On July 1, the very eminent psychiatrist Ronald Pies, MD, wrote an article for Psychiatric Times titled Positivism, Humanism and the Case for Psychiatric Diagnosis. The article also appeared in Medscape on August 20.
Dr. Pies begins by discussing websites ” . . . that critically examine psychiatry.” These websites, he tells us,
” . . . vary from the viscerally enraged, to the politely skeptical, to the constructively critical, and everything in between. The worst antipsychiatry Web sites, in my view, are veritable bastions of bigotry, in which psychiatrists are subjected to invective and abuse that would never be tolerated if directed, say, at some ethnic or racial minority.”
I have expressed the belief before – indeed on several occasions – that Dr. Pies is psychiatry’s master of spin, and the above quote from his paper is a wonderful demonstration of his gifts in this area. By presenting anti-psychiatry invective and expressions of racial hatred side by side in the same sentence, he is attempting to convey the impression that these activities are essentially on a par.
But, in fact, this is simply not the case. Racially motivated invective and abuse are directed against people purely and simply on the basis of their skin color. Anti-psychiatry invective and abuse, however, are based on the activities of psychiatrists.
Criticism based purely on skin color is indeed bigoted and unfair. But criticism based on an assessment that a person has acted in a destructive or deceptive manner is not in the same category. Whether the criticism is couched in expressive language or in the measured tones of academic debate is very much a secondary issue.
Dr. Pies’ attempt to liken invective and abuse directed at psychiatry with invective and abuse aimed at racial or ethnic minorities is nothing more than a cheap ploy to marginalize his detractors.
Dr. Pies continues:
“If you look for something resembling a philosophical position on the more vituperative Web sites, you usually find objections to psychiatric diagnosis and treatment based on one or more of 3 basic claims:
- Only physical (bodily) illness, demonstrated by the presence of a lesion or physiological abnormality, constitutes ‘real disease.’ Psychiatry doesn’t deal with real diseases, but with invented ones; therefore, its diagnoses and ‘treatments’ are bogus.
- Whatever their claims to science, psychiatric treatments are either useless or harmful.
- Psychiatry is inherently coercive; it stigmatizes people with pejorative labels and forces its (bogus) treatments on unwilling victims, who, in many cases, are hospitalized against their will.”
The illness vs. invented illness issue is a great deal more complex than Dr. Pies suggests, but also, and more importantly, has to be seen in its proper context. And the proper context is that for the past several decades, psychiatrists have been telling their clients, and the general public, and journalists, that virtually all significant problems of thinking, feeling, and/or behaving are caused by chemical imbalances in the brain. They have stated clearly and unambiguously that these putative imbalances constitute “real illnesses, just like diabetes,” and that the imbalances are corrected by psychiatric drugs. The phrase “a real illness, just like diabetes” entails, I suggest, the assertion that these “illnesses” involve real biological pathology. And this is certainly how the message is received. So when we mental illness “deniers” point out that the various problems of thinking, feeling, and/or behaving listed in the DSM are not real illnesses, we are actually using the term illness in the same sense as is entailed in psychiatry’s scandalously deceptive assertion.
But Dr. Pies circumvents this entire matter with two deceptive maneuvers. Firstly – and almost unbelievably – he asserts that psychiatry never promoted the spurious chemical imbalance explanation. On July 11, 2011, he wrote an article for Psychiatric Times titled Psychiatry’s New Brain-Mind and the Legend of the “Chemical Imbalance.“ In that article he wrote:
“In truth, the ‘chemical imbalance’ notion was always a kind of urban legend – never a theory seriously propounded by well-informed psychiatrists.”
I have dealt with this in an earlier post – Psychiatry DID Promote the Chemical Imbalance Theory – in which I provided abundant quotes from eminent psychiatrists in which they asserted the chemical imbalance theory clearly and forcefully. To the best of my knowledge, Dr. Pies has never retracted his position, and so presumably continues to deny what is common knowledge: that the vast majority of psychiatrists did indeed routinely lie to their clients on this matter, and did indeed promote the chemical imbalance theory as a justification for prescribing psychiatric drugs. On March 11, 2014, Dr. Pies did refer to this deception as “this little white lie. (Psychiatric Times, Nuances, Narratives and the ‘Chemical Imbalance” Debate in Psychiatry.) A month later, however, the phrase was changed to “simplistic notion.” A Medscape article of the same name, dated April 15, still refers to the “little white lie.” (Nuances, Narratives and the ‘Chemical Imbalance’ Debate in Psychiatry)
Secondly, Dr. Pies simply eliminates the presence of biological pathology from the essential definition of illness.
Now this is really slick. For decades, the foundation of pharmacological psychiatry was that problems such as depression, inattention, anxiety, etc., are caused by chemical imbalances in the brain, and are therefore to be considered illnesses best “treated” by drugs. Then the chemical imbalance theory went down the drain. (Well, it was always down the drain, but was deceptively promoted by psychiatrists as valid science. What happened in the last ten or fifteen years is that the hoax has been so exposed that it has become untenable.)
But, Dr. Pies to the rescue: illness doesn’t require pathology. All that’s needed, to assert the presence of illness or disease, is “prolonged or intense suffering and incapacity.” And, in fairness to Dr Pies, he presents five very compelling arguments, including references, in support of this position. These arguments are summarized briefly, but, I believe, accurately below:
- Dr. Pies himself has said so. On Myths and Countermyths, Arch Gen Psych, 1979: 33: 139-144
- Dr. Pies himself has said so again: Moving beyond the “myth” of mental illness. In: Schaler JA, ed. Szasz Under Fire: The Psychiatric Abolitionist Faces His Critics. Chicago: Open Court Publishing Company; 2004:327-353.
- M.S. Moore, JD, (who at the time of writing was a Fellow in Law and Humanities, Harvard University) has said so: Some myths about “mental illness.” Arch Gen Psychiatry. 1975;32:1483-1497.
- L.S. King, MD, (a pathologist and medical historian) has said so: What is disease? Philos Sci. 1954;21:193-203.
- G.W. Thorn, MD, (physician who dealt with kidney and adrenal gland disorders), R.D. Adams, MD (neurologist and neuropathologist), K.J. Isselbacher, MD, (gastroenterologist), E. Braunwald, MD (cardiologist), R.G. Petersdorf, MD (infectious diseases physician) (editors) have said so: Harrison’s Principles of Internal Medicine. 8th ed. New York: McGraw-Hill; 1977.
And there it is – just as it has always been: every significant problem of thinking, feeling, and/or behaving is an illness, because psychiatrists (and incidentally some other physicians) say so!
Of course, psychiatrists are free to use words any way they choose. But playing around with words doesn’t alter fundamental realities. And the fundamental reality in this context is the fact that disease (in-the-sense-of-a-physical-pathology-within-the-organism) is not the conceptual, or indeed physical, equivalent of disease (in-the-sense-of-marked-distress-or-functional-impairment).
For Dr. Pies, or other psychiatrists, to assert that these two phenomena are essentially the same, and should be treated as functionally equivalent, isn’t just false, it’s nonsense. All that they are doing is making dogmatic statements about the meaning of words! If the words “illness” or “disease” merely mean a condition that entails significant distress or functional impairment, then it is the case that all the DSM entities are indeed illnesses – because that’s how they are written. Every DSM “diagnosis” has, as one of its criteria, the presence of distress or functional impairment.
Criterion H for dysthymia, for instance, states: “The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.” (p 168)
Criterion G for social anxiety disorder states: “The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.” (p 203)
Criterion A for somatic symptom disorder states: “One or more somatic symptoms that are distressing or result in significant disruption of daily life.” (p 311)
Criterion B for obsessive compulsive disorder states: “The obsessions or compulsions…cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.” (p 237).
And so on throughout the manual.
So when Dr. Pies asserts that these conditions are illnesses, all he’s actually saying is that: conditions whose definitions entail distress or functional impairment, are conditions that entail distress or functional impairment. And somehow in all of this, Dr. Pies seems to believe that his assertions constitute constructive dialogue.
It’s not quantum physics; it’s logic 101.
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This article appeared today on Philip Hickey’s website,
Behaviorism and Mental Health
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.