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I think you are overly worried that a psychiatrist would have a conflict of interest. A psychiatrist is an MD, they practice psychopharmacology. Even a psychologist would have no reason to keep you untreated. There are plenty of patients who need help and a shortage of mental health professionals in general.

They don't have a great track of curing people. They tend to help people "manage" their mental health issues.

Color me unimpressed.

I think it's more likely that we're just not that great at "curing" mental illness (whatever that means) than it is that the entire industry has a conflict on interest where they COULD be helping people get better faster but they don't.

I've never had a therapist bat an eye when I tell them I'm doing well and I don't need to come in for a while. My last therapist went on maternity leave and recommended me to a colleague who they thought I might enjoy working with. It's been great and I'm not going back to see my original therapist. I guess they should've sent me to a bad therapist so that I would come back and be their client again, but the person they recommended me to is great.

Conflict of interest means you can never be sure why they recommended X, not that X was recommended with malice aforethought. That's precisely why it's such a thorny issue. People with malice aforethought are relatively easy to root out compared to people who mean well, but can't quite get it right for reasons no one can quite put their finger on.

How far do you take this kind of logic though?

Do you never go to a dentist because you can never be sure they're fixing your teeth? You don't know if they're superficially treating your teeth just enough to warrant another visit instead of "fixing" them once and for all.

Do you never hire an engineer onto your team at work? You can never be sure if they're putting bugs into their code on purpose for job security.

I mean if you take this kind of thinking to its logical conclusion, it gets pretty ridiculous.

In any case, "be skeptical to some extent, but don't be _scared_" seems like a good middle ground in this debate.

Well - "drill and fill" (i.e. unnecessary work, supposedly for medical reasons, but actually just for cash) is a recognised problem in the dental industry, at least in the UK.

Some dentists even had their contracts changed to encourage them away from the practice.

https://healthmedia.blog.gov.uk/2016/11/14/drill-and-fill-cu...

Realistically, blind faith in professionals is as unrealistic as blind paranoia.

I don't think it's possible to say "Of course we should trust psychiatrists" in one sentence and then add "But of course we don't really know much about mental illness anyway" in the next. The reality is that pharma in general has a mixed reputation, and psychiatric drug treatments have a very spotty scientific record - as do the various kinds of talking cure.

Psychiatrists probably won't encourage session dependency, but psychotherapists might - especially in countries where you can hang out a shingle with no training or background at all.

Getting help for difficult personal and emotional issues can be a minefield, with minimal consumer protection. You literally have more guarantees that your toaster is going to work as advertised.

Your last point seems so obvious. It’s much easier to toast bread than it is to treat chronic mental illness. Of course your toaster roasts bread. Doctors can’t cure plenty of things, despite all of our efforts. Psychiatry is an even younger field than modern medicine. You have tons of consumer protection in psychiatry.

> Do you never go to a dentist because you can never be sure they're fixing your teeth? You don't know if they're superficially treating your teeth just enough to warrant another visit instead of "fixing" them once and for all.

Shady dentists performing unnecessary procedures so they can rip off their patients is a rare but serious problem.

Do go to a dentist when you have a clear problem you know about, and do go to the dentist from time to time for routine checkups / cleanings, but be careful about choosing a dentist and skeptical when a new dentist suggests your apparently healthy teeth actually need extensive work.

Certainly, it can be management of a complex disease basically. A depressive episode might be temporary or it might be longer lasting or even treatment resistant. Diabetes is a complex disease as well that is in most cases (but not all) managed.

> A stranger or advice columnist may not give good advice, but they are somewhat less likely to give advice designed to encourage you to cut your own throat for their personal benefit.

Why is that? I think it's just as likely they are willing to give advice they think the majority of their audience will agree with regardless of how well it helps the person in question. In this case, the conflict is fame vs usefulness.

I think every source will have some perverse incentives, so you can't just go by whether one exists, but instead by how likely it is, what the repercussions are if they're caught, and are there cultural or personal biases that work against those perverse incentives.

Does your psychiatrist seem like someone that actually wants to help people? Do they appear to be greedy or in financial trouble? Perhaps worrying they are trying to keep you as income is unwarranted, or perhaps it should be reconsidered after progress is stalled or they don't seem to have anything useful to contribute.

Are you going to family members or friends that you believe care about you and your well-being, and/or that are upstanding people in their own right? Perhaps that should be what you focus on instead of perceived favoritism or vying for inheritance.

Sometimes good advice is hard to take, and points out flaws you would rather not address given an alternative. Discounting everyone that might actually have knowledge of the situation and other perspectives in lieu of a distant third party seems like a convenient way to discount that advice when it doesn't match expectations because "they just don't understand the situation well enough".

I recently experienced something like this:

My patent attorney notified me that I had a small window to do X, and Y, or I can do Z later but it doesn't have the efficacy of X and Y.

What I knew was that my patent attorney just told me that I have to pay him four or five figures NOW or else. And that has the hallmarks of a bad investment, scams, or conflicts of interest.

Well, for different reasons, I was introduced to a seasoned "Non Practicing Entity" who also told me it was really important to do X and Y.

I went back to my patent attorney and did it. Granted, this wasn't amateur advice in the least bit, but you're right that it is unlikely to find someone to talk to whose personal biases would be more aligned.

> If you pay a psychiatrist, you have to worry that they have a conflict of interest. If you really get well, you won't need them anymore. They have an inherent motive to help you only enough to take credit for things going better, not enough to set you free from needing their services.

Is that really different to any professional providing one to one services or what not? After all, you could say every tutor in existence has the exact same incentives; the better you do at whatever you're learning, the less you need to see them or pay them for their services.

Yet no one really thinks their music teacher or fitness coach or what not wants them to struggle for the extra money. Same goes with driving schools and instructors. The better the student and instructor do, the less the latter get paid.

Regardless, it doesn't really work out in quite the cynical way you think it will here. For professionals in fields like this, it's helping people and making them better at what they're learning or asking for help with that boosts their reputation and gets them more business in future.

It's something you can worry about, but you don't necessarily need to. When I have seen therapists, one of the things we discussed at the first meeting was our projection for how long the engagement would be. I asked, and was told that in most cases, both parties reach a point where they feel that further engagement is not necessary. And that's exactly what happened. We met twice a month for about 4 months, and after that, we both agreed that things were improved, and I had built strategies to help deal with my issue, and I stopped.

It's a concern, but one that can be addressed head on. Many good therapists are over-booked anyways, so their incentive to keep you on is low, as there are other people who want additional appointments and can't get them.

Granted it is anecdotal, but I've seen a psychiatrist. After a short time he said he didn't think there was any need for future appointments. The original reason for seeing him had been resolved. I do continue to go on a less frequent basis because it is helpful.

>...advice columnist may not give good advice, but they are somewhat less likely to give advice designed to encourage you to cut your own throat for their personal benefit.

Yeah, they have absolutely no mechanism to verify that their advice is good, or any consequences if it is terrible, and their primary incentive (far more than a psychiatrist's incentive for the malpractice you describe) is to entertain and satisfy you for more attention.

This is a horrible rationalization.

If you pay a programmer, you have to worry that they have a conflict of interest. If they finish the job, you won't need them anymore.

> If you pay a programmer, you have to worry that they have a conflict of interest. If they finish the job, you won't need them anymore.

Yes - this is a real problem especially if you don’t have the expertise to know how long a task should take.

That’s where many agile practices like 2 week scrums came from.

I see you've worked with BobX!

http://thedailywtf.com/articles/We-Use-BobX

A psychiatrist that behaves as you describe is literally engaging in malpractice.

You are a perfect example of what the article describes: your rationalization process for mistrusting experts seems rational at first glance, but upon closer examination it falls apart as quite simply an irrational fear used to rationalize not trusting an expert.

The thing about free advice online is that... you didn't go to school for 4-6 years and practice under an established expert for years further to learn how to give good advice the right way.

The idea that some jack in an online forum will provide better advice than a licensed psychiatrist simply because you're irrationally afraid that the psychiatrist will engage in malpractice -- frankly it's ludacris! It's literally insane to me.

But this is how we end up with an America where multiple doctors diagnose you with cancer but your Facebook Group swears by essential oils and power crystals....

A psychiatrist that behaves as you describe is literally engaging in malpractice.

Not if he is giving the standard advice everyone in the industry gives. There are lots of conditions where the standard expectation is that "people like you don't really get well" and "symptom management is the name of the game." It would be considered malpractice to even tell people with certain diagnoses that you will shoot for curing them.

But if you don't even try to get someone well, if you only shoot for muddling through, don't you think that has bearing on the kind of results you get? If actually getting them well isn't even a goal, no, of course, you won't get them well.

Not if he is giving the standard advice everyone in the industry gives. There are lots of conditions where the standard expectation is that "people like you don't really get well" and "symptom management is the name of the game." It would be considered malpractice to even tell people with certain diagnoses that you will shoot for curing them.

This is not a fair summary of your previous point. You previously implied that a psychiatrist will maliciously give information they know to be against the patient's interests purely to continue a financial relationship.

In this second post, you have walked back your irrational and ridiculous claim from "a psychiatrist will give you bad advice so you pay them forever to" "a psychiatrist will offer you evidence and science based advice that doesn't lie to you about your condition or future and instead seeks to give you the best options or advice that evidence teaches us can help"

Sure, that sounds great to me. That's why you trust an expert.

Now you seem to be mostly upset that a specific mental illness or condition isn't curable and may be permanent as the result of damage or pathology, and are blaming humanity's best experts for not having a panacea for your troubles.

I haven't walked anything back. An awful lot of people are woefully misreading what I said in a much more negative light than I intended, then acting like I changed my story when I try to communicate about the issue.

It's probably best for me to walk away at this point. Most of the remarks here do not strike me as good faith engagement.

Part of the problem is that nowadays, people don't even recognise their accusations as such, but consider them benign, universally-understood downsides.

"Professionals tend to act based on financial motives" is among these. You seem to think it's just human nature, and don't even expect anything different. Yet ask any psychologist, and they'll react as the would to an accusation of murder.

That's because in their job, intentional deviations from the standard-of-care can quite easily turn into murder (or manslaughter/negligent homicide to be more precise).

Very similar: accusations against journalists that they are acting on behalf of some publication-wide agenda, take money from the subjects they cover, or write/don't write certain articles with an eye towards the sector's financial future ("The Times studiously avoids mentioning adblockers")

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No, but remarks like this essentially are malicious, regardless of whatever else is going on here. It's basically a personal attack that in no way tries to engage me about whatever point I was trying to make.

The fact that you created an account just moments before taking a dig at me only reinforces the idea that this is absolutely not a good faith comment by you.

There are lots of things that can cause a conversation to go sideways. It's really common for the group to then blame the person at the center. It only serves to compound and entrench the problem.

Its a malicious rhetorical tool to use attempts at clarification as evidence of retreat. That's what politicians do. People here are not professional communicators, you can't expect them to say things perfectly the first time.

it's probably not that they're all stupid and malicious

... any more than psychiatrists are stupid and malicious for acting in accordance with the norms of their profession.

In both cases, people can be wrong without being stupid/malicious, and likewise, people can be wrong whilst adhering firmly to the status quo.

> A psychiatrist that behaves as you describe is literally engaging in malpractice.

That's only a deterrent to the extent you can prove it, which is zero.

> frankly it's ludacris!

Nearly every professional I've ever been in a position to independently assess has "rounded in their own favor," often quite heavily, frequently egregiously, and always with a firm rationalization in hand. Psychiatry has especially blurry lines to round -- but you expect me to believe that psychiatrists buck this trend? Frankly, that's ludicrous.

You are providing an example of why people wind up reasonably overreacting to when they reject experts.

The fact that someone is an expert makes them an authority figure. Whether or not they are effective is an independent question. In some areas it does. In others it doesn't. As long as that person follows the standards of practice for their profession.

Believe it or not, a significant fraction of medical treatments offered have no quantifiable evidence saying whether or not they work. Admittedly a lot fewer than used to be the case since the movement towards insisting on evidence-based approaches in medicine started in the 1990s. But it has not reached all areas of medicine yet.

In particular there is no evidence that talk-based therapy is better than a placebo (such as acupuncture) at treating basic conditions like depression. See http://theconversation.com/counselling-doesnt-work-in-the-lo... for a random link verifying this.

Now if this shocks you, then reflect on the fact that within my lifetime, therapy gave large numbers of people false memory of abuse that didn't happen, psychiatry subjected large numbers of people to electroshock therapy despite a lack of evidence that it worked. If you go back just a little further, to my parent's lifetime, tens of thousands of people had their brains very literally scrambled in frontal lobotomies (usually with an ice pick inserted through the eye socket).

So here is the problem. There are lots of experts who you really should listen to. If you have cancer, don't be like Steve Jobs. But there are also plenty of professions whose practitioners who can be safely disregarded even though by all outwards appearances they are are just as expert. In a situation like this, can you blame people for identifying the wrong professions as ignorable?

Unfortunately for your argument, available experimental evidence indicates that the example that you're responding to is one of the ones that actually IS ignorable.

> but upon closer examination it falls apart as quite simply an irrational fear

Yet you didn’t actually explain where it falls apart.

Valid malpractice claims are reasonably common in other much more measurable types of medicine.

It’s often a good idea to get a second or third opinion when you see a normal doctor.

To be wary of a branch of medicine like psychiatry with its far fewer checks and balances seems prudent.

Malpractice is mostly about errors of negligence. The accusation here was about intentional behaviour, which would actually be criminal.

> The accusation here was about intentional behaviour, which would actually be criminal.

Is that the accusation? My understanding is the parent was trying to say that incentives can bias a professionals decision making.

That line of thinking is so alien to me. Does it apply to any time you go looking for goods or services? Do you go online for advice in complying with tax codes because your accountant wants you to get audited and need their services, do you make all your own food because the restaurant chefs want you to leave hungry so you have to order another serving, do you avoid the doctor since if you get better you won't come back into the office?

I think this just speaks the the modern trend of anti-intellectualism. Distrust of an expert because of phantom biases and the regression toward getting advice from your "tribe".

Does it apply to any time you go looking for goods or services?

No, of course not. I eat at restaurants all the time. People will be hungry again shortly, even if fed wonderfully well. There are other things to worry about more, like if they are meeting food safety codes, which some don't.

I did therapy with a military chaplain. I had a really positive experience there. He wasn't being paid by me to deal with me. He was on salary. If I got better, that had no bearing on how much he made.

Some of the best hospitals in the US put their doctors on salary a long time ago. How many tests they order has no bearing on their income the way it can for a lot of private practice.

I have serious health issues and have gotten healthier via alternative approaches. I've thought a lot about what's wrong with modern medicine and I do think the way it gets paid for in the US is part of the problem. That doesn't mean I would never go to a doctor.

I've had lots of medical care and I would have died without it a long time ago, but I also was told at some point "People like you don't get well." When I didn't like that answer, I was scheduled fewer appointments and the rest of the world has since decided to malign me as a nutcase who "refuses" to see a doctor, which isn't the case.

I'm not an anti-intellectual by any stretch of the imagination. Nor do I think you should never seek expert advice. I'm just saying that advice free from conflict of interest is actually very valuable and one of the things offered by things like advice columns.

Example scenario:

If you are crying on the shoulder of some woman friend about your marital problems, you ultimately get divorced and end up with her, you have to wonder if she was really giving you advice designed to enhance your life or designed to enhance hers. You have to wonder if you can really trust her. It's a situation where she probably should have recused herself and told you "I'm not the person to get advice from on this matter. Sorry." But that's often not how it goes.

I don't want to invalidate your experience, but, jeez, I really feel awful for anyone that has to live in a world where they're constantly wondering if their friends are trying to take advantage of them. Most situations in life aren't zero sum, what's good for them may very well be what's good for you. Even less situations are zero sum and material; one patient's business is not likely to make or break a psychiatry practice so why not give good advice (misery loves company after all, healthy outcomes probably exponentially generates new customers).

This is especially apparent when the alternative is often some faceless person(s) on the internet who may very well bring their own (unknowable to you) biases to the table.

I've had the following college classes: Intro to Psychology; Social Psychology; Negotiation and Conflict Management. I had a corporate job for over five years. Part of that job was looking for "red flags" and referring it to the fraud department if it looked fishy enough. I also was taught proper procedure for how to handle a file where I had conflict of interest in order to protect the company legally (Answer: You don't. You leave note and send it back to the queues and let someone else handle the file.)

Framing this as opinion based on "my experience" is basically hanging an awful lot of baggage on me and acting like I've simply had a sucktastic life surrounded by people I can't trust, etc. It's a pretty ugly suggestion and not only serves to invalidate me, it invalidates the point entirely by presuming it has no real basis other than "Wow, that woman must have the worst life ever. Sucks to be her, I guess." And that's really not a good faith means to engage the point.

This exchange is a wonderful example of why amateur/anonymous advice shouldn't be automatically taken as better than professional advice! You are both filling in the blanks with your own experience and biases.

I never said it was automatically better. Where are you getting this nonsense? I only indicated that there are situations where one might want to hear from an uninvolved outsider for perspective and this is one reason why "amateur advice" in newspaper columns can have genuine value for some people.

Anyway, I'm done here. This entire discussion is completely off the rails from my perspective.

>I did therapy with a military chaplain. I had a really positive experience there. He wasn't being paid by me to deal with me. He was on salary. If I got better, that had no bearing on how much he made.

Actually, military chaplains do have a conflict of interest. They have to be endorsed by a religious organization, and said endorsement must be maintained throughout the chaplain's military service and can be withdrawn at any time for religious or disciplinary reasons. If they're not consistent with the teachings of their denomination, they stand to lose their military benefits and a pension.

If an accountant screws up, you're not likely to hire the same accountant again.

You might come back to a restaurant if you enjoyed your experience. The incentive is to give you as good a meal as possible. If you're hungry, you won't come back.

Doctors have a more concrete job to do. There's plenty of malpractice in the medical industry, by the way.

Psychiatry? It's much less concrete what a patient's needs are than other forms of business. It's perfectly reasonable for someone to bring up a potential conflict of interest there.

Equating things at random which don't make logical sense doesn't invalidate the point someone is trying to make.