Dr. Pies and Psychiatry’s ‘Solid Center’

Ronald Pies, MD, is one of American’s most eminent and prestigious psychiatrists.  He is the Editor-in-Chief Emeritus of Psychiatric Times, and he is a Professor of Psychiatry at both Syracuse and Tufts.

I disagree with many of Dr. Pies’ contentions, and I have expressed these disagreements in detail in various posts (for instance, here, here, and here).  But there is one area where I have to acknowledge Dr. Pies’ efforts:  he never gives up in his defense of his beloved psychiatry, even in the face of the most damaging counter-evidence.

For instance, on more than one occasion, he has asserted, with apparent sincerity and conviction, that psychiatry never promoted the chemical imbalance theory of depression!

Here’s a quote from Nuances, Narratives, and the ‘Chemical Imbalance’ Debate in Psychiatry, April 15, 2014:

“…the ‘chemical imbalance theory’ was never a real theory, nor was it widely propounded by responsible practitioners in the field of psychiatry.”

And from Serotonin:  How Psychiatry Got Over its “High School Crush”, on September 15, 2015:

“Alas, antipsychiatry bloggers continue to bang away at the notion that ‘Psychiatry’ (that sinister, monolithic corporate entity) deliberately duped the public by promoting a bogus ‘chemical imbalance theory,’ in cahoots with ‘Big Pharma.’ Suffice it to say that this line of argumentation is itself bogus, for reasons I have reiterated at length in several venues.”

His latest contentions in this area were demolished by Robert Whitaker on September 21, 2015, but Dr. Pies has demonstrated a remarkable resilience against factual material that runs contrary to his cherished notions.  So it remains to be seen whether or not he will be back with this particular message.

. . . . . 

Meanwhile, he’s working on another buttress to shore up the crumbling psychiatric sandcastle.  On October 7, 2015, he published Psychiatry’s Solid Center in the Psychiatric times.  Here’s the opening paragraph:

“Most psychiatrists do not fit neatly into the biological or psychodynamic camps. Instead, like surgeons, they will implement tools that reduce the suffering and enhance the well-being of the patient.”

I’m not familiar with the state of psychiatry at Syracuse or Tufts, but in the rest of the US, the vast majority of psychiatrists very emphatically do fit neatly into the biological camp, and do conduct their practices in accordance with a simplistic biological model.

Of course, my experiences are limited by my horizons.  It may be that, outside of my ken, psychiatrists are busy providing hour-long therapy sessions to their clients – helping them identify and unravel their unconscious emotional conflicts, or engaging in family therapy, conflict resolution, skill training, etc.  Or maybe not.

Douglas Mossman, MD, Professor of Psychiatry, and Director of the Institute of Law and Psychiatry  at the University of Cincinnati, has written on this topic.  Dr. Mossman writes a regular column called Malpractice Rx in the publication Current Psychiatry.  The following quote is from an article dated June 2010, and is in response to a reader psychiatrist who had asked how he could “…attend to patients’ needs, be empathic, listen actively, and still produce proper documentation?”

“In medical malpractice cases, the jury decides ‘whether the physician’s actions were consistent with what other physicians customarily do under similar circumstances.’  Even psychiatrists who deplore 15-minute med checks recognize that they have become standard care in psychiatry.”

In other words, if all, or even most, psychiatrists are doing 15-minute med checks, then there is little chance of a successful malpractice suit.  He is also saying quite clearly that 15-minute med checks have become “standard care” in psychiatry.  And lest there be any residual uncertainty, at the end of the article under the heading BOTTOM LINE, Dr. Mossman wrote:

“Brief medication visits—also known as 15-minute ‘med checks’—have become standard care in psychiatry.”

Not much ambiguity there.

. . . . .

And Glen Gabbard, MD, a widely published professor of psychiatry at Baylor and, interestingly, Syracuse, has written in Psychiatric Times, on September 3, 2009:

“There can be little doubt in our current era that the brief ‘med check’ is becoming standard practice in psychiatry.”

This was in 2009, and there have been no indications in the interim that psychiatry is backing away from this approach.

So if the majority of psychiatrists are spending the majority of their practice time doing 15-minute med checks, isn’t it reasonable to infer that they might “fit neatly”, to use Dr. Pies’ own phrase, into the biological camp?  And in fact, Dr. Pies himself, in an earlier paper (Psychiatrists, Physicians, and the Prescriptive Bond) has written:

“Unfortunately, many prescriptions for psychotropics are written in haste—often after the infamous ’15-minute med check’ – and without any real understanding of the patient’s inner life or psychopathology.” 

. . . . . 

Dr. Pies continues by telling us that he was fortunate in that his psychiatric training was fostered by those in what he calls the “great solid center” of psychiatry.  This is interesting, of course, and one can readily entertain feelings of joy and gratitude, that Dr. Pies apparently escaped the bio-reductionist nonsense, that has now become a dominant feature of psychiatric training and practice.

Dr. Pies continues:

“And critics of psychiatry who insist that the field has become exclusively ‘biological’ are also missing the larger and more enduring picture.”

Well I think I could count myself as a critic of psychiatry, and I have to say that one of us is certainly missing the bigger picture.  Since the 70’s, I have interacted with a great many psychiatrists in a wide range of contexts and locations, but I cannot recall one who conceptualized his/her role as anything other than the prescribing of drugs or high-voltage electric shocks to the brain.  And in fact, I can recall only one psychiatrist, an elderly man who had trained in Vienna in the ’30’s, who expressed even the slightest regrets or misgivings in this regard.  I can still remember his exact words:  “I was trained as a psychotherapist, but all they want me to do now is prescribe drugs.”

Every other psychiatrist I’ve ever met has expressed nothing but satisfaction with what is sometimes referred to as the “drug revolution” that, according to the rhetoric, has enabled psychiatry to take its “rightful place” as a legitimate science-based medical specialty.

. . . . .

Dr. Pies continues at some length on the wide-ranging aspects of his psychiatric training. He tells us that at one point in his training, he ran a poetry therapy group on an inpatient unit, and that he “…became a believer in pragmatic pluralism and psychiatry’s crucial role as a bridge between the medical sciences and the humanities.”

This last statement is ambiguous, in that it could mean that Dr. Pies believes that psychiatry should be such a bridge, or that psychiatry is such a bridge.  If Dr. Pies intended the former, then that’s interesting, though not pertinent to his main thesis, but if he meant the latter, then I suggest his contention is not only false, but entirely lacking in credibility.  Indeed, in my experience, it is one of psychiatry’s great priorities to dispel any such perceptions, and to establish itself as a “real” medical specialty with expertise in biochemistry, drugs, electric shocks, etc…  In this regard, it is noteworthy that Jeffrey Lieberman, MD, arguably the greatest and most eminent psychiatrist in the world today, has appeared in promotional videos wearing a white lab coat!  One wouldn’t want to make too much of this.  Perhaps he just couldn’t find anything else to wear.  But it certainly militates against the notion that psychiatry is involved in any bridge-building to the humanities.

Dr. Pies tells us that in his 35 years of practice, psychiatry has been such a bridge for him, and I certainly have no reason to doubt this.  But this is not, I suggest, an accurate description of psychiatry generally.  Indeed, with a measure of wistfulness, Dr. Pies himself concedes this point:

“Maybe that’s why I find it so troubling that many in the general public—and indeed, many within the profession—see psychiatry as having pitched its tent squarely and solely in the ‘biological’ camp.” [Emphasis added]

Note the phrase:  “…many within the profession…”  I would say the vast, vast majority within the profession, but let’s not quibble over details.

. . . . .

Back to Dr. Pies’ article: 

“This perception [that psychiatry has pitched its tent squarely and solely in the biological camp] is not without some foundation, and there is no question that, in the 1990s, American psychiatry took a ‘biological turn’ that has never fully swung back to the psychosocial end of the continuum.  But to view today’s psychiatry as merely biology-based is to see it ‘through a glass, darkly.’  When we look to the solid center of this profession, we see thousands of skilled clinicians, researchers, and teachers who are as comfortable with motives as with molecules. The solid center rejects the notion that we must choose between biology or psychology, between medication and psychotherapy.”

Well, perhaps we, on this side of the debate, are seeing psychiatry “through a glass darkly”, but I suggest it is more plausible that Dr. Pies is seeing his beloved profession through a rose-colored glass.  He tells us that there are  “thousands of skilled clinicians, researchers, and teachers who are as comfortable with motives as with molecules”.  This may be true.  But in their actual work, the vast majority of clinicians and researchers appear far more concerned with the latter.  Indeed, indifference to motivation has been enshrined in the DSM since Robert Spitzer’s DSM-III.  Within the context of “psychiatric diagnosis”, it doesn’t matter why a person might, for instance, be very suspicious of his neighbors.  If the suspiciousness crosses a vaguely-defined threshold of severity/implausibility, then it becomes a symptom of “schizophrenia”. Similarly, if a child is routinely disobedient to his/her parents, no attempt is made within psychiatry to explore why this might be so.  The disobedience is simply chalked up as a “symptom” of oppositional defiant disorder.  Similarly, no attention is given within the DSM as to why an individual is feeling depressed, anxious, angry, etc..  The presence of the particular thought, feeling, or behavior is all that’s needed to establish the “diagnosis”, and the “diagnosis” is all that’s needed to justify the prescription.  The why questions are never even asked.

Daniel Carlat, MD, Associate Clinical Professor of Psychiatry at Tufts, and author of the book Unhinged:  The Trouble with Psychiatry – A Doctor’s Revelations about a Profession in Crisis, is very open about this.  Here’s a quote from an interview he gave on NPR on July 13, 2010:

“…there’s kind of an unofficial policy among psychiatrists, at least among some, which is the don’t-ask-don’t-tell policy, which is that we have our patients coming in, we know we have 15 or 20 minutes to see them. We want to learn a certain amount about how they’re doing, obviously, because we want to make sure that our medications are working and that we know if we need to increase the dose or add something else.

But on the other hand, we don’t want to ask too many questions because if we start to hear too much information, then we’re going to run into a time issue where we’re going to have to kind of push them out of the office perhaps just at the point where they’re about to reveal something that could really be crucial to understanding their treatment.”

Sounds a bit like biological psychiatry to me.

. . . . .

Back to Dr. Pies:

“As a broad generalization, those in the center conceive psychiatric ‘disease’ as something that afflicts persons, not ‘minds’ or ‘brains’—a point stressed by the late Dr Robert Kendell.  Thus, the ‘mental versus physical’ debates are seen as sterile and fruitless. Those following the ‘Middle Path’ (to borrow a term from Buddhism) are preoccupied not with elaborate theories, but with relieving the suffering and incapacity of those who seek our help. Those in psychiatry’s solid center use the best established treatments to alleviate the patient’s illness—whether with ‘talk therapy,’ medication, or both.”

There are several noteworthy features in this paragraph.  Firstly, note that Dr. Pies has placed the word “disease” inside quotation marks.  In normal usage, this would indicate that he’s using the word to mean:  not a real disease. A  Freudian slip perhaps, as Dr. Pies has asserted the disease status of psychiatric “diagnoses” on many previous occasions.

Secondly, the first sentence in the above quote is a truly delightful piece of psychiatric spin.  Let’s open it up.  Dr. Pies is asserting that he and his right-minded colleagues in the “solid center” conceive of psychiatric disease as something that afflicts persons, not minds or brains.  But this is entirely incidental to the main issue.  Take, for example, depression.  Psychiatry conceives of this as an illness (provided a certain ill-defined level of severity is present) – specifically an illness of the brain.  Those of us on this side of the debate argue otherwise – that it is not an illness, but rather the normal, adaptive response to loss, or to an unfulfilling lifestyle.  But both groups agree, indeed it’s hard to imagine how we could disagree, that depression afflicts persons.  Even the most die-hard bio-reductionist would subscribe to that:  depression is a brain disease that afflicts the person who owns the brain!  While those of us on this side would say:  depression is a normal reaction to depressing events/circumstances that afflicts the person experiencing these events/circumstances.

What Dr. Pies has done here is make a statement that looks and sounds like an important distinction, but which in reality is banal to the point of meaninglessness.  And he’s used this non-distinction in his ongoing, futile attempt to defend his beloved profession.  But he’s avoiding the reality:  that psychiatry’s blatant promotion of its various illness theories is a hoax.

Thirdly, the statement “Thus, the ‘mental versus physical’ debates are seen as sterile and fruitless” has similar problems.  The issue is not “mental vs. physical”, posed by Dr. Pies as a kind of theoretical dichotomy.  The issue is whether or not depression, say, should be conceptualized as a normal response to depressing events/circumstances or as a neurological pathology.  This is not a sterile or fruitless debate, and by mischaracterizing it as such, Dr. Pies is either being deliberately deceptive, or has missed the point of the entire conflict.  In fact, whether depression should be conceptualized as a normal response or as a neurological pathology isn’t really a matter for debate at all.   It’s a question of fact:  do all the individuals whom psychiatry identifies as having depressive illness have a characteristic neural pathology?  After forty years of highly motivated and well-funded research, no such pathology has been identified, and the time honored notion, that depression is the normal response to depressing circumstances is as credible today as it has always been.

Fourthly, “Those following the ‘Middle Path’ (to borrow a term from Buddhism) are preoccupied not with elaborate theories, but with relieving the suffering and incapacity of those who seek our help.”  In other words, Dr. Pies and his stalwart colleagues from the solid center are not preoccupied with elaborate theories, (which is good to know, because as a general rule, most of his incursions in this area are riddled with error and fallacy), but with relieving the suffering and incapacity of those who seek their help.  And here again, dear readers, marvel at the spin – the implication, so beautifully and expertly wrapped up, that those of us who do feel strongly about psychiatric fallacy, deception, and destructiveness, are somehow neglecting our responsibilities to relieve the suffering and incapacity of those who seek our help.  Such cads we are.  But never worry, Dr. Pies and his cadre in the “solid center” will step into the breach of our remissness, pick up the slack, and minister dutifully to those who seek their help.  This is such a comfort!

As I’ve said on other occasions about Dr. Pies’ writings:  this is doctoral level spin.

. . . . .

Dr. Pies next provides brief sketches of Karl Jaspers, MD, Eric Kandel, MD, and Glen Gabbard, MD, all of whom Dr. Pies describes as exemplary of the “holistic tradition”.  These are interesting diversions, of course, but they shed no light on Dr. Pies’ primary thesis that “Most psychiatrists do not fit neatly into the biological or psychodynamic camp.”

Conclusion

The great irony of all this is that to the best of my knowledge, Dr. Pies has never aligned himself with the bio-reductionist majority, that has dominated psychiatry for the past 40 or 50 years.  But no amount of humanism or eclecticism can rescue him from  psychiatry’s fundamental and pervasive fallacy:  that all significant problems of thinking , feeling, and/or behaving regardless of their genesis – are illnesses.  The fact is that the vast majority of problems of thinking, feeling, and/or behaving are not illnesses, and that treating these problems as if they were illnesses is counter-productive, disempowering, stigmatizing, and deceptive.  This is the critical issue that no amount of psychiatric sophistry or verbal chicanery can neutralize.

Dr. Pies indicated in the article that he has a liking for poetry.  I also have a fondness for poetry, and in the current debate, I often find comfort in the poem Say not the Struggle nought Availeth, by the great Victorian poet Arthur Hugh Clough.  Here’s the third stanza:

“For while the tired waves, vainly breaking,  Seem here no painful inch to gain,  Far back, through creeks and inlets making, Comes silent, flooding in, the main.”

The main, Dr. Pies, a symbol of that great, cleansing surge of truth and logic, whose flowing tide is already eating at psychiatry’s foundations, and which will one day, when the lifeline of pharma money dries up, wash psychiatry, and all its spurious trappings, into the depths of historical obscurity.