by Yong Lee, MD
[Spring 1997; Vol. 24 No.1]
(Dr. Lee, a resident in psychiatry at Johns Hopkins, is the 1996 winner of the MPS Residents & Fellows Committee Essay Contest.)
Several months ago, there was some interest in the national media
about reckless drivers. Locally, a Baltimore man plowed his car into a group waiting at a bus stop, killing a number of children; apparently he was running late for work and lost control of the car in the rush. No drugs or alcohol were involved in this case; nor were they involved in another accident, which also attracted public attention. Two men raced down a local busy interstate-one of whom cut off the other-thus culminating in the death of one and the maiming of the other. Examples of this type are endless and piling up daily along our highways.
A Production assistant of Larry King's talk show contacted a psychiatrist at my institution to inquire if he wanted to participate on a show dealing with reckless drivers, This psychiatrist begged off for a day or so to mull it over. What did he know about reckless drivers, except that they annoyed him? As far as he knew, reckless driving was not (yet) in the DSM-IV. Were there any papers written on the subject?-and even if there were, this would hardly qualify him as an expert. Moreover, would he be speaking for himself, our department, or psychiatrists in general?
"Gee," he said. "I can just imagine the kind of calls I'll get: 'My husband's always had a problem with speeding. He's gotten all these tickets. Doctor, should I get him into treatment?" (Ultimately, to his relief, this particular show never made it past the planning stage.)
I sometimes wonder what the general public thinks about psychiatrists. More so than any other specialty of physicians, we are expected to have informed opinions and keen insights on social conditions - even if they have little to do with disorders of mind, affect, and behavior, our purported area of expertise. Much to my embarrassment, I have read in the popular press and seen on television that psychiatrists-men ind women trained as physicians, not social scientists offer up snap analyses of such topics as how to get a date or what might have been running through the mind of O.J. Simpson as he was to elude the authorities n his white Ford Bronco.
The problem is not only that we are asked our opinions on subjects that are beyond our area of expertise: the problem is that we are often too willing to give our opinions and that we give our opinions as psychiatrists. Personal opinions are one thing; psychiatric opinions are another.
This unfortunate tendency to confuse personal and professional opinions runs throughout the history of psychiatry. As Robert Coles, a child psychiatrist who also happens to be firmly grounded in the social sciences, noted of Sigmund Freud in his collection of personal essays, Harvard Diary: when he was analyzing mental behavior, he was marvelously knowing, and usually, rather tentative; when he wrote about religion he became bitter, preachy, and anxious to bow before his faith (science), while ridiculing everyone else’s as a set of ‘illusions."
During the post-war romance with psychoanalysis, during the latter 1940s and 50s, the language of psychoanalysis (then, and as to some degree now, in the public’s mind synonymous with psychiatrists) became the lingua franca of the educated elite. As influential as Freud has been in psychiatry, his legacy was--and still is--even more pervasive in the social sciences, art, and popular thought. Instead of having a bad temper, you had unresolved conflicts (usually with your mother). Instead of being unhappy, you were neurotic. Misstatements became Freudian slips. The edict to know thyself became get thyself analyzed.
Psychiatrists found themselves idealized as all-knowing, beneficent truth-seekers--a heady reversal from being known as "alienists" or "quacks"--who had special insights into human condition. So when public policy makers consulted psychiatrists for their opinions, we were ready to hold court on any number of topics--education, child abuse, juvenile delinquency, teen pregnancy, pornography, drug addiction, poverty, homelessness, to name a few--whether we were qualified to do so or not. This regrettable tendency persists to this day.
Certainly, there were psychiatrists with eclectic backgrounds who were able to write knowledgeably and cogently on areas outside of psychiatry. Robert Coles wrote about the impact of racism, economics, and other social issues on children in Pulitzer-prizewinning, five-volume series Children of Crisis. Karl Jaspers and Jerome Frank wrote extensively of nuclear disarmament. These psychiatrists, however, took pains to preface their non-psychiatric writings as just that: outside the scope of psychiatry. Their arguments stand or fall on their own merits, not by jerry-rigging an alliance with the medical professions, so as to claim some unearned modicum of legitimacy.
As psychiatrists, we do have special, professional knowledge that can inform public policy. Child abuse, sexual abuse, poverty, and racism do exist and can have devastating effects on the emotional, cognitive, and physical development of children; child psychiatrists would be remiss if they were not well prepared to educate public policy makers, the general public, and other health care professionals about their findings; they can thus act as advocates for the rights of children. In the current debate about physician assisted suicide, policy makers need to be educated by us psychiatrists to the high prevalence of major depression in the terminally ill who request to be put to death. Our clinical experience and research can help shape public policy about how this nation will handle drug addiction.
We can--and should--offer our opinions as psychiatrists, but we must acts as physicians--not social engineers, arm-chair philosophers, politicians, or know-it-all pundits. Much of our prestige as a profession comes from the fact that we are physicians. When we make a public opinion, we should jealously guard our professional role. Personal opinions should be prefaced as such. To do so otherwise would undermine our standing as a medical profession and confuse the general public, our patients, and ourselves.
Paul McHugh, in his essay "Psychiatric Misadventures," in The American Scholar, Autumn 1992 argued that personal opinions and agendas--very much in keeping with the then fashionable Zeitgeist --held by a certain faction of psychiatrists became accepted as psychiatric opinions because they were made by psychiatrists, with deleterious results for both our patients and the credibility of our profession. He gives three illustrations: the indiscriminate dismissal of the chronically mentally ill--most notably patients suffering from schizophrenia--from state hospitals in the name of liberating them from an oppressive "institutional psychiatry" that did not tolerate their "alternative lifestyle"; how psychiatrists condoned the mutilation of healthy human tissue in “sexual reassignment” surgeries in the name of freeing patients “inner selves”; and the epidemic number of cases of Multiple Personality Disorder (MPD) being diagnosed, despite evidence that this condition can be largely iatrogenic--an artifact initiated and sustained by the suggestions of therapists.
Psychiatry, more so than any other field of medicine, is susceptible to the vagaries of personal opinion and popular beliefs. Imagine an internist describing hypertension as an “alternative" state of being that should be tolerated and not treated. If a patient had the overvalued idea that having two kidneys is redundant and that his life would be completely transformed by having one of them removed, I doubt that any responsible surgeon would condone the operation. As far as MPD is concerned, I can think of no other precedent in medicine. Except maybe in psychiatry.
Because our field has few objective laboratory tests, genetic markers, well-localized lesions, and molecular-cellular neuropathological mechanisms established, much of what we present as knowledge is tenuous. There is nothing wrong in admitting our ignorance: if we are to progress as a medical specialty, we have to know what we don’t know . Opinions are beliefs that are held, based on the best available evidence, yet without the certainty of absolute, positive knowledge. Therefore, much of what we say are opinions--albeit, professional opinions offered in good faith, based on clinical and basic science research, epidemiological studies, double-blind medication and treatment trials, and, perhaps most importantly, what we have learned from taking care of our patients.
As far as reckless drivers are concerned, I think they should be kept off our roads. Zero tolerance. Stiff, stiff penalties.
But that’s just my personal opinion.