Okay, so, I couldn’t completely dispense with the plays on the name ‘Pies,’ but please be clear, I am using ‘slice’ in the sense of a ‘slice of life,’ – or, in this case, a ‘slice’ of conversation – and in no other way.
For those of you who haven’t read it, I published a blog post called, ‘Too Much Pies,’ on Mad in America on Wednesday, April 10th. The post included an invitation to psychiatrist Ronald Pies (who caught the interest of many when he wrote a letter to the New York Times about psychiatric diagnosis) to a real dialogue, not limited by number of words, frequency of reply or professional licensure.
I copied the letter directly to Mr. Pies, not knowing if he would reply. On Thursday, April 11th I received a direct reply that Mr. Pies has authorized me to repost here. I am also including my response to him, sent Friday, April 12th.
Depending on whether or not there are multiple replies that I am given permission to share, I will be doing my best to figure out a way to share them on Mad in America that is as accessible as possible, so be sure to check back if this dialogue is of interest to you!
Received from Ronald Pies on Thursday, April 11th at 10:13 PM:
Dear Ms. Davidow:
I’m sorry that you felt that my response to your letter in the Times “…summarily disregarded so many years of pain and loss and abuse of power”, which evidently has been your experience with psychiatric care. Like you and the other correspondents, I was severely limited by the structure of the Sunday Dialogue, including the very strict word limits. More than that, I’m sorry that your experience with psychiatric care has been so painful. Having practiced in Massachusetts for more than 25 years, I have seen both the best and the worst of care–with most falling somewhere in the “average” range.
My letter to the Times was aimed at asserting the medical and ethical legitimacy of the diagnostic process in psychiatry. It was neither a defense of the DSM categories, nor a rationalization for deficiencies in the legal system, nor an apologia for over-zealous and inappropriate use of medication.
I am aware that the theoretical legal safeguards for those diagnosed with mental illness are not always put into practice, and that some individuals facing civil commitment are not adequately represented by legal counsel–despite requirements for due process of law. But in my view, these are not failings that can be laid at the feet of psychiatrists or psychiatry. They are part of a broken-down “non-system” of mental health care in the U.S., which has also transformed the U.S. prison system into the nation’s largest de facto psychiatric “care” facility–as detailed in the 4/11 New York Times re: California. I was frankly surprised that this injustice was not addressed in your own letter to the Times.
I’m sure you are aware that it is not just psychiatrists who have been “tapped” by the states to be involved in emergency hospitalization of individuals deemedan immediate danger to self or others, by virtue of mental illness. A physician in any medical specialty is able to enact an emergency (involuntary) hospitalization–lasting usually no longer than 48 to 72 hours – when the doctor believes that the patient represents an immediate danger to himself or others. It is only after this initial emergency detention that formal civil commitment is usually considered, and that is the decision of a judge--not a psychiatrist or other physician. In those proceedings, the patient must be represented by counsel, and there must be clear and convincing evidence presented, establishing the “dangerousness” to self or others. Judges do not move to commit a patient simply because a psychiatrist “says so”.
I do not defend this system as ideal or always in the best interests of the patient – nor was it a system created by psychiatrists or other physicians. But the system will not be changed by launching vituperative character attacks against psychiatrists or psychiatry; it will change only when our legislators find the will and wisdom to ensure adequate mental health care for all who need it; and adequate legal protection for those with mental illness who face judicial hearings and decisions.
None of these issues was the focus of my Times Dialogue, which simply asserted that a psychiatric diagnosis is not, in itself, “stigmatizing” or dehumanizing; and that, when carefully and respectfully carried out, diagnosis may lead to appropriate treatment and relief of the very substantial suffering often accompanying serious mental illness. Indeed, over more than 25 years of practice, I witnessed many more patients benefit from psychiatric treatment than were harmed by it–including many who were chronically suicidal, psychotic, or incapacitated by severe depression, until they received appropriate treatment.
I have read your recent blog and–despite its rather insulting language – I do appreciate the benign intent behind your invitation to continue a dialogue on the Mad in America (MIA) website. Alas, I do not have confidence that further exchanges on the MIA website are likely to be fruitful or respectful. My experience with the MIA website – and based on the experience of one of my colleagues, who used to post on MIA – has not been positive. I believe that the profusion of anonymous and insulting comments – poorly-moderated by the website administrators – makes for a very unhelpful and demeaning forum. Having read some of the hateful comments and personal attacks that followed your blog, I think my judgment has been amply confirmed.
I do understand that many on the MIA website have had very bad experiences with psychiatry, but that is no excuse for the abusive (and usually anonymous) comments that are often posted in the MIA forums. This is unfortunate, since I would like to foster a collegial and respectful dialogue between mental health professionals and patients (or “consumers”, clients, etc.) But that would require a modicum of mutual tolerance and good will, which I do not find in abundance on the MIA website.
I hope you will understand my decision, and while I do not intend to post replies on the MIA website, you do have my permission to post this letter in its entirety(not edited or excerpted) on the MIA website, if you care to do so.
I wish you well in your efforts at helping those you serve, in their recovery process.
Ronald Pies MD
My reply to Ronald Pies sent Friday, April 12th at 2:57 pm
Dear Mr. Pies,
Thank you for your reply. I will post it on Mad in America in its entirety, per your permission.
First, I guess I would like to clarify this point: I absolutely do not lay the failings of an entire system solely at the feet of psychiatrists. In some ways, I think psychiatrists actually have a somewhat limited role in the problems of the bigger picture. Terms like ‘anti-psychiatry’ and the ‘psychiatric system’ get broadly applied these days, but very often they have more to do with a psychiatric model that hovers above the actual psychiatrists themselves.
In actuality, the abuses I have observed have involved many more nurses, social workers, psychologists, police, lawyers, judges and paraprofessionals than medical doctors of any kind. And yet, it cannot be ignored that psychiatrists, even in their lesser numbers, take up the most ‘space’ with their ‘power.’ This is true whether or not they want it, though some have also seen fit to attempt to use some of that power for a different purpose (e.g, Dan Fisher, Mark Foster, etc.).
Said power is held by psychiatrists exclusively; their ability to approve sections and testify as the oft-unquestionable ‘expert’ and, most of all, their ability to influence opinions and both literally and figuratively silence the voice of those most commonly oppressed in the process. That you have chosen to post responses to a public dialogue in a forum where anyone can ‘watch’ but only ‘qualified healthcare professionals’ are able to respond is a perfect example of how that power can be used in a way that perhaps seems benign to you, but replicates the sense of powerlessness so very many have experienced in their lifetimes.
You point out that it is the decision of a judge – not a doctor – whether or not someone is committed. Indeed, it is, but the decisions are often made – as one commenter on Mad in America pointed out – by judges seated in rooms within the very hospitals where people are to be committed. Hardly neutral territory, wouldn’t you say? Moreover, the testimony of the psychiatrist, with whom the judge is already often quite familiar, is given inequitably heavy weighting. Both social capital (which cannot be underestimated) and credentials play a critical role here.
In 2010, I sat in on a commitment hearing as an advocate for a woman who was trying to fight against hospitalization. When testifying, flat affect was common, and questions were typically answered in monotone and with pronounced delays. But, wait! To be clear, I am referring to the psychiatrist, and not the psychiatrically labeled Defendant! It was further notable that the psychiatrist repeatedly made arguments for commitment like, “She almost hit someone.” When questioned by the Defendant’s lawyer as to what that meant, he would explain that, “She yelled really loudly at a nurse.” And, when the Defendant’s lawyer countered with, “So, she did NOT hit anyone or threaten to hit anyone,” he would just circle back around to, “She almost hit someone.” This – along with the Defendant’s refusal to acknowledge that she was ‘mentally ill’ (and in spite of her acknowledgment that she was a trauma survivor who did really struggle with life at times) – was a large part of what led to her commitment.
Sure, it was ultimately the Judge’s decision to commit her, but a ridiculous amount of credence was given to a psychiatrist who seemed barely able to form his own sentences. This may be just one story, but it is one of many and does quite well to exemplify the power afforded to psychiatrists by judges, lawyers, police and so many others who have been conditioned not to question that sort of authority and/or to believe wholeheartedly in the expertise of doctors.
To your credit, you do acknowledge that there are indeed misuses of power and problems within this system. You go on to say, “I have seen both the best and the worst of care–with most falling somewhere in the ‘average’ range.” I would certainly agree that there is a range of experiences in the system, and most do inevitably fall in the middle, if for no other reason then because of the bell curve nature of all things. However, I would argue that ‘average’ typically involves at least some level of disempowerment of the person supposedly being helped. I don’t have 25-years to claim, but I do have about 15 years worth of exposure (not including my own personal experiences) to witnessing and/or hearing the stories of people who have been treated inside the psychiatric system and it seems to me that the bar has been set quite low.
Your points here are valid:
“But the system will not be changed by launching vituperative character attacks against psychiatrists or psychiatry; it will change only when our legislators find the will and wisdom to ensure adequate mental health care for all who need it; and adequate legal protection for those with mental illness who face judicial hearings and decisions.”
While you clearly found some of my words insulting and I was admittedly sarcastic in places, my style does not generally include personal attacks. I can’t speak for others. Overall, I would agree that it is broader systemic change that is needed, and that all of us – psychiatrists included – are often trapped in a system that has limited options and tolerances for doing things differently. However, I find it naïve to lay the responsibility for change on the backs of legislators who are tasked with making decisions about any number of topics on which they are very ill informed. In the limited time they have to become even a little bit informed and make a decision about a myriad of issues, who do you suppose they will most tend to ‘hear’? Yes, this does indeed circle back around to psychiatrists such as yourself and other professionals regarded as having ‘the answers.’ In all but perhaps the Mad in America circle, you are much more likely than I to be ‘heard’ by professionals and legislators. More importantly you also have much more access than I to shape the minds of students who will someday enter this same profession. I hope you will not only carefully contemplate why that is true, but also consider your power carefully.
But to the main point: You say, “None of these issues was the focus of my Times Dialogue, which simply asserted that a psychiatric diagnosis is not, in itself, “stigmatizing” or dehumanizing; and that, when carefully and respectfully carried out, diagnosis may lead to appropriate treatment and relief of the very substantial suffering often accompanying serious mental illness.’
Fair enough. Perhaps in a utopia, the discrimination, oppression and power abuses I’ve written about would not naturally follow a process that starts at the point of labeling someone with a diagnosis that is popularly thought to be a life-changing and permanent condition. Perhaps it would simply serve to help organize our thoughts around a common understanding of what may be happening and how to move forward. However, this is not a utopia and we can not treat it as one. As such, this assertion seems relatively meaningless.
Moreover, while I do believe that there are many people who have experienced relief through some aspect of diagnosis and treatment within a traditional model, I would argue that the relief seems primarily founded in finding someone who is providing some hope about next steps, some access to resources and some reassurance that their experience makes sense within some framework and that they are not alone. While diagnosis can provide a dose of all that, it is not the only thing that can and it continues to strike me as absurd to suggest that psychiatric diagnosis is not fundamentally problematic.
Consider the following:
Inequity of Power – The reality is that psychiatric diagnosis is just one version of what might be ‘wrong’ with someone. While you might believe in it, the scientific proof put forward so far has been dubious at best and often debunked entirely. I personally buy most strongly into a trauma framework for many people’s distress (including my own), but I take an agnostic approach to the rest and would never attempt to blindly apply a trauma framework to everybody. It is not within my power to truly know, nor is it within yours. We’re in the same boat here, in spite of all my years of first-hand experience and exposure to hundreds of reports from others and in spite of all your years of training and practice; Here we are, together.
That so many people accumulate different diagnoses simply by going to different doctors certainly seems to be supporting evidence of the fact that no one really knows. (It seems to me it would be far less likely that someone would receive varying diagnoses on their comparatively straight forward headache experience by visiting multiple physicians.) To speak about psychiatric diagnosis as if you do know – as if you have an answer – as if there is only one framework within which we must exist – has the impact of giving you all the power. What do you suppose the harm would be in equalizing some of that power by acknowledging that you don’t really know? Or do you really feel that you do?
Lack of Transparency & Lack of Choice: By speaking of diagnosis as if it were harmless and absolute truth, one fails to be transparent by sharing the wealth of information (including scientific research) that supports many other perspectives. By failing to share information, one fails to give one the tools they need to make an informed choice. I will never forget a woman in her 50’s who – at a trauma training – burst out with, “You mean maybe this didn’t need to be my life?” She had been diagnosed, medicated and hospitalized for many years and had never heard there were any other options for what her story could be. To hear that there were other choices that she perhaps could have entertained catapulted her into a grieving process that was profound. One has to wonder how many others have had this experience.
Dehumanizing: I’m not personally interested in the word or concept of ‘stigma,’ (see my post, ‘Anti-Anti-Stigma,’ if you’re so inclined!), so you’ll have to find someone else to argue with about that one. However, I am interested in the concept of dehumanization. When someone is diagnosed with migraines, they don’t become ‘a migraine.’ No one goes around saying, “Hi, my name is X and I’m a migrainiac.’ Whereas, it is QUITE common for doctors to refer to people with a psychiatric diagnosis as if they ARE that diagnosis. (He is a schizophrenic. She is bipolar.) In turn, it’s also quite common for people who have been diagnosed to refer to themselves in that way. So, there is a dehumanization of people that happens. But, perhaps more importantly, what leads to the dehumanization of the whole person is the dehumanization of human experience. Hearing voices doesn’t have to represent pathology. It is within the spectrum of human experience, and is often quite connected to what has happened to someone in their lives. The same could be said of so many other ‘symptoms’ that lead to diagnosis. Are you not able to see how it might be invalidating to someone to have a reaction to a real trauma in their life treated as if it were not on the spectrum of ‘normal’?
How do we define ‘benefit’: Toward the end of your response, you said, “over more than 25 years of practice, I witnessed many more patients benefit from psychiatric treatment than were harmed by it.” It’s hard to know how to proceed with this without understanding how you might be defining ‘benefit’ and ‘harm.’ As aforementioned, I acknowledge that many people have reported feeling helped by psychiatrists, therapist, medications and so on and I will not deny them their stories. However, sometimes words like ‘benefit’ and ‘harm’ are defined differently within the psychiatric system than they are elsewhere.
Take, for example, the incredibly depressing way in which one Connecticut-based clubhouse seems to define a ‘recovery model of care’:
“[We] embrace a “recovery” model of care which holds that people with mental illness can and do adjust to their disabilities by an ongoing process of acceptance and adaptation, the development of a positive self-image, and the reformulation of their life aspirations.”
Every time I read that statement, I experience a rush of sadness. Adjust to their disabilities? Reformulate their life aspirations? But there you have it. That is one whole organization’s apparent definition of recovery.
Similarly, I recently heard a man speak up at a town hearing and offer that he had been in ‘recovery’ for over two decades. But how did he define recovery? Well, he hadn’t been working, but had been taking his medications consistently in spite of all the physical and cognitive effects that were evident in his speech. While I don’t want to take anything away from him or how he chooses to tell his story, I can’t help but ask, is THAT what we mean when we talk about ‘recovery?’
And what of the studies that seem to indicate that people treated within the psychiatric system show greater improvement than others in the first few months, but then seem to hit a threshold that they can’t quite ever break through? Is THAT what we mean when we talk about positive outcomes?
Or how about the people who maybe manage to stay out of the hospital, but die 25 years younger (as is the average number of years lost off of life expectancy for people receiving services in the mental health system)?
So, it would be helpful if you would define ‘benefit,’ for me because all too often, I have seen people refer to the ‘benefits’ of various elements of the psychiatric system based on their own priorities and goals.
I suppose, while we’re at it, could you also define what ‘respectful’ and ‘careful’ diagnosis might look like? Is it when you do tell people that you’re not sure if this is really the answer? When you share with them the possible other answers? When you are transparent as to the purpose of the diagnosis and involve them in the process? When you let them know the risks and benefits of having a diagnosis on file? What does it look like, exactly?
And one final question: Your main argument seems to be that diagnosis can help guide someone toward the ‘right’ treatment. How does a one or two word diagnosis do that any better than a description of the person’s actual experience?
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.