17164101.

3:  DeGowin, EL, DeGowin, RL. Bedside Diagnostic Examination. United Kingdom: Macmillan, 1976.

4:  Sifenos PE.  Short-term Dynamic Psychotherapy.  New York.  Plenum Medical Book Company, 1979.

5:  Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES.  Interpersonal Psychotherapy of Depression, New York: Basic Books, 1984.

6:  Yalom ID.  Existential Psychotherapy.  New York: Basic Books, 1980.

7:  Beck AT, Rush JA, Shaw BF, Emery G.  Cognitive Therapy of Depression.  New York: Guilford Press, 1979.

8:  Bennett D.  Social and community approaches.  In:  Paykel ES (ed).  Handbook of Affective Disorders.  New York:  Guilford Press, 1982:  pp.  346-357.

9:  Arieti S.  Individual psychotherapy.  In: Paykel ES (ed).  Handbook of Affective Disorders.  New York:  Guilford Press, 1982:  pp.  298-305.

10:  Stein A.  Group therapy.  Paykel ES (ed).  Handbook of Affective Disorders.  New York:  Guilford Press, 1982:  pp.  307-317.

11:  Viederman M. The psychodynamic life narrative: a psychotherapeutic intervention useful in crisis situations. Psychiatry. 1983 Aug;46(3):236-46.

Explanatory Note:  When I use the terms psychiatric, neurological, and medical diagnoses - I am referring to medical as including all internal medicine specialties (Infectious Disease, Endocrinology, Nephrology, Cardiology, Rheumatology, Allergy and Immunology) as well as general Internal Medicine and Family Medicine.  Neurology and Psychiatry generally have non-overlapping conditions but there is a considerable amount of comorbidity from the medical fields.

The Irrational American Voter – Arrogance, Ignorance, or Both?

 

 “Critics are men who watch a battle from a high place then come down and shoot the survivors."  -  Ernest Hemingway

Let me preface this essay by saying that I am an expert in assessing cognition and cognitive disorders  based on my 35 years as a psychiatrist doing that specific job in acute care settings, outpatient clinics, nursing homes and other healthcare centers, guardianship and conservatorship proceedings, and contested hearings about decisional capacity.  For 15 years I ran a Geriatric Psychiatry and Memory Disorders Clinic.  I have made positive diagnoses of the various forms of dementia, detected and treated reversible forms of cognitive impairment, and corrected misdiagnoses of dementia. So, I was more than slightly taken back by all the armchair diagnosing of President Biden during the debate last Thursday. The press got (at least) – 3 days of sensational and speculative headlines. I just saw a poll today that showed an increase in the number of Americans who think “President Biden has a cognitive problem” from 35% prior to the debate to 70% after the debate.  As an expert – with no special knowledge of the President’s health status I can tell you why there is no sufficient information to make that determination.  I also have doubts about what “cognitive problem” means to the average American based on the hundreds of family conferences I have had to explain that concept.  

Just based on the debate, the President’s responses and overall presentation were suboptimal - but there are many untouched explanations.  I would describe the resulting press as excessive and discriminatory against Biden. Here are a few possible explanations:

My first thought was he was over preprepared and probably angry about having to confront a liar and a propagandist.  Let’s face it – this is the first time any Presidential debater has been forced to do this.  Trump is the first convicted felon and repetitive liar in any presidential debate.  He is good at it.  Recall how Trump made his fellow Republican primary candidates look in those debates.  Many of them were speechless and ineffective.  Trump’s propaganda style clearly makes it difficult for the media to criticize him.  He effectively neutralized the moderators who were unable to get him to answer questions.  Some in the press described him as a “ball of energy” rather than a “ball of lies”. They know that no matter what they say – Trump is repetitive and successful in wearing them down.  The best example is “The Big Lie” about how the election was stolen but there are more. He maintains lies in the face of solid evidence and even the press does not know how to handle it. They eventually acquiesce and start to treat the propaganda as fact.  During the debate he was able to not provide responses to questions while repeating his own brand of propaganda.  

Second, the cognitive task was much more demanding for Biden.  In the news leading up to the debate there was clear messaging from both camps on how they were being prepared. Trumps preparation was clearly casual and not information intensive. That was reflected exactly in his ease with repeating his overlearned propaganda, dodging solid answers to questions, and ad hominem attacks on Biden.  The Biden camp reported an intensive schedule of fact-based mock debates and attempting to answer moderators’ questions based on much more factual content.  Clearly the Trump strategy presented a markedly lower cognitive load and practically no information content to memorize.

Third, a single debate is not a marker of much – recall Barack Obama’s problematic debate from 2012 when CNN stated that Mitt Romney “trounced” Barack Obama in a debate. That is one reason Obama came out two days ago with the statement that “bad debates happen”.

Fourth, choking in a presentation even substantially should be a common experience. Public speaking is an almost universal fear. It happened to me in a memorable incident where I found myself suddenly blank and thinking about driving across Montana – as I was presenting in a pharmacology seminar in medical school.  I was about 26 years old at the time. My professor snapped me out of it by reminding me where I was and what we were doing. I was intensely prepared and sleep deprived at the time. Since then, I have found that the ability to focus and pay attention to what is happening in a presentation is inversely related to preparation intensity.  In other words – if I overprepare, I am likely to get bored with the content and will find my mind wandering in the presentation even to the point that I do not want to be there. Now, once I have the content mastered – I stop studying it and my plan is to just free associate to the bullet points.  President Biden had no bullet points.

Fifth, the reaction of the pundits has bordered on mass hysteria. Their conclusions that Biden is acutely impaired and too “feeble” has very little basis in fact. Several people including some pundits have described talking to Biden and noticing that in his face-to-face conversations there is no doubt that he is capable and mentally competent.  The fact that he seemed like his old self immediately after the debate in a Waffle House and the next day in a rally also defies the common explanation of what happened in the debate – that he is somehow irreparably impaired. I also had some interesting reactions to this when I was contacted and asked about “what they gave Biden after the debate that brought him back to normal.”  To my knowledge there is nothing.  Memantine was suggested to me, but as a physician who has prescribed this medication for cognitive problems the results are far from impressive. The real question is whether he took anything for cold symptoms before the debate.  Typical medications used have clear cognitive side effects. 

Sixth, time of day – the debate started at 9 PM and went to 10:30 PM Eastern time.  Circadian rhythms are important.  Drawing on my own experience I would never schedule a presentation or a lecture in the morning.  I am not a morning person and that is probably the main reason I did not elect to go into a surgical specialty.  I could not imagine trying to concentrate intensely in the early morning hours. The later in the day the better. I don’t know Biden’s typical schedule but speculate it is loaded in the mornings rather than evenings.

Seventh, Biden’s longstanding articulation disorder.  He has never tried to cover it up. It is a life long problem with no cure, but he has discovered some management strategies. It is probably worsened by stress and changes in voice quality from a recent cold.

Eighth, the pervasive ageism bias has never been more real.  The next day Biden observed that he doesn’t walk, talk, or debate like he did when he was a young man but he is still competent to do the job. His record of accomplishments in the face of an obstructionist party and their Supreme Court - backs him up.

If anything, the debate has taken the focus off Trump’s severe deficiencies.  There were several attempts to fact check the candidates and it was clear Trump had 3 to 4 times as many inaccurate statements.  Some were obvious like the stolen election and infanticide propaganda.  Like all propagandists – repetition seems to work on an unknowing or willfully ignorant public. Apparently, Mussolini was such a skillful propagandist that some of what he said is still believed as accurate today.  In this case the focus on Biden has basically given Trump and the MAGA GOP a free pass and they have been emboldened to the point of suggesting the 25^th Amendment be invoked against Biden based on a 90-minute television broadcast.

Rather than provide another point-by-point contrast between the candidates like I have done in the past there is a simple thought experiment that involves common sense thinking that can be applied. It is not based on wishful thinking or speculation.  It involves looking at the Presidency like a job application. Anyone who has ever applied for a job knows that you need to get recommendations from previous employers, supervisors, and in some cases co-workers.  The Presidency is interesting from this perspective because – all the coworkers are hand selected by the President himself.   Of the 15 cabinet level positions in the Trump administration only 6 people endorse him for re-election.  Eleven do not.  That number does not add up to 15 because of the turnover in the Trump administration and there are probably more people that I missed.  In addition, the most recent same party President George W. Bush and 2 of his 3 Chiefs of Staff, and a National Security Advisor do not endorse Trump in some cases criticizing him with the harshest possible language.  I am not aware of a single Biden staffer who has not endorsed him and President Obama came out with a statement of his support after the debate.

Although a direct comparison of Trump versus Biden is not possible on Cabinet level endorsements because of the lack of a survey of the Biden cabinet – the Trump results are striking based on the level of vehement criticism and what they say about the former President’s intelligence, inquisitiveness, and character.  A direct comparison across multiple dimensions is possible in the survey that President Biden described during the debate.  Presidential scholars rank Presidents across a number of dimensions and in that process, Biden ranks number 14 and Trump is dead last at number 45. Refer to the link for the specifics and outside validation.  The survey has received no coverage post debate relative to President Biden’s performance – even though it is an acknowledgement of his administrations’ accomplishments and a stark contrast to Trump’s rhetoric about how Biden has “destroyed” the country (he used the word destroy 22 times) and he is the “worst” President – (he used the word worst 22 times).  That contrast alone reveals Trump’s strategy.

That is my analysis of the debate from the perspective of a physician who has done thousands of cognitive and decisional capacity examinations.  To be clear, I have no way of knowing whether my suggestions are accurate.  I have not examined either candidate or their medical records. But I know that it takes a lot more to determine a person’s cognitive capacity than what we saw in that debate. The most straightforward solution would be to have each candidate take a standard assessment of their cognitive status and release the results to the public – but politics rarely takes a rational approach.  In the meantime, it is best to avoid the assessments of partisan politicians and party members, comedians, and gossip show pundits.  

This is not a laughing or pitiable matter.

 

George Dawson, MD, DFAPA

 

References:

1:  Nicholas P, Liebowitz M.  Dozens served in Trump’s Cabinet. Four say he should be re-elected.  NBC News July 30, 2023 https://www.nbcnews.com/politics/donald-trump/trump-cabinet-endorsements-rcna96648

2:  Joint Statement from Elections Infrastructure Government Coordinating Council & the Election Infrastructure Sector Coordinating Executive Committees.  November 12, 2020.  Accessed July 1, 2024  https://www.cisa.gov/news-events/news/joint-statement-elections-infrastructure-government-coordinating-council-election

This was known within days of the 2020 election. It is still not accepted by former President Trump and MAGA Republicans:

“The November 3rd election was the most secure in American history. Right now, across the country, election officials are reviewing and double checking the entire election process prior to finalizing the result.

“When states have close elections, many will recount ballots. All of the states with close results in the 2020 presidential race have paper records of each vote, allowing the ability to go back and count each ballot if necessary. This is an added benefit for security and resilience. This process allows for the identification and correction of any mistakes or errors. There is no evidence that any voting system deleted or lost votes, changed votes, or was in any way compromised."

3:  Presidential Greatness Project - see rankings at this site.  Biden #14  Trump #45   

No mention of this comment by Biden or the survey by any of the press.

Graphics Credit:  

Wikimedia Commons - click on photo for full credits and Creative Commons License

Disclaimer: 

As previously noted I am not now and have never been a member of any political party in the United States.  At the same time, it is clear to me that the Republican party, their Presidential candidate Donald Trump, and their partisan Supreme Court are an unprecedented danger to the United States that I have known all of my life and that they should be defeated. It is also clear that they have a level of organization that resulted in political advantages over the opposition and that their rhetorical strategy is to blame the opposition for what they in fact are doing.   

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.