The Myth of the Psychiatrist as Bogeyman

Probably the most annoying aspect of being a real psychiatrist is the constant attacks on the profession.  Psychiatry is unique among medical specialties in that there are a number of philosophies, special interests, critics for profit, and some might say cults out there who generate a constant barrage of criticism of widely varying quality.  There are even attacks from within the field.  Most medical specialists are concerned primarily with patient care, but that is not true for the self appointed critics of psychiatry who like to attack psychiatry at any possible point in time.  In this negative atmosphere - real psychiatrists like me are dedicated to patient care and continue to provide a valued service that has recently been demonstrated to deliver treatment results on par with other medical specialists.  Our reason for existence in the negative environment is the sole fact that we will treat severe problems successfully that nobody else will approach.  Unique psychiatric training allows us to do that.  So how do we explain the incongruence between what real psychiatrists do every day and how they are treated in the media?  It is basically a two step process.

The first step is looking at what is said in the media and what it really means.  When Senator Grassley began investigating psychiatrists and their relationships to the pharmaceutical industry on a selective basis ignoring other medical specialties despite widespread relationships between other specialists and the pharmaceutical and medical device industry what was the real message there?  When the DSM5 is critiqued for being an inaccurate device designed to make as much money for the pharmaceutical industry and organized psychiatry as possible - what is the real message there?  When psychiatric diagnosis is described as being totally arbitrary and lacking validity by people who think that validity has something to do with a laboratory test, what is the real message there?  Let me translate it for you.  It means that psychiatrists are at best totally incompetent and at their worst greedy, dishonest, manipulative, unethical, and interested basically taking money for a worthless diagnostic and treatment exercise that frequently harms people.  In other words perpetrating fraud.  There is really no way to sugar coat it.  If all of the critiques of psychiatry in the media are accurate - that is the only logical conclusion.   If you accept that position psychiatry has been devalued as an essentially worthless medical specialty.

The second critical step is to ignore all of the flaws associated with the rest of medicine.  Let's forget the fact that 30% of patients entering a medical clinic will not get an adequate explanation for their symptoms even after extensive investigation with those gold standard tests.  You know - the tests that mean the diagnosis is "valid".  Let's forget that reliability estimates for medical diagnoses - even using those gold standard tests are no better than the so-called poor reliability estimates of psychiatric diagnoses.  Let's forget the fact that diagnostic and treatment errors in medicine are common.  Let's forget that treatments for medical disorders generally carry a much higher risk of death and complications.  Let's forget the fact that patients with factitious disorders get admitted to general hospitals for extended periods of time and pretend that only psychiatrists can't detect a pseudopatient.  Let's forget the fact that significant numbers of medical diagnoses are routinely made in the same way that psychiatric diagnoses are made.  Let's forget the fact that consensus medical diagnoses by experts are common within all medical specialties.  Let's forget the fact that other specialists work for pharmaceutical and medical device companies.  Let's forget the fact that many specialty organizations have revenues from industries that easily exceed the revenue stream of the American Psychiatric Association (APA).  Let's forget an entire list of imperfections in the practice of medicine and pretend that general medicine is perfect for the sake of comparison with with an imperfect psychiatry.  We have succeeded in overidealizing medicine.

That two step dynamic of devaluing psychiatry on a purely arbitrary basis and idealizing the rest of medicine and choosing not to apply the same criticisms that are used in the case of psychiatry is the recipe for the psychiatric bogeyman that you keep reading about in the papers.

If you really believe that there is a psychiatric bogeyman - I have a bridge in Brooklyn that I can sell you.

George Dawson, MD, DFAPA