Why the term ‘it’s psychological’ doesn’t cut it as a real medical diagnosis

A while back a downtown Auckland tower-block was evacuated after the occupants fell ill with what was first thought to be gas from the air conditioning. It wasn’t. But a dozen people were hospitalised. That evening, more people fell ill and the building was closed.

Before a formal investigation reported on the problem, a university lecturer told the media that: ‘The most likely scenario is that it is psychogenically transmitted‘. According to the report, she qualified the assertion with the point that the victims were not making up the symptoms and more research had to be done. However, the idea that it was an imaginary panic was taken seriously enough that media approached someone at UCLA who commented on the phenomenon of mass hysteria in general.

Setting the particulars of this incident aside, to me the fact that comments implying a ‘psychological’ component emerged ahead of a technical investigation – and were seized upon by the media – echoes a mind-set I’ve seen in the medical profession. It’s where highly qualified medical professionals seem to think that, if they cannot immediately explain something in a patient, it can only be psychological – which, irrespective of the way ‘psychology’ has been abstracted by the academy, boils down to blaming the victim. The implied stigma of being ‘psychologically weak’ as a result renders such claim a pernicious form of invalidation. However, this general attitude is one to which medical professionals sometimes seem to fall back as default.

‘Bwahahaha, you have psychological weakness. Now look at the trophy I got for my intelligence!’ Public domain, via https://publicdomainvectors.org/en/free-clipart/Mad-scientist-with-a-trophy/55674.html

I first saw this in the GP I had as a teenager, who was a useless doctor; but he was a master at intellectualising his way out of an issue. If there was something he couldn’t explain – which was most things, because he was that useless – it wasn’t that he didn’t know, it was because the patient had psychological problems they wouldn’t admit to. This happened virtually every consultation because once he’d decided you were mentally weak, that was that, and it got him off the hook.

Luckily my experiences since have been mostly positive, with a couple of exceptions in which the pretense of ‘psychological fault’ was mixed with open invalidation of any rights I had as a person. The first was in 2006 when I had a deeply unpleasant encounter with an ‘allergist’ whose behaviour – in front of a witness – was so aggressive and abusive that, had he been confronting me in a pub, I’d have assumed he was trying to provoke a fight. He began abusing me as soon as I handed him my prior test results, which he threw down and told me were worthless. That set the tenor for a consultation in which he invalidated everything I said at every turn – a relentless barrage of abuse that didn’t stop until I left. He actually told me that no matter what I said, he would say something different, which basically laid out that he wasn’t interested in helping or diagnosing me, just using me as a punching bag for his ego. His final diagnosis was that I had no allergy and therefore what I had was psychological – and before I could speak or react he leaned towards me and added: ‘why don’t you believe me?’ Yup – he’d already decided on my reaction and was attacking me for something that I hadn’t even said. See what I mean about this asshole being provocative?

Later I discovered he’d missed the clinical results shown in his own tests. Afterwards I went to the Medical Association to see what redress I had. I also found out from other sources that I was far from alone – I was told of patients this guy had so badly hammered when seeking help that they left his consulting room in tears. But I could see how he’d got away with it: when push came to shove, I declined to lodge a complaint. He was such an openly nasty, arrogant, angry and abusive little man that – despite my witness and my legal rights – I figured the only response would have been a threatening letter from his lawyer.

The other incident came in 2017 when a specialist I’d never seen before wasted $295 trying to hammer me into a diagnosis he’d clearly decided upon in the first three minutes, totally without empirical evidence. The problem was that he then failed to show the slightest respect for my integrity when reporting symptoms, still less any genuine concern for my well-being. Everything I said was either dismissed or ‘translated’ to fit what he kept insisting was the problem, and I staggered out of his consulting room feeling as if I’d just lost a fight known only to the other guy.

Wright_Velociraptor Mongoliensis
I want to help you. Really!

Of course I never went back; but afterwards I tackled him about his failure to correct an error he’d made in his record of the consultation, which I’d asked him to fix at the time he made it – he was taking notes as we went. He refused. I felt I needed to push it – if only so that I got some recognition from him that he had any respect for my rights. Alas, he only complied on the third attempt when I pointed out my legal position (doctors are legally required to correct errors in records on request).

Artwork by Plognark http://www.plognark.com/ Creative Commons license

To me, the supposition by medical professionals that their expertise sets them them above any need to follow the law and normal social morality, with no requirement to show such basic human values as care for others, or even simple courtesies, are a clear demonstration of human nature. As a species, it appears we have evolved so our first response is to invalidate those around us in an apparently zero-sum game of power and status. It must have produced some advantage for the group as a whole during hunter-gatherer days. The issue, as always, is that none of the successful hunter-gatherer social behaviours – conducts this evolution has hard-wired into us – work well when society is scaled beyond ‘group’ level.

Into that mix has to be added the fact that western society – particularly – conditions us to suppose that the professions upheld as ‘expert’ also have a social and ethical status that cannot be challenged. When mixed with the usual range of human character the result is a field that seems to attract superficially capable intellectuals who score well on IQ tests, but need to validate themselves as people by being seen to have the answers.  If they don’t, they have to invalidate the challenger, irrespective of the fact that this challenger may be someone who is vulnerable, sick, and came to them for help. And they do so using the power available to them, irrespective of the outcomes, in ways that also avert liabilities in terms of normal human ethical obligations – often, it seems, by weaponising ‘psychology’.

Thoughts?

Copyright © Matthew Wright 2018

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9 thoughts on “Why the term ‘it’s psychological’ doesn’t cut it as a real medical diagnosis

  1. Don’t know how they train physicians in NZ, but here in the States they tend to employ a boot-camp approach for interns, characterized by long working hours and corresponding lack of sleep. I can see one justification for this, i.e., “it doesn’t matter how tired you are, you still have to have the right answer, so suck it up and get back to work, you young puppy doctor.” Because the first two phrases could easily be true, and especially the second: a doctor has to have the right answer (even if, in the final analysis, a physician may only be able to give the answer he is taught to give, which may also be part of the problem for those who lack imagination, but read on).

    But boot camps destroy one personality to replace it with another, and that process makes more sense to me in a military context as opposed to a medical one. Military training is or can be specialized to allow you to function when your brain’s higher functions diminish in the face of fear and sensory overload. But a physician’s higher functions must NEVER shut down.

    Be that as it may, having the “right answer” instantly is beaten (figuratively but no less effectively) into some or all medical professionals. Yet, in a previous life, I worked for an attorney who did a lot of medical negligence cases. One primary cause of negligence in all professional fields is fatigue.

    What, one might wonder, are the habits one learns when fatigue and fear are combined with an ability to memorize answers to questions? Not all questions can be answered immediately, and yet, in medical school, that’s the way these folks are taught. And up to a point I can see that. It’s the failure of teacher and student both to understand that knowledge is finite, and sometimes answers have to be worked out and are not immediately obvious, that seems to be at work here.

    At the risk of psychoanalyzing, one might wonder if the physician who asked “why won’t you believe me?” was in effect admitting his own worst fear, that of being wrong. If you believed him, then it’s sort of like a confession to a crime obtained by force. “He confessed!” being the equivalent to “He believes me!” In both cases, more a personal validation of the abuser than achieving the actual objective.

    One could see the actions of the physician who delayed correcting your records in the same way. So long as he didn’t admit to it, he’s done nothing wrong.

    One sees behavior of this sort in criminal prosecutors and, too often, policemen. “Being right” in the sense of personal validation is more important to this personality than actually doing the job and arriving at the truth.

    I don’t know that this is, necessarily, a hunter-gatherer thing. I’ve just been reading an article in Evonomics that argued quite the opposite: http://evonomics.com/norway-toxic-trickle-down-david-sloan-wilson/?utm_source=newsletter&utm_campaign=organic

    I might argue that this is more a facet of the so-called “authoritarian personality” or, if one follows the work of Riane Eisler, a “dominator personality.” It underscores the actual weakness of that personality, in accordance with what you wrote above, in terms of a more enlightened ethos. By “enlightened ethos” I mean nothing more or less than enough respect for the truth to go looking for it, and, perhaps, to never be 100% satisfied that you’ve found it and so be willing to go back and look again. That takes more strength and moral character (again, which I take to be your point, and quite right) than insisting that one is right because one is right. Sometimes 99.9% has to be good enough!

    I’ve never had any particular respect for the argument from authority, i.e., an argument of the form: “Socrates is infallible. Socrates says ‘X’. Therefore, ‘X’ is true.” In the case of medical men, once upon a time they argued for the humor theory of disease. Some, I understand, held to what they were taught even during the influenza epidemic of 1917-18, nearly a half-century after Louis Pasteur published his germ theory of disease.

    And, as you can see, once more you have found a most interesting and thought-provoking topic! From here one could branch into the history of medicine: imagine, for example, an old professor in a medical school in 1885 who doesn’t hold with the “modern tom-foolery” of Pasteur and advises his students to ignore Pasteur and “stick with the tried and true.” Tried and true…by what standard? Certainly not Karl Popper’s. Yet this is part of the mind-set of physicians, perhaps even of the most enlightened. Not knowing the answer in the face of (worst case) life and death is a terrifying responsibility. Having the “tried and true” to fall back on is enormously comforting, even, in some respects, relieving a physician of liability for medical negligence (the “standard of care of local physicians.”)

    None of this is to say it’s right for you to have been treated the way you were. Far from it! I think physicians should be a lot more pro-active about policing their own; and it is food for thought that they do NOT do so.

    1. I think the medical training system is much the same in NZ as in the US and elsewhere – here it’s exactly as you describe, a ton of hard work in which newly graduated doctors typically work in a fog of exhaustion in hospitals. Every so often, the issue of their ridiculously long hours makes the media. And every so often, one of them slips up and somebody dies.

      I think the issue I (and others) have had with various specialists is different – yet related. One of the outcomes of medical training is that few doctors learn how to think or analyse; everything get slammed into a pre-set pattern, and if it doesn’t fit the pattern, it’s the patient’s fault. Rote-diagnosis, basically. The training mechanisms, including via the hospital ‘work-house’ system, tend to endorse that. And yet complex diagnosis requires a form of abstract analysis and synthesis that simply isn’t taught.

      Into that, though, I think that some people become specialists not because they have a genuine desire to help or care for others – and the two I mentioned above certainly didn’t – but because it is an easy road to ego-gratification and status. The ‘allergist’ I saw was, first and foremost, an A-grade asshole and bully whose sole focus when I saw him was a relentless attack on my validity and worth – all, it seems, because I’d come to see him with a prior diagnosis. Apparently he was so threatened by it that he felt I had no need to be treated after that as a human with any rights or self-worth: I was a target to be crushed into submission to his will at all cost. It quite likely masked a very deep insecurity, as you say. But that wasn’t reason for him to effectively beat up on the vulnerable, as he tried to me and also to others I spoke to afterwards. The nasty little bastard left me about $1500 out of pocket, taking into account the cost of getting to the city he was practising in, accommodation etc – and the irony is that after treating me like a war criminal, all the while telling me how intelligent and capable he was, he still missed the diagnosis!

      You have to wonder if these people ever worry about how they might be remembered by those they target with their power, but I somehow doubt any of them care.

  2. Oh yes. I always particularly loved the abbreviation “LMF” as a diagnosis. Who gets to say how much “MF” a man/woman should have, and under what circumstances? That always seemed to say more about social/cultural expectations than an actual psychological diagnosis.

    1. Oh yes, for sure. That was definitely the case in WW1 with the way PTSD was initially handled as a kind of personal failure of courage. There’s compelling evidence that a fair number of those shot for cowardice and desertion were actually suffering from severe PTSD. And while some steps were taken to recognise and address what was actually happening psychologically (nicely summarised by Lord Moran in his book on courage) it never lost that socially-framed stigma – I guess LMF falls into the same category. Wasn’t it an RAF WW2 term? Personally I can’t imagine anything more likely to provoke PTSD than a 30-night tour of duty on one of those thousand-bomber raids.

      1. Funny, I always thought it was the infantry stuff that would send me over the line. I knew a guy who flew B-24s in the 15th AF. He said they had an exchange program once, a pilot for a front-line infantry officer, and when they came back each swore the other had the scariest job.

        1. I can understand that! As I understand it, what seemed to ‘get’ the bomber crews in WW1 was the thirty-day tours – it really ground them down (and I’d hate to be the guy in the B-17 rear turret). Even in WW1, front-line units were usually rotated every 3 weeks – because, even then, army command knew the men would be worn down to nothing if they had to confront combat for longer without a break. I honestly don’t know which would be worse.

  3. I don’t know if it comes from incompetence or arrogance or, more likely, both, but my last nine years have been one battle after another with bad doctors, and in two different cities. Nine years ago I was misdiagnosed and when I insisted they were wrong I was sent to a psychiatrist. Six months and two ravaged lungs later it was discovered that—whoops!—they were wrong.

    Once out of the hospital (a month later), and working with a specialist, I was overdosed with Prednisone and had manic episodes. Rushed to the hospital, I was sent to the psych ward until I could recover, but—whoops!—no one bothered to consult with anyone else and so they kept overdosing me for two weeks.

    Turning to a different specialist didn’t make any difference. More poor treatment continued for the next three years with me demanding there must be a way to at least even out my symptoms, but I got nowhere. I moved away four years ago and repeated the same problems with a different doctor who refused to provide a referral to a specialist.

    I dumped that doctor and got another, but she wouldn’t give me a referral either (8 years of a serious, chronic lung disease and she thought she could treat it). So it continued. Her treatment would work for a couple of weeks and then I’d have months of misery before she’d deem me sick enough to treat again. I got lucky in late 2016 when she was out sick and a different person saw me, was horrified at my condition, and made noise until I got my referral.

    The specialist I went to put me on a treatment program that has given me my life back. It took eight years to find a competent doctor. He retired and his replacement has been just as good. I keep wondering how many people are wasting money (even with insurance I was wiped out financially twice) and suffering in this country (USA) because of countless doctors who don’t know what they’re doing?

    I’m no doctor, but in 2010 I insisted there had to be a way to even out my symptoms so I could know what to expect each day. They said it wasn’t possible. In 2017 a doctor made it happen in less than a month. A freaking month!

    1. Hi Christina – sounds like you had the complete run-around. I totally appreciate how that can happen – my own adventures have been nowhere as serious, but the way that an early misdiagnosis usually shapes every subsequent examination seems to be par for the course with doctors. The fallback ‘it’s psychological’ is all too common! Your experience being misdiagnosed and sent to a psych ward after medication sounds dreadful. It happened to a friend of mine, too, who ended up in a psych ward, confidently diagnosed by the hospital as schizophrenic. Actually it was a reaction to morphine provided post-surgery. To the extent that these doctors have never seen the patient before and have to take what they see on face value it’s understandable, but you’d think that if somebody presents with zero history of any actual psych problem, they might look into a possible other explanation. Sigh! Good that your problems were resolved – and the fact that it was possible to fix in less than a month, after eight years, really speaks volumes about the nature of the profession. Sigh…

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