Psychiatry

Pat Croskerry croskerry at EASTLINK.CA
Mon Dec 15 14:05:29 UTC 2014


We certainly need to include psychiatrists, and I doubt they will be
resistant. I recently presented it as the topic for their grand rounds, and
it appeared to resonate well with them.

They may even feel a little vindicated that the unconscious mind is now
getting some respectable consideration.

They are aware of the impact of bias on their clinical practice - see
attached paper from Ireland.

 

More recently an insightful  book by clinical psychologist Richard O'Connor
Rewire (2014) leans fairly heavily on dual process theory (see the first
chapter) and draws parallels between it and dynamic (Freudian) concepts -
metaphorically rather than literally.

(before anyone gets alarmed about Freudian ideas being resurrected O'Connor
does point out that, although mainstream Freudian analysis is mostly a thing
of the past,  we now actually have an expanded notion of his original idea
of the unconscious mind). Stanovich refers to System 1 as TASS (The
Autonomous Set of Systems) - autonomous in that they are not consciously
deliberated and clearly emphasizing their unconscious nature. 

Freud's original concept of counter transference has also moved into the
larger domain of social cognition and certainly has practical application in
clinical medicine. Ccounter transference (residing unconsciously in System
1) appears to be a prominent affective bias.

 

On another note, we have just had our first cohort of faculty go through our
TACT (Teaching and Assessing Critical Thinking) course here at Dalhousie
-dual process theory, heuristics and biases were prominent in the earlier
part of the course. 

There were several psychiatrists taking the course and all appeared to
appreciate the relevance of this approach to their clinical practice.

Pat

 

 

 

rom: Harold Lehmann [mailto:lehmann at JHMI.EDU] 
Sent: Thursday, December 11, 2014 6:09 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Psychiatry

 

Thanks to you and the others who have answered.

 

My perhaps-too-subtle question is-does psychiatry use the dual-process
theory (explicitly; not implicitly, in countertransference)? If not, should
it? If it should, should we be including them in our target audience? Or
should they be a different kind of ally? (Or: are we too narrow in our own
thinking of diagnosis?) Because they worry about the "mind," I think they
are a different group than the "typical" physician-target, as Rob's note
makes clear.

 

And yes, I think we should avoid "interpreting" any "resistance" from
psychiatrists, using their terminology! 

 

Harold

 

From: <Hamm>, Robert Hamm <Robert-Hamm at ouhsc.edu>
Date: Thursday, December 11, 2014 at 11:38 AM
To: Society to Improve Diagnosis in Medicine
<IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, "Perlis, Roy H., M.D."
<RPERLIS at MGH.HARVARD.EDU>, Harold Lehmann <lehmann at jhmi.edu>
Subject: RE: Psychiatry

 

I agree with Roy Perlis. To expand:  

 

We can see three realms where psychiatry or clinical psychology has
recognized that there are errors in thinking due to heuristic strategies,
short cuts, dual processes: 

 

Non-psychiatrists seeing patients with a psychiatric diagnosis, and
dismissing their complaints as a sign of their psychiatric illness rather
than as a report of an organic illness. 

 

Psychiatrists understanding of how patients think: unconscious, emotional
processes, and how it is irrelevant to provide rational explanations for the
patient to use. 

 

Understanding of psychiatrists' own dual processes, in relation with the
patient: the countertransference, the unconscious emotional reaction to the
patient's appearance or actions. Harry Stack Sullivan's rectal twitch sign
as a cue to the male patient's sexual orientation, for a joke example. 

 

The theme of raising the issue here is that somehow psychiatry is missing
the opportunity to make more accurate diagnoses because the teaching of
psychiatry has not (often) taken up a reference to the errors of heuristics,
biases, dual processes. We can see there might be a resistance to taking up
some ideas which seem to be a de-emotionalized import of psychiatric ideas
into mainstream psychology (risk as affect; unconscious automatic use of
strategies), and then asking psychiatry to take them back, in simplified
form, with an attitude of gratitude. 

 

Yet one might argue that as psychiatric practice itself becomes simplified
to pattern recognition and the assignment of the indicated drug, the same
cognitive errors made by physicians in general can show up in psychiatry
with the same frequency; and perhaps the same remedy is needed.   

 

But psychiatrists could also be justified to say, show us that consciousness
raising about heuristics and biases, dual processes in clinician reasoning,
makes any difference in any area of medical training, let alone in
psychiatric training. 

 

Rob

 

 

Robert M. Hamm, PhD

Clinical Decision Making Program

Department of Family and Preventive Medicine

University of Oklahoma Health Sciences Center

900 NE 10th Street

Oklahoma City OK 73104

405 271 5362 ext 32306       Fax 405 271 2784

robert-hamm at ouhsc.edu


  _____  


From: Perlis, Roy H., M.D. [RPERLIS at MGH.HARVARD.EDU]
Sent: Thursday, December 11, 2014 9:23 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Psychiatry

Harold - Psychiatry uses different terminology but of course consideration
of biases is a crucial element of training even among more
biologically-oriented programs. The only difference is whether it's
addressed in terms like countertransference, or with reference to specific
cortical/subcortical structures. Remember these folks were thinking about
the unconscious long before the rest of medicine.


  _____  


From: Harold Lehmann [lehmann at JHMI.EDU]
Sent: Thursday, December 11, 2014 9:40 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [IMPROVEDX] Psychiatry

A bit off topic, but related to Brent Smith's question about debiasing med
students.

 

I was speaking with our psychiatry clerkship director. It seems that
dual-process theory has not made it into psychiatry, in general, let alone a
curriculum on decision making (either physician or patient).

 

Does anyone have experience in bringing together these two magisteria?
(There are 5 articles in PubMed [dual-process theory AND psychiatry], most
recently 

PMID: 

25000504.)

 

Harold

 

***************************************************************************

Harold P Lehmann, MD PhD

Professor and Interim Director

Division of Health Sciences Informatics

Johns Hopkins School of Medicine

 


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