psychiatry thinks…

Posted on Friday 29 May 2015

According to Jean Piaget, the ability to create and use categories, to classify things, is a developmental achievement that antedates the ability to think abstractly – characterizing the period roughly spanning the Elementary School years. And categorical thinking remains an essential tool throughout the life cycle. In his landmark book, The Nature of Prejudice, Psychologist Gordon Allport said …
The human mind must think with the aid of categories… Once formed, categories are the basis for normal prejudgment. We cannot possibly avoid this process. Orderly living depends upon it. 
… before he goes on to explore that down side of categorical thought we call prejudice.

Categorical thinking is thinking in general rather than specific terms – putting things into categories rather than seeing the details within them. And one can even think categorically about categorical thinking ["Doctors are locked into disease model thinking, and can’t see the person."]. Then, of course, there’s the almost universal tendency to put the category one belongs to on the top rung of any hierarchy of values.

The Square of OppositionAristotle’s first shot at rules of logic was designed to insure that we didn’t make categorical errors – called Categorical Syllogisms. You might recall them as the "some" or "all" logic:
    Major premise: All humans are mortal.
    Minor premise: All Greeks are humans.
    Conclusion: All Greeks are mortal.
    Major premise: All rabbits have fur.
    Minor premise: Some pets are rabbits.
    Conclusion: Some pets have fur.
But alas, having Aristotle’s Syllogistic Logic and the Square of Opposition [right] is no barrier to the infinite human mind. So we’re still at it, making categorical errors – sometimes on purpose, sometimes unconsciously, and sometimes just because we’re human…

Young physicians often offend patients by ‘talking to the disease‘ rather than the specific person – assuming the textbook version rather than some unique variant within the many possible presentation of any affliction [the "classic heart attack" that really is "indigestion," and the more ominous reverse]. Another common error is using using disease or category names as personal nouns – "a Schizophrenic", "a Cirrhotic", "a Chronic Lunger", "a Borderline".

A common version that gets to me  personally, particularly these days, is "Psychiatrists think…" followed often by something I’ve never thought in my life. In my case, there’s been little relief from the guilt by category meme. Over the years, I morphed seamlessly from "You psychoanalysts think «some horrible thing»" to "You psychiatrists think «some other horrible thing»". I can usually hold my tongue with those. But there’s a variation on that theme that requires the greatest restraint. It’s when a whole category is personified as if it is a  unity or an individual as in "Psychiatry thinks" – to wit:
"Why would the American Psychiatric Association elect Lieberman president in 2012? Because psychiatry sees nothing wrong with these psychotic symptom exacerbation and provocation experiments."
The piece, Leading American Psychiatrist Conducted Disturbing Experiments – and Now He’s Smearing Journo Who Uncovered It, suggests that Jeffrey Lieberman’s rant against Robert Whitaker [see just stop…] on Canadian radio was a retaliation for Whitaker’s 1998 series on Lieberman’s experiments giving psychostimulants to Schizophrenic patients. In the quote, the American Psychiatric Association is a single entity electing Lieberman. The APA-entity is then merged with the Psychiatry-entity. And that then leads directly to "Because psychiatry sees nothing wrong with these psychotic symptom exacerbation and provocation experiments." Earlier in the piece, we had already heard:
The Nuremberg Code of research ethics, established after the horrific human experiments by doctors in Nazi Germany, states that medical experiments on human subjects “should be so conducted as to avoid all unnecessary physical and mental suffering and injury.” This is obvious ethics, as one would hope that only Nazi doctors would see nothing wrong with using human subjects to test whether hypothesized harmful agents are in fact harmful.
I was once told that you can be assured that you’re deep into the realm of a categorical indictment when someone rolls out the Nazis – the universally recognized symbol for sadism and evil for its own sake. It’s not hard to see why I wince whenever somebody says, "Psychiatry thinks" or uses "Psychiatry" as a personified noun…
    May 29, 2015 | 9:18 PM

    The rhetorical flourish of comparing one’s opponent to Nazis, or specifically Hitler, is so common and seemingly inevitable online that it has its own name: Godwin’s Law. It’s a recognized end of rational debate.

    However, there are exceptions. When the topic at hand really does relate to Nazism in some way, the comparison is not an instance of Godwin’s Law. Here, the implication is that Lieberman violated the Nuremberg Code by using human subjects to test whether hypothesized harmful agents are in fact harmful. However, Lieberman wasn’t testing whether methylphenidate (Ritalin) was harmful, he was testing whether it might serve to predict relapse in people with schizophrenia. There are legitimate concerns to raise about this research, but it hardly justifies Nazi comparisons, much less roundhouse condemnation of psychiatry.

    This is in the air lately, isn’t it? Are pharmascolds slamming industry and physician involvement too indiscriminately, as Drazen/Rosenbaum say in NEJM? Or are those very critics, by dint of labels like “pharmascold”, being dismissed en masse, without granting that at least some of the criticism has merit?

    It doesn’t help to take a balanced view either: half the time I’m one of those dehumanizing, reductionistic psychiatrists, and the other half I’m a pharmascold turncoat. All port was right that we can’t avoid categorization. But wouldn’t we all benefit by backing away from lobbing denigrating labels and overgeneralizations at each other?

    Bernard Carroll
    May 29, 2015 | 9:43 PM

    Well, there’s a fine conspiracy theory on the blog you linked to. The comparison with Tuskegee was way overheated rhetoric. That’s a classic category error! We should also note that the author didn’t do his homework concerning the duration and outcome of the symptoms provoked in Dr. Lieberman’s study.

    May 29, 2015 | 9:48 PM

    You are correct. It is one of the more common rhetorical devices used to attack psychiatry – whoever we may be. I think it says a lot that they have institutionalized it to the point that they don’t have to invoke Godwin’s Law.

    Maybe we have Nardo’s law – just substitute the word psychiatry.

    berit bryn jensen
    May 30, 2015 | 7:57 AM

    Psychiatry – at its best – is searching for truth, discarding untruth, deception, falshood, hypocricy, egotism, becoming aware of our habits of thinking and culturally sanctioned and regimented “truths”. We are not untouched by establishment narratives, aptly named BOSS TEXTS by Bonnie Burstow in her excellent book Psychiatry and the Business of Madness, An Ethical and Epistemological Accounting.
    I did not understand my painful experiences with psychiatry till I read history and textbooks that simply skipped the horrible truth that the leading doctors and psychiatrists in Nazi Germany, inspired by American “scientific” thinking, led the way into euthanasia of those they defined and diagnosed as unworthy to live because of physical and psychic disabilities.
    Most doctors obliged and lent themselves to legitimize the horrors that followed. Few were held to account after the war. They slipped back into civil society and continued to practice their chosen trade.
    Psychiatry as a profession, as a guild, still struggles under the boss text and the corrupting influences of personal greed, cowardice, competition, survival. It’s sad and complicated and corrupted as humans have been and most of us are, even when trying to do better. The salvation is in the steady trying, I think, of which I consider dr Nardo a good example.

    May 30, 2015 | 10:30 AM

    some of the complaints and criticisms of psychiatry evoke an emotional response and claim of “victim-hood” that I don’t fathom

    May 30, 2015 | 12:59 PM

    Like I was saying…..

    May 30, 2015 | 5:54 PM

    What is the relationship of the American Psychiatric Association and its spokespeople to psychiatry?

    The APA claims on–psychiatry that it is “the voice and conscience of modern psychiatry.” It often represents the profession in discussions with the US government. It publishes a handbook that is supposed to define psychiatric practice.

    Confusing the APA with psychiatry may be unfortunate but it is not entirely wrong. I can certainly see why psychiatrists who don’t agree with the APA might be angered by this.

    The way I look at it, the APA controls the brand of psychiatry. All its efforts go towards positioning the brand. It does everything it can to be the face and voicebox of the brand.

    Psychiatry the practice is something else, but how linguistically to make the distinction?

    May 30, 2015 | 6:47 PM


    That is a good question without any good answer that I know of. It’s not exactly like the La Résistance française versus the Vichy régime in wartime France, though maybe that fits for some of us who have become a bit more public. Like the Résistance, if you’re too public, you get slammed from both within and without. And I, for one, don’t agree with Whitaker/Cosgrove’s new book that it is a fundamentally corrupt institution, though their point that too much corruption has occurred and we’ve had way too many corrupt people in high places is obvious. I don’t talk about it much because it sounds like excuse making, but psychiatry has taken an enormous hit from Government, from Managed Care, from the Antipsychiatrists, from Medicine proper, and even from PHARMA, so the specialty has been playing with less than half a deck – but even with that, it has been managed badly enough to engender no sympathy from me for the woes we all can see.

    My opinion [a minority opinion] is that by taking control in 1980 with the DSM-III, the APA created a top-down organization. They may have had to do that then. I wouldn’t be the person to judge that as I was still something of a neophyte through it all. But what I can say is that they created a organization that was ruled from the top, that pushed a very specific ideology, that made no attempt to relinquish the “emergency powers” they had assumed, and in the process created exactly what it is today – a homogeneous subset of psychiatry that has its tail between its legs and is heading for something called Collaborative Care – one of the worst ideas I can imagine [seeing no patients directly and advising clinical specialists about drug management to pass on to primary care doctors]. What is the future? I have no idea. I do know that the APA ought to ask its members rather than driving the ship. My focus is on making sure that it’s not determined by industry and industry’s KOLs as has been the case in the recent past. Like the La Résistance française, when you can’t see the future, or the path to the future, your only choice is to do what seems right and hope that somewhere down the road, it will help move things in the right direction.

    May 30, 2015 | 9:15 PM

    Mickey, I understand that from your point of view, in which I’d very much like to believe, the APA is the subset, but from the APA’s point of view, the dissenters are the subset.

    Someone who uses the construction “psychiatry says” is probably thinking the APA represents the profession. It’s hard to see it as a rogue organization.

    Maybe if the dissenters were more visible as a group, “psychiatry” would not be perceived as a monolith represented by the APA. Join Critical Psychiatry US? Sandy Steingard knows something about this.

    May 30, 2015 | 9:50 PM

    The AMA is an even better example. Leaving out low-fee memberships to trainees, only 15% of practicing American physicians are members. Yet the AMA purports to speak for all U.S. doctors. It’s easy to cite non-medical examples too: the NRA doesn’t really speak for all gun (or rifle) owners, etc. The largest or best known membership organization in any field is apt to claim to be the “voice” for that field, gaining clout for itself while silencing diversity and dissent.

    For this reason, confusing the APA with psychiatry is wrong but it is not surprising, as this type of confusion is common. And for good reason, as each organization does its best to “control the brand.”

    May 30, 2015 | 10:17 PM

    Steven’s point is well taken, and well made. But I think the problem Alto poses is a good one, but genuinely unsolvable. CPN is an example of why. It is ideological. Admittedly, there are some good people there, but there is a “like-mindedness” that many psychiatrists wouldn’t accept. The other APA [psychology] solves the diversity of opinions and orientations in mental health by having many, many divisions that function as separate groups almost. But they don’t say “psychology thinks” either. Psychiatry, Psychology, Social work don’t lend themselves to that kind of unity seen from Cardiology or Gastroenterology. It is perhaps a hindrance in negotiating for various things, but it’s just in the nature of the beast. I don’t think there is a voice for psychiatry. Any unifying organization would have to tolerate a cacophony of voices. That’s what the APA seemed like in my youth, but they fixed all the noisiness with the DSM-III.

    “Herding cats” ain’t easy…

    May 31, 2015 | 2:58 AM

    I’d guess that what people often mean when they say “psychiatry thinks” is some variant of “many psychiatrists think”; “most psychiatrists think”; “the psychiatrists I’ve read or heard from think”; “I’ve commonly heard it stated in psychiatric textbooks that…” etc.

    You’re right that the tendency to generalize and categorize makes it appear as if people are trying to erase the individuality and differences among psychiatrists. But, I don’t think that is (usually) the intent, although your reaction is understandable. The intent is probably more to erase uncertainty and have a feeling of strength and knowledge, within the person making the generalized statement, rather than to dismiss the viewpoint of a minority. People care less about our views than we sometimes think.

    And, there are large grains of truth to many of these general statements. For example, when Whitaker wrote, “Because psychiatry sees nothing wrong (with Lieberman’s experiements)…” it probably was true that not all, but a significant number of powerful psychiatrists were not sufficiently bothered by Lieberman’s decisions to stop them from electing him. Perhaps you are correct that the statement could have been more nuanced and ambivalent.

    As for psychiatrists, they – or at least many of them – make generalized statements whenever they write about “schizophrenia” or some other invalid fictional concoction (schizophrenia is just the best example of a nonexistent diagnosis). Schizophrenia represents another reification/concretization or generalization of an abstract concept that serves to erase differences. Schizophrenia is an illusory projection that serves this function for many psychiatrists looking at severely emotionally distressed people, just like saying “psychiatry thinks” can be an illusory projection that serves to erase ambivalence for anti-psychiatrists looking at groups of psychiatrists
    Probably thinking in this generalized way, i.e. erasing nuance or variation in one’s thinking, is evolutionarily adaptive, otherwise why would it often predominate over the capacity to see reality in a more ambivalent, in-depth way?

    May 31, 2015 | 4:15 AM

    Mickey wrote: “I don’t talk about it much because it sounds like excuse making, but psychiatry has taken an enormous hit from Government, from Managed Care, from the Antipsychiatrists, from Medicine proper, and even from PHARMA, so the specialty has been playing with less than half a deck – but even with that, it has been managed badly enough to engender no sympathy from me for the woes we all can see.”

    Don’t take this as criticism, I’m just jesting. But is psychiatry really an entity that can take hits from other entities such as government? Is government an entity? PHARMA entity gives a punch to psychiatry entity.

    May 31, 2015 | 5:08 AM


    Actually an excellent point, jesting or not. Like I said, “there’s the almost universal tendency to put the category one belongs to on the top rung of any hierarchy of values.

    berit bryn jensen
    May 31, 2015 | 8:44 AM

    Last week I spent a day in Gulating lagmannsrett i Stavanger, to witness a case brought before the second highest court here in Norway, by a gifted, highly educated, sensitive, very kind and generous young man labelled with the invalid schizophrenia diagnosis, treated coercively for years by an assorted array of the dangerous drugs wrongly called anti-psychotics, of which Xeplion (Paliperidon) is the last, at a monthly price of more than 300 dollars to Janssen Cilag and Johnson and Johnson, from our national health system, i e all of us as taxpayers.
    The two psychiatrists – one of five judges and a hospital psychiatrist as expert witness for the Government, seeking to keep him on community orders and continued coercive treatment, seemed equally uninformed about the crisis in their profession, displaying their ignorance as when Peter Goetzsche and metaanalysis from the Cochrane Collaboration were refered to. What’s that? Who’s he? Is he a doctor? revealing that they do not even read the major medical journals to stay informed about the state of their profession and the diversity of voices partaking in this discussion. Western biological psychiatry is dominant and may remain so, to the detriment of people in severe emotional distress and societies, as long as the undocumented hypothesis of “brain diseases” is upheld by most psychiatrists, many of whom are on the take – here too. The profession, the industry, the corruption – It’s global.

    May 31, 2015 | 2:58 PM

    Isn’t the DSM an effort to unify thinking in psychiatry?

    (The “psychiatry sees” quote above is from the author of the essay, Bruce E. Levine, not from Robert Whitaker. The context of the quote — APA election of Lieberman as president — indicates the author thinks the APA represents psychiatry.)

    I’m doing everything I can to find dissenting patient-oriented psychiatrists and refer patients to them. It’s very hard. Very few look critically at the literature.

    Winge D. Monke, Ph.D.
    May 31, 2015 | 3:10 PM

    Levin earned himself a 1BOM post by failing to say what he meant. He wanted to convince us that “psychiatry” is not bothered by ethically questionable research–and is therefore immoral. (Quotes because a thing can’t feel bothered.)

    He wrote, “Why would the American Psychiatric Association elect Lieberman president in 2012? Because psychiatry sees nothing wrong with these psychotic symptom exacerbation…”

    But his reason is not a fact that answers his question. It can be inferred, but not concluded, from the fact of the election’s outcome. An inference from an outcome can’t explain the outcome.

    He’d have done better with “Psychiatrists are not bothered by ethically questionable research. After all, they elected Lieberman president of the APA in 2012.” But that’s weak, too. How many psychiatrists voted, did they all know of the studies, and what share of the vote did JL get? I think it was 52%.

    Re: Alto Strata’s contributions

    If I were to say said “Psychiatry thinks,” I’d mean “the DSM says.” Edward D.’s suggestions are also plausible. I doubt anyone refers to the APA’s views. How many know they exist?

    The linguistic problem you posed could be solved by calling the APA and psychiatry “the APA” and “psychiatry.” If not, I have made too shallow a read of your thinking.

    Regarding the APA’s controlling the “brand” of psychiatry: are there other parties within psychiatry seeking to shape the specialty’s brand? If not, the APA isn’t controlling it, they’re just developing it. I don’t think psychiatry has a brand anyway. It has an image (poor) and a reputation (poor).

    You added this, which isn’t correct: “All [APA’s] efforts go towards positioning the brand.” Brand-positioning is over my head, but the APA isn’t concerned with a brand except incidentally. It has an agenda, which is more insidious and farther-reaching than a brand. They revise the DSM, publish books and journals, run web sites, and issue position statements like these:

    12: Position Statement on Mentally Ill Prisoners and Death Row

    13: Position Statement on Moratorium on Capital Punishment in the United States

    14: Position Statement on Need to Monitor and Assess the Public Health and Safety Consequences of Legalizing Marijuana.

    …all so we’ll see things their way and line up for our pills, hoping we deserve fruit-cup.

    James O'Brien, M.D.
    June 1, 2015 | 10:07 AM

    What percentage of psychiatrists belong to the APA?

    If not a majority, then the accurate statement would be “institutional psychiatry supports”…

Sorry, the comment form is closed at this time.