On September 4, 2017, the very eminent and prestigious psychiatrist Ronald Pies, MD, published an article on Psychiatric Times. The piece is titled: “Hearing Voices and Psychiatry’s (Real) Medical Model.” Dr. Pies is Editor-in-Chief Emeritus of Psychiatric Times and a professor of psychiatry at SUNY and Tufts. He has written extensively on psychiatric and other matters, and has acquired a reputation for scholarship and erudition. His credibility, however, took a considerable knock in 2014 when, in a Medscape article, he asserted that the chemical imbalance theory of depression was just a kind of urban legend that was never seriously promoted by psychiatry. This assertion, which was widely disputed, added a whole new dimension to the concept of the ivory tower. But it also provided an important insight into Dr. Pies’ primary position: that psychiatry is inherently benign, scientifically founded, and helpful, and that all suggestions to the contrary are logically flawed, factually mistaken, or both. The present “Hearing Voices…” piece is in this same vein.
In his opening paragraph, Dr. Pies states:
“I believe critics [of psychiatry] misconstrue the nature of the medical model used in clinical psychiatry—and often overlook the seminal contributions psychiatrists have made to the psychological understanding of ‘hearing voices.'”
Later in the article, Dr. Pies provides some examples of these “contributions”:
“In his classic 1974 work, Interpretation of Schizophrenia, the psychiatrist Silvano Arieti presents a useful psychodynamic formulation of ‘hearing voices.’ For Arieti—who by no means excludes a neurophysiological basis for auditory hallucinations—the patient ‘hears voices’ in part because she expects to hear them. Arieti calls this ‘the listening attitude.’ He gives this example: [A] patient has the idea that people laugh at him. He actually hears them laughing . . . we must help the patient to recognize that he sees or hears people laughing at him when he expects to see or hear them . . . when the treatment is more advanced, the patient recognizes that he feels people should laugh at him because he is a laughable individual. He hears them laughing because he believes they should laugh at him. What he thinks of himself becomes the cause of his symptoms.
Arieti may well be right, at least in some instances—but we needn’t agree with him entirely to appreciate that he is not dismissing the content of the patient’s voices as ‘random or meaningless.’ Similarly, in their excellent volume (1987) on psychiatric differential diagnosis, psychiatrists Stephen M. Soreff and George N. McNeil provide an elegant discussion of the psychodynamics of ‘voices’: Wish fulfillment creates and propels the hallucinatory experience. Freud made reference to the wish-derived quality and function of the false perception. The hallucination represents an unconscious wish, striving or hope. . . . Hallucinations provide a method to momentarily restore a loss. The [hallucinatory] experience retains in life . . . those who have died or are far away. [For example], after a couple lost their 6-year-old son to leukemia, they frequently heard his voice calling them. Occasionally, the mother saw him standing in the stairway. The voice and image kept him alive and still part of them.”
Interesting as they may be, these references to psychoanalytic thinking have little bearing on present-day psychiatry, where psychoanalytic concepts have been long-abandoned. It is also noteworthy that the appreciation that Dr. Pies demonstrates for psychoanalysis in the above quote is apparently new-found, as we shall see later.
THE MEDICAL MODEL
It is an obvious fact that psychiatry has received considerable criticism over the past 50 years, particularly in the last decade, for applying the medical model of diagnosis and treatment to non-medical problems and experiences, for which it is entirely unsuited. The general point here is that while the medical model is very effective in real illnesses such as pneumonia, kidney failure, etc., where the general aspects of the issue largely eclipse individual considerations, it is unhelpful and even destructive in non-medical matters such as depression or hearing voices, or childhood inattentiveness, in which the reverse is the case. The notion that non-medical human experiences, such as depression, anxiety, hallucinating voices, misbehavior, etc., are illnesses is a hoax, and the “treatment” of these so-called mental illnesses with pills and electric shocks is destructive, disempowering, and stigmatizing, particularly in the long term.
But Dr. Pies will have none of this. Here is a quote from his opening defense:
“…one of the enduring myths about psychiatrists is that we rigidly apply ‘the medical model’ to persons who ‘hear voices’; that is, who have the experience of hearing voices in the absence of any relevant external auditory stimulus. Critics charge that by applying the medical model, psychiatrists ‘pathologize’ a rich, psychologically meaningful human experience.”
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Under the heading “What is ‘the real medical model’ in psychiatry?”, Dr. Pies identifies three different formulations of this concept.
Medical model, version 1 contends that the so-called mental disorders are brain diseases and promotes the use of pharmacological “treatment” to correct neuro-biological abnormalities.
Medical model, version 2. To describe this version, Dr. Pies provides a quotation from Dominic Murphy, PhD, University of Sydney: “…mental illnesses are regularly co-occurring clusters of signs and symptoms that doubtless depend on physical processes but are not defined or classified in terms of those physical processes.” (here)
Medical model, version 3. For this version, Dr. Pies provides a quotation from Premal Shah, MD (Consultant Psychiatrist, University of Glasgow) and Deborah Mountain, MD (Consultant Psychiatrist, University of Edinburgh) (here): “… a process whereby, informed by the best available evidence, doctors advise on, coordinate or deliver interventions for health improvement.”
Then Dr. Pies tells us:
“While all 3 formulations of the medical model have their virtues, they all omit some central philosophical principles which, in my view, underlie the model most psychiatrists actually use in their clinical work. I believe there are 6 fundamental assumptions in what I call ‘the real medical model’ of psychiatry…”
Well, so far, the article is following Dr. Pies’ customary trajectory: critics accuse us of applying an inappropriate medical model to the problems we encounter, but these critics have got it all wrong. In particular, they misconstrue the meaning of the term. Psychiatrists, Dr. Pies tells us, don’t actually use the medical model version that is attributed to them. Rather, they use the “real” medical model, which, presumably, will avoid the pitfalls of versions 1, 2, and 3, and will steer a path of validated righteousness through the thicket of spurious accusations in which those poor, beleaguered psychiatrists labor so assiduously in the service of their clients — sorry, patients.
THE SIX FUNDAMENTAL ASSUMPTIONS
So, let’s take a look at the six fundamental assumptions that the eminent and scholarly Dr. Pies assures us “underlie the model most psychiatrists actually use in their clinical work.”
“1) In so far as human emotion, cognition, and behavior are mediated by brain function, there is always an inherent biological foundation to dysfunctional states, such as clinical depression, psychosis, etc”
This looks interesting, and significant, but in fact it says virtually nothing. In reality, all human activity, from the simple twitch of a finger to composing a symphony, is mediated by brain function. There is a biological foundation to everything we do — not just “dysfunctional states.” By singling out “dysfunctional states” as having a biological foundation, and omitting the obvious reality that all human activity is similarly founded, Dr. Pies is creating the impression (without actually saying so) that brain functions that underlie “dysfunctional states” are somehow particularly noteworthy.
But it’s more subtle than that. The issue around which Dr. Pies is skirting — with, I must add, the finesse that we have come to expect from this eminent scholar — is the notion that “dysfunctional states” must be founded on dysfunctional biology, i.e. biological pathology. This fallacious notion is the basis of the entire psychiatric hoax. And note, Dr. Pies has not said this. However, he has managed to convey this impression. What he actually wrote was: “…there is always an inherent biological foundation to dysfunctional states…” This is trite almost to the point of tautological. So why would a person of Dr. Pies’ prestige, erudition, and communicative parsimony waste time in telling us something so obvious? And why would he present such an obvious truth as the first fundamental assumption of his “real medical model”? And — most tellingly of all — why did he not point out the obviousness and universal applicability of this assertion?
These are questions to ponder. But let’s soldier on.
“2) Valid psychosocial and cultural explanations of human experiences do not nullify (or contradict) the biological foundations of these experiences”
As I’ve pointed out above, its biological foundations are an integral, constant, and essential part of all human experience. We cannot see without eyes and optic nerves; we cannot experience pain without pain receptors; we cannot move without nerves and muscles; etc. The biological foundations of human experience are an ever-present reality that cannot be nullified or contradicted by anything. So, of course, they cannot be nullified by psychosocial and cultural explanations of human experience.
So why is Dr. Pies once more wasting space and words to affirm something so trite and obvious? Does he believe that there are people on this side of the issue who believe that valid psychosocial and cultural explanations do nullify the biological foundations of human experience? Is this second fundamental assumption of the “real” medical model of psychiatry intended to be a rebuttal of this hypothesized position?
Or is this simply the impression that Dr. Pies is trying to create?
Again, lots of unanswered questions. But let’s keeping going — perhaps things will become clearer.
“3) Conversely, biological explanations of human experiences do not negate (and often complement) valid psychosocial and cultural explanations and formulations”
Here again, an interesting statement, but let’s consider a concrete example. Suppose two people, A and B, are brawling in the street, in the course of which A kicks B in the head. The question arises: Why did A do this? And following Dr. Pies’ lead, let’s look at the matter from both the biological and psychosocial perspectives.
Biologically we could — in theory at least — describe the entire sequence of neuro-musculo-skeletal-endocrinological-etc. events leading up to, and through, the actual act of kicking. And provided we had everything correct, we could have therein a valid explanation of the act in question.
Or we could study the matter from the psychosocial-cultural perspective, and might perhaps find that both individuals grew up in rough neighborhoods, where fisticuffs were considered to be valid conflict resolution procedures; that A had been getting the worse of things, and was experiencing some injuries to his pride; that B bent over to retrieve something he had dropped, and A availed of the opportunity to kick him in the head. And, here again, assuming that we’ve got the facts right, we have a valid explanation of the incident. The biological explanation would, of course, be interesting and helpful to biology students and researchers; but the psychosocial explanation would have a great deal more relevance to people involved in helping the individuals develop less violent ways to resolve their disagreements.
But there’s no contradiction between the two accounts. Any incident or occurrence can be studied and explained at different levels of abstraction. And if the explanations are accurate, they will always be compatible.
But, interesting as all this is, it is just more of Dr. Pies’ ivory tower theorizing. In practice, spurious biological explanations (e.g. chemical imbalances) are routinely used by psychiatrists to negate valid psychosocial explanations. Ask any mental health worker who has tried in a staff meeting to draw attention to a client’s poverty, bereavement, or other abiding adverse circumstances, only to be cursorily dismissed by the psychiatrist asserting: we have to treat the depression first, clearly implying that the adverse circumstances do not constitute a valid explanation of the client’s despondency, and that what the client really needs is a prescription for psychiatric drugs, which is promptly provided.
And although I’m confident that nothing so crass would ever happen in Dr. Pies’ ivory tower, I can assure him that it is absolutely routine in mental health centers and other psychiatric locations.
“4) Biological factors are always part of a comprehensive differential diagnosis of serious emotional, cognitive, and behavioral disturbances—even if, upon careful analysis, psychosocial or cultural explanations prove more relevant or informative”
Now this is a little more nitty-gritty, but it’s also ambiguous. When Dr. Pies asserts that biological factors are always a part of a comprehensive differential diagnosis, is he saying that, as a matter of fact this is the case; or that this should always be the case? And, of course, we don’t know, because the passage is simply ambiguous. But let’s see if we can apply the concept, vague as it is, to the experience of hearing “voices,” which is the central theme of Dr. Pies’ article.
Let’s imagine an individual who reports hearing voices in his head that berate him at odd intervals. The voices say things like: you’re bad; you’re no good, etc., and this causes the individual considerable distress, and impacts his ability to function effectively in his work and other activities.
And let’s imagine that this individual goes to see a psychiatrist for help with this matter. Dr. Pies tells us — or at least appears to be telling us — that in seeking an understanding of these matters, the psychiatrist must include biological factors in his assessment/evaluation. And I think it’s reasonable to assume that Dr. Pies is referring primarily to neurobiological factors. In other words, according to Dr. Pies, a psychiatrist, in order to make a “diagnosis,” must explore how and to what extent neurological factors have precipitated this distressing experience.
But there are two problems with this. Firstly, there is no neuro-pathology that has been causally linked to reporting “voices”; hence there is no reliable way to explore this matter from a neuropathological perspective. And even if there were, I have never met, or even heard of, a psychiatrist who routinely deferred “diagnosis” in these matters pending a neurological evaluation.
Secondly, DSM-5, psychiatry’s current definitive volume on psychiatric diagnoses, contains no requirement, or even recommendation, of a neurological examination in such cases. According to DSM-5, auditory hallucinations are one of the defining features of that loose collection of vaguely-defined problems that psychiatry calls schizophrenia, and all that is required on this item is “…the clear presence of . . . hallucinations…” (p 100), which is routinely assessed through interview or collateral informants. In fact, DSM-5 specifically points out that “…there are no radiological, laboratory, or psychometric tests for the disorder.” (p 101)
“5) That certain human experiences or perceptions (eg, ‘voices’) have a discernible ‘meaning,’ symbolism, or psychological significance for the patient does not mean they have no neuropathological etiology”
Essentially what Dr. Pies is saying in this fifth fundamental assumption is that the experience of having a brain illness (a real brain illness) might have some symbolic or psychological meaning for the afflicted individual. And here again, this is non-contentious. A person with epilepsy, for instance, might believe that this afforded him special insights, and was a kind of blessing. Another might consider it a curse visited upon him because of some transgression on the part of his parents. And so on. But, assuming the diagnosis is correct, he still has epilepsy; he still has a genuine brain pathology. The attachment by the individual of meaning, symbolism, or psychological significance to the epilepsy has no bearing on that.
With regards to hearing “voices,” the critical question is this: is there compelling evidence, in a particular case, that the experience of hearing “voices” is caused by an identifiable neuropathology? If there is not, and this is almost always the case, then an assumption to this effect is unwarranted. Nevertheless, such assumptions have long been routine in psychiatric practice, and are falsely and self-servingly foisted on clients and their families by psychiatrists.
“6) All somatic and psychological treatment modalities—whether medication or ‘talk therapy’—have meaningful (and sometimes measurable) effects on brain function and structure”
Here again, the dominant feature of this sixth fundamental assumption of the “real” medical model of psychiatry is its obviousness! Everything that we do or experience or ingest has an effect on brain function and structure. If I walk down a street that I’ve never visited before, I will retain some memory of the terrain, the houses, etc., and, without a doubt, this memory will be underpinned by some changes in my brain. So if one of Dr. Pies’ clients ingests a mood-altering drug or converses with a therapist, these experiences, of course, have effects on the person’s brain. How could it be otherwise?
RECAP AND REGROUP
So, where are we? Dr. Pies has noted that critics sometimes accuse psychiatrists of applying the medical model to situations in which it is not appropriate. Dr. Pies discusses this issue at some length and, predictably, concludes that we critics of psychiatry have it all wrong; that psychiatrists don’t use the bad versions of the medical model, but rather the real medical model, which as we’ve seen, consists of nothing more than a string of obvious, almost tautological, platitudes.
And I describe Dr. Pies’ conclusions as predictable, because there is a good deal of relevant context here. As already mentioned, Dr. Pies responded to accusations that psychiatry’s chemical imbalance theory was a hoax, by asserting that psychiatrists had never seriously promoted this theory.
“In short, the ‘chemical imbalance theory’ was never a real theory, nor was it widely propounded by responsible practitioners in the field of psychiatry.” (here)
In reality, the vast majority of psychiatrists promoted the chemical imbalance theory, as I demonstrated clearly in an earlier post.
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When psychiatrists were accused of adopting a bio-bio-bio approach to problems of thinking, feeling, and behaving, Dr. Pies countered by saying that psychiatry has always maintained a biopsychosocial perspective.
“In their recently released book, The Social Determinants of Mental Health, psychiatrists Michael T. Compton, MD, and Ruth S. Shim, MD, cite the following risk factors for depression: racial discrimination, poverty, unemployment, lack of social skills, reduced frustration tolerance and self-regulation, and food insecurity.
All this is nothing radically new—it’s really an elaboration of the biopsychosocial model that has dominated academic psychiatry since the 1980s.” (here).
Perhaps this is the case in academic psychiatry, but it is certainly not the case in psychiatric practice, where the disease-mongering and the pushing of drugs and electric shocks has held dominion for decades.
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When members of the anti-psychiatry movement pointed out that the problems that psychiatry purports to treat are not illnesses in any ordinary sense of the term, Dr. Pies dodged the issue by contending that the term illness does not entail the notion of biological pathology, but merely the presence of suffering and incapacity:
“So long as the patient is experiencing a substantial or enduring state of suffering and incapacity, the patient has disease (dis-ease)” (here)
“…namely, that disease is best conceptualized as prolonged or intense suffering and incapacity…” (here).
And how do we know that this is the best way to conceptualize disease? Because the learned and eminent Dr. Pies, who apparently has arrogated the power to legislate on the meaning of words, tells us so. Isn’t it a great comfort to know that our lexicography is lodged in such capable and impartial hands?
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And when it was pointed out that psychiatric diagnoses had no validity in the sense of correspondence to a real, identifiable pathology, Dr. Pies again pointed out that we simply didn’t understand the issues, and that psychiatric diagnoses had instrumental validity — a concept he apparently invented, which means that the “diagnoses” served some purpose, which, of course, they do. They enable psychiatrists to pass themselves off as real doctors and make a good living pushing drugs.
“I define ‘instrumental validity’ as that property of a diagnostic criteria set which bears on how fully it achieves a particular aim or goal.” (here)
“I would contrast this [instrumental validity] with what I would call etiological validity, which, in recent years, has often been the focus of proposals for modifying psychiatric nosology; e.g., by classifying disorders according to putative ‘aberrant neurocircuitry’.” [Emphasis in original] (here)
Of course, etiological validity is what is claimed in the routine psychiatric assertion that “mental illnesses” are real illnesses, just like diabetes, and not only in recent years, but for decades. Dr. Pies knows this full well, as the above quote shows clearly. He also knows that no “mental illness” has been causally linked to an identifiable etiology. But instead of acknowledging this publicly, and critiquing his colleagues for asserting otherwise, he again evades the issue by contending that etiological validity doesn’t really matter as long as psychiatric diagnoses have instrumental validity. This is directly analogous to a forger of fine art who justifies his fraudulent activity on the grounds that his customers accept his forgeries as genuine, and are willing to pay for them.
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So having set out the six fundamental assumptions of the “real” medical model, Dr. Pies continues:
“There is nothing strikingly original in these principles.”
How true! Not only is there nothing strikingly original in the principles, there is nothing of any substance whatsoever. They are content-empty platitudes.
“But it should be clear that this medical model does not empty the experience of ‘hearing voices’ of psychological meaning; nor does psychiatry’s medical model in any way hold that the content of the patient’s voices is ‘random and meaningless.'”
Now this is Dr. Pies at his obfuscatory best:
“…this medical model does not empty the experience of ‘hearing voices’ of psychological meaning;”
“…psychiatry’s medical model (by which he clearly means the six empty platitudes) [does not] in any way hold that the content of the patient’s voices is ‘random and meaningless.'”
So the medical model that Dr. Pies has invented, and is spuriously trying to pass off as psychiatry’s standard version, does not empty the client’s experience of meaning. Well of course it doesn’t. That’s set down in principle number 3: “…biological explanations . . . do not negate (and often complement) valid psychosocial and cultural explanations and formulations.” Dr. Pies appears to be laboring under the impression that because he has written down these principles, they must therefore be the framework underlying psychiatry as it is practiced. But the critical question is: are these really the principles that underlie and drive the medical model as it is applied by the vast majority of psychiatrists today? And Dr. Pies affords a passing recognition of this issue.
“While some psychiatrists may apply a very narrow, reductionistic version of the medical model to the experience of hearing voices—relegating it, perhaps, to the misfiring of some errant dopaminergic circuits in the brain—this procrustean formulation is not characteristic of clinical psychiatry, in my experience.”
“While this sort of biological reductionism doubtless occurs in some medical settings, it is not the ‘medical model’ of academic psychiatry, or—in my view—of most experienced psychiatrists.”
Well what can I say? Dr. Pies’ experience of psychiatrists does not coincide with mine. Virtually all the psychiatrists I’ve encountered since about the mid-70’s apply “…a very narrow, reductionistic version of the medical model to the experience of hearing voices.” Perhaps things are different in the ivory tower!
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And, under the heading CONCLUSION:
“Some critics of psychiatry have rightly objected to ‘. . . a reductionistic biomedical model that is practiced in numerous hospitals in the Western world’ in which ‘…voice-hearing [is] seen as a meaningless symptom of disease.’12 While this sort of biological reductionism doubtless occurs in some medical settings, it is not the ‘medical model’ of academic psychiatry, or—in my view—of most experienced psychiatrists. We must guard against simplistic theories on both sides of the ideological divide: those that construe every human phenomenon in terms of misaligned molecules, and those that mistakenly impute ‘normality’ to serious pathological conditions.”
In my experience, the kind of simplistic reductionism that Dr. Pies disavows is the medical model of the vast majority of psychiatrists, including those who are most experienced. And if this is not the model of academic psychiatry, then it has to be concluded either that the latter are not very good teachers, or that the newly emerging graduates promptly abandon the putative humanistic philosophies of their mentors, and give themselves entirely to the 15-minute med-checks and pills-and-shocks-for-brain-illnesses perspectives that dominate psychiatry today.
And note the other fallacy that Dr. Pies has introduced: labeling psychiatry’s critics as “those that mistakenly impute ‘normality’ to serious pathological conditions.” Certainly some of the thoughts, feelings, and behaviors that psychiatry considers “symptoms of mental illness” could be viewed more parsimoniously as variations of normality. But that’s not the central issue. The central issue is that the problems embraced by psychiatry’s taxonomy are not illnesses in the ordinary, conventional sense of the term, but are constantly and deceptively presented by psychiatrists as if they were. Whether these problems should be considered variations of normality is a separate issue.
To provide some historical context on these matters, here are some quotes from Ronald Pies from an interview he gave to Psychiatric Times in November 2005. It was noted in the article that Dr. Pies had done his residency in psychiatry at SUNY Syracuse, and that this residency had stimulated his interest in psychopharmacology. Then:
“We had a very fine program and really excellent teachers, but it was focused much more on psychodynamic psychiatry, including object relations theory, and less so on psychopharmacology,” [Emphasis added]
Note the word “but,” implying that Dr. Pies wasn’t entirely happy with the emphasis on psychodynamics. Yet in the present article, he’s citing psychodynamic explanations as evidence of psychiatry’s embracement of psychosocial perspectives. The reality is that there is virtually no psychoanalysis, or other forms of talk therapy, practiced by psychiatrists at the present time, and citing psychodynamic explanations as evidence of an extant psychosocial perspective in psychiatry today is, I suggest, deceptive. It is also clear from the above quote that from the earliest days of his career, Dr. Pies favored psychopharmacology over psychodynamic approaches.
“Pies wanted more, so he and a resident colleague started a monthly newsletter discussing psychopharmacology.”
“Much of Pies’ subsequent career has included psychopharmacology. He wrote the Handbook of Essential Psychopharmacology (2005, 1998; American Psychiatric Association), and he authored the Handbook of Geriatric Psychopharmacology (2002; American Psychiatric Publishing, Inc.) with Sandra A. Jacobson, M.D., and David J. Greenblatt, M.D. He has been director of psychopharmacology and research at Bay Cove Mental Health Center in Massachusetts; staff psychiatrist and director of psychopharmacology at Harry Solomon Mental Health Center in Massachusetts; and chair of the Psychopharmacology Interest Group for the Massachusetts Psychiatric Society.”
“‘I consider myself a general adult psychiatrist who has always had–and this goes back to college–a very strong interest in the biological functions that underlie thinking and feeling,’ he explained. ‘Even as a freshman and sophomore at Cornell … I was very interested in neurotransmitters, how the brain works and how that fits in with broader ideas about the mind, which, I think, leads one almost naturally to have an interest in how medications can work for mood disorders and other psychiatric conditions.'”
There’s not much psycho-socio-economic-cultural stuff there.
“Asked about the direction of psychopharmacology, Pies said he found it fascinating that some of the medications being used and tested work not so much by increasing neurotransmitters but by actually improving neuronal growth and development. He disagrees with those who criticize medication use as being ‘cosmetic’ by covering up patients’ root problems.”
Still sounds very bio-bio-bio.
“On the controversial issue of prescribing antidepressants for children, Pies said, ‘In general, antidepressants, if used appropriately and for the right indications, do much more good than harm, and I believe that is true in both children and adults.'”
Of course he did.
“With regard to suicidality, Pies said, ‘The jury is still out.'”
“Pies suggested that some of the children who become agitated and possibly suicidal after receiving antidepressants may actually be children who have undiagnosed bipolar disorder.”
Ah! The old bugaboo: latent bipolar disorder. Who could have known?
“‘Psychiatry needs to redefine itself as a medical specialty, and that is a real challenge,’ Pies told PT.”
Indeed! Like turning base metals into gold. And how does Dr. Pies propose psychiatry pursue this endeavor?
“‘Psychiatry’s future, if we are to have a future as a medical specialty,’ he said, ‘will involve our creating a field, a new language and a new level of discourse.’ Pies proposes to call this new field encephiatrics. The term is derived from the Greek roots enkephalos (brain) and iatros (healer).
‘What that means really is that we become healers of the brain. This idea of healing the brain is based on the notion that the brain is the final common arbiter of all of the input it receives, whether biological or social or psychological or spiritual. The way psychiatry will define itself is as the medical specialty that provides optimal healing for patients with brain dysfunction,’ Pies said. ‘I see that as occurring through a mastery of not only psychopharmacology, but also of all those approaches to human suffering that we have learned as healers over these many centuries.’ [Emphasis added]
Included in encephiatrics would be talk therapies and even literary approaches, such as poetry therapy, according to Pies.
‘I believe there are many ways of influencing the brain for the good. The brain is a kind of funnel that takes in all of these different stimuli. I see psychiatry as moving into that very comprehensive and all-inconclusive direction. There is a risk of becoming distracted by all of these opportunities to change the brain function. [But] I believe we can surmount that and become a truly comprehensive, brain-healing discipline.'”
All of which, despite the sop to talk therapy and poetry, sounds very like bad medical model, version 1: which posits that: “…mental disorders are brain diseases and emphasizes pharmacological treatment to target presumed biological abnormalities.”
And the “symptom” of hearing voices, like the “symptoms” of all “mental illnesses,” would be conceptualized as a “brain dysfunction” to be addressed by healing the brain.
Isn’t this the medical model which Dr. Pies vigorously disavowed in the opening paragraph of the “Hearing Voices” article? Isn’t this the same medical model that Dr. Pies claimed was erroneously attributed to psychiatry by its critics? And, given the lack of evidence of a biological etiology underlying any “mental illness,” isn’t this a hoax?
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.
Ha! Legitimate medical specialties lack the political power of psychiatry. Why would that quack Pies want to be a “mere doctor” when he can wield all power and authority over his psychiatric test subjects as an absolute monarch?
Real doctors can’t lock people up and perform experiments on them without their consent.
My neuroleptics brought on psychotic episodes. Everyone claimed this was nonsense. Recently I read about tardive psychosis. I also believe they exacerbated obsessive thoughts. When my drugs were changed these got better. They drove all around me crazy–so they accused me of not taking my “medicines” when they were causing these problems.
My question is how anyone can actually believe these help people? Anyone who says that crap must either be a mental illness professional who makes $$$$ off inflicting brain damage–creating illnesses that wouldn’t otherwise exist–or stupid, cruel, abusive family members–some of whom comment here. MONSTERS.
“My neuroleptics brought on psychotic episodes,” mine did, too. It’s called antipsychotic induced anticholinergic toxidrome.
“The symptoms of an anticholinergic toxidrome include … hallucinations, … psychosis, seizures … Substances that may cause this toxidrome include the four ‘anti’s of antihistamines, antipsychotics, antidepressants, and antiparkinsonian drugs as well as ….” (from Wiki)
“Everyone claimed this was nonsense.” That’s because anticholinergic toxidrome is not a billable DSM disorder, so the “mental health professionals” are largely ignorant of the fact that it’s already medically known that the neuroleptics can make people “psychotic.” Or they claim ignorance, due to their greed and lack of ethics.
By the way, great blog, as always, Philip. I love your sense of humor. I found this interesting. “‘Psychiatry’s future, if we are to have a future as a medical specialty,’ he said, ‘will involve our creating a field, a new language and a new level of discourse.’ Pies proposes to call this new field encephiatrics. The term is derived from the Greek roots enkephalos (brain) and iatros (healer).”
So they’ll be called encephiatrists, as opposed to psych (mind) tryst (f-ck) specialists? Although his attitude in that comment does seem to imply he knows the field of psychiatry is a complete scientific fraud, beyond repair. Thus the need to change the name of the speciality and create “a new language and a new level of discourse.”
What do they say? “First they ignore you, then they laugh at you, then they fight you, then you win.” I guess Pies is at the fighting with us stage, so we’re making some progress. And even Pies seems to think psychiatry will need to be morphed into a different field to survive. Which is kind-of like saying psychiatry needs to be abolished, don’t you agree? So maybe we’re even getting close to winning? Pray to God. Thanks as always, Philip.
After reading Pies article, I would like to comment on two things.
1.) “While some psychiatrists may apply a very narrow, reductionistic version of the medical model to the experience of hearing voices—relegating it, perhaps, to the misfiring of some errant dopaminergic circuits in the brain—this procrustean formulation is not characteristic of clinical psychiatry, in my experience.”
This is exactly what every single “mental health professional” and mainstream medical “professional” I dealt with claimed to believe, until I could medically point out their error. But I will confess, my “hearing voices” problem was one caused by “the misfiring of some errant dopaminergic circuits in the brain” that was caused by antipsychotic induced anticholinergic toxidrome poisoning, and none of my “mental health professionals” nor mainstream medical “professionals” wanted to admit to their iatrogenesis/malpractice.
2.) “Psychiatry also recognizes the cultural and religious context in which some people ‘hear voices’—and the non-pathological nature of such experiences. Thus, DSM-5 notes, ‘In some cultures, visual or auditory hallucinations with a religious content (eg, hearing God’s voice) are a normal part of religious experience.'”
Since the rationale for putting me on antipsychotics initially was my query regarding a dream about what being “moved by the Holy Spirit” meant. I highly beg to differ that even those who call themselves “Christian talk therapists” or “Jewish psychiatrists” recognize “the cultural and religious context in which some people ‘hear voices.'”
They absolutely do not, today’s “mental health professionals” are all about drugging up those going through a spiritual journey, and I believe it is still illegal in the US to torture and try to murder people for belief in God in the US. Thus, I do still hope and pray that God is on our side, as opposed to the side of the Holy Spirit denying and blaspheming, DSM deluded “mental health professionals.”
It is my experience that “Mental Health” Drugs cause “Mental Disorder”. I was given permission in Ireland by my Consultant Psychiatrist to stop taking “my medication” in 1983 and I ended up in hospital fairly quickly.
While I was in hospital I struck up a conversation with an Experienced Psychologist who assured me that everyone could recover – without “medication”.
Ultimately I did recover, through a Careful Drug Taper (with the help of ‘Psychology’).
After I explained this to my Consultant Psychiatrist + Bio Psychiatric Researcher, Dr P A Carney in 1986 he (by coincidence) registered in Ontario, Reg No. 57892 as a Non Specialist (Doctor).
There are those who “psych out” without drugs. But I guess those are the minority. And in the past 70% would snap out of it on their own.
100 years ago I would not have wound up labeled mad. The standards for what constituted “madness” were a lot stricter too. People with it enough to write articles and posts were not considered madhouse material.
Gonna look this very eminent quack up. My tentative thought on voice hearing, is that it is the bodies way of dealing with severe distress and is linked to Long term potentiation, because that is where – it is widely thought – the biological basis of learning and memory is. The memory inputs caused by severe human distress sets up this on-going cascade of events by two neurotransmitter receptors. Who knows could it be some kind of biological holography within our perception of reality. Or maybe I’m just talking bollocks. You certainly see people who just can not move on from what happened, including myself, it’s as if LTP has taken hold. Another thought is that it’s quantum biology breaking into our world. But then such talk is likely to bring another MH diagnosis my way.
Biological psychiatry comes under flack from critics of the strictly biological approach to ‘problems in living’.
Biological psychiatry adherents respond by saying, “Look, we’re not so bio-bio-bio (biologically minded) as all that after all, we’re actually pretty bio-psycho-social.”
1. Assumption of Pie’s 6 assumptions: the biological presumption…
All 5 of the other assumptions further reinforce and support this basic presumption.
Thank you for reminding Pies and others of his ilk that real science is not a matter of presumption.
And it must be stated that other cultures in other part of the world do not interpret nor deal with hearing voices in that say way that they’re dealt with in the United States. You can generally boil it down to about four basic approaches with the United States and Western cultures using the approach which is most punitive and judgmental of the four. It’s only in western cultures that hearing voices is interpreted as being such a negative experience.
I can’t think of her name at the moment, but there is an American anthropologist who studies the hearing voices phenomenon in various cultures and her work is quite interesting and revealing. I wish that I could remember her name. I was alerted to her by an anthropology doctoral student who came and spent a number of weeks on our units of the state “hospital” where I work to gather facts and information for her doctoral dissertation. She promised to send a copy of said dissertation when she finished it.
I’m not sure about “Social Science” and voice hearing:- Looking at my historical records recently, I can see just one voice hearing reference from my Irish Consultant Psychiatrist claiming I had heard voices telling me I was a good painter which started in childhood, and that these might have been my Aunts and Uncles voices.
I actually did become a very good painter in adulthood. But this was a house painter not an artist.
I have never heard “a voice” in my life!
Thank you for this analysis.
Does Pies also exclude the issue of violence in his article? It seems to me that it is not a coincidence that you cite the example of two people fighting in the street to question the relationship between biology and sociology.
Everything is a combat, everything is a struggle, and psychiatry is involved in this fight that stretches to flatten and smooth out social conflicts, by violence, if necessary. The biological explanation of social conflicts must be apprehended as a particularly brutal symbolic violence.
Ok. I googled it and her name is Dr. Tanya Luhrmann. I expect that you can find her on YouTube.
Great job using logic/reason to refute everything Dr. Pies said. It must be tough for people like him to do public relations for a field that’s purely about deception, illogical thinking, and parasitic harm. At least the fact that psychiatry is doing such public relations shows that we’re starting to get the truth out there, enough for it to need to go on the defensive.
Yes. And the APA hired the services of Porter Novelli, a world-renowned PR company. PR is all they have left.
Dr. K, I frequently feel frustrated because no one around me is open to any ideas about “mental illness” they don’t get off television. People are ignorant as ever–ordinary Joe Blows–and I feel hopeless to ever educate them.
Barely resisting urge to become a misanthropic recluse and hole up away from the creeps and idiots. (The two types of people on planet Earth.)
Isn’t the APA overestimating their enemy–if they even have one?
I disagree with a couple assumptions made in this article. First, I consider the “medical model” to be a misnomer; it gives credibility to the “disease model” of natural problems with living. The “medical model” falsely implies that psychiatry has any medical (biological) legitimacy. Second, I disagree with describing problems with living as “dysfunctional states.” Emotional suffering (and other natural problems with living) may be undesirable and may appear dysfunctional within our cultural paradigm, but that does not make them dysfunctional. A “dysfunctional state” implies a “mental disorder” which implies “dysfunctional biology.” Distressful experiences naturally cause painful anxiety and depressing experiences naturally cause painful depression; these experiences can be debilitating and unpleasant to witness, but they are not dysfunctional.
problems with living
I think this sort of phrase is vague and serves to minimize the severity of people’s problems.
Unfortunately, I agree. I usually describe “problems with living” as “emotional suffering” but that also tends to lack the proper connotation of severity; I described anxiety and depression as “painful” because that is more accurate. Emotional suffering is painful and extreme emotional suffering is constantly as painful as a police taser (and can thereby nullify a taser’s intended affect). The popular paradigm controls the vocabulary so challenging it can cause vocabulary problems.
Best wishes, Steve
Sometimes fear of pain is worse than the pain itself, which probably makes fear the most effective element of coercion. Just look at all the commercials for corporate “cancer care.”
“Mental illness” though via exaggeration is a way to maximize such ‘problems in living’, and once this exaggeration starts, it’s hard to stop it short of termination.
I tend to think minimizing much more workable.
Sure. Keep telling people their problems aren’t real. That’ll totally make them question psychiatry.
For what it’s worth, Frank, belief in my “mental illness” made me act crazier than just the pills could have done. I’ve heard a firm belief in your own “mental illness” can have that effect. Like hypnosis.
People are considered “dysfunctional” when their assigned “function” within a culture is to be quiet and work on an assembly line, literally or figuratively.
I must have been half asleep when I wrote this. It should read more like: People are considered “dysfunctional” when they fail to fulfill their assigned “function” in society, such as staying quiet and keeping the assembly line running, literally or figuratively.
My assigned function has been to shut up and take my “meds” from age 20. They went out of their way to discourage me from doing anything useful or productive.
And what is the difference between “disease model” and “medical model”? Doctors and nurses, or viruses and infections? I think they are the same. This profession for tending fabricated fictitious diseases, and the bogus illnesses that it would, with its quackery, *cough, cough* forge and “treat”.
Medical model wasn’t arrived at by people who subscribed to biological psychiatry, quite the opposite, it, as a rule, has been a term used by people who were highly critical of this form of treatment which they saw as a form of medicalization, that is, providing medical treatment for non-medical problems. Disease model, similarly, would take personal problems for “brain dysfunction”, or “disease”. There’s more difference between a tomato and a potato.
The “Medical Model” did originate with people who were critical of “Biological Psychiatry” and its form of “treatment,” but it has the opposite affect. “Biological Psychiatry” is a redundancy (since psychiatry is currently an accredited medical, biological science) that is intended to promote biological legitimacy for psychiatry. “Biological Psychiatry” replaced Freudian Psychiatry to significantly expand the range of non-medical problems that psychiatry addresses, but both forms of psychiatry seek medical (biological) science legitimacy for treating non-medical problems. Psychiatry promotes a “Disease Model” of non-medical problems; the term “Medical Model” erroneously implies that their BS has anything to do with real medical (biological) science.
The “Medical Model” did originate with people who were critical of “Biological Psychiatry” and its form of “treatment”
What??? The “medical model” has been in effect since the dawn of psychiatry, which has from the start purportedly been a field of medicine treating diseases.
It seems that people whose intellectual memories start with the DSMs have only a vague understanding of the history of psychiatry. They were administering Thorazine etc. as “medications” in the 50’s. Szasz was already deconstructing the “medical model” in 1960, way before anyone was talking about “biological psychiatry” — a term which should be abandoned, as it implies that there’s some other, more legitimate form of psychiatry. And yes, “medical model” and “disease model” are the same thing.
If we do a search we find out all sorts of things. Things, such as, ‘the biomedical model has been around since the mid-nineteenth century’, and…
“Unlike the biopsychosocial model, the biomedical model does not consider diagnosis, which affects treatment of the patient, to be the result of a negotiation between doctor and patient.”
We will skip the biopsychosocial model as I consider it mainly a ploy used by biomedical model psychiatry to defend itself by pretending to be something it is not. (The Ronald Pies article is a case in point.)
One model that would contrast with the biomedical model is the trauma model, but as trauma is actually injury, and another excuse to bring in the medical profession, I don’t see it.
Disease model is applied mainly to substance abuse (huh?), or addiction. Something that you get if you resort to biomedical model treatment for non-biomedical conditions (social and/or “mental” problems), drug prescriptions.
“The disease model of addiction describes an addiction as a disease with biological, neurological, genetic, and environmental sources of origin”
Contrasted with the above approaches is the social model.
“The social model of disability is a reaction to the dominant medical model of disability which in itself is a functional analysis of the body as machine to be fixed in order to conform with normative values. The social model of disability identifies systemic barriers, negative attitudes and exclusion by society (purposely or inadvertently) that mean society is the main contributory factor in disabling people.”
The only problem I have with the above ‘definition’ is with the concept of “disability” as applied to people with ‘problems in living’. “Social disability” like “mental illness” is a metaphor in my book, but still the last model, the social model, comes closest to addressing some of the very real problems we have with conventional biomedical treatment of non-biomedical problems (i.e. medicalization).
I understand the history of psychiatry; it is the “medicalized model” of “problems with living.” I contend that the term “medical model” falsely implies medical (biological) legitimacy. In contrast, I consider the “disease model” to imply that psychiatry is describing a medical problem but that other options (like wellness) exist. Hence, “medical model” and “disease model” are not the same thing.
If we do a search we find out all sorts of things.
Or lots of different opinions. But yes, it’s not hard to see that the very term “psychiatry” is implicitly medical, or claims to be.
Another unspecified question: “Model” of what?
Basically, Steven Spiegel, I guess I should have included the sentence before the sentence before the sentence about not considering diagnosis to be a negotiation between patient and doctor.
This is from Wikipedia on Biomedical Model.
“According to the biomedical model, health constitutes the freedom from disease, pain, or defect, making the normal human condition “healthy.””
I don’t invent these things. Do you?
Hence disease model and biomedical model are essentially the same thing.
Frank, while this is not a rebuttal of what you are basically saying, every time you use Wikipedia as a source for anything it feels like chalk screeching across the blackboard in my head. A random high school student would be just as credible.
We disagree about Wikipedia, OldHead. You see it as totally unreliable. I see it as a peoples’ reference that anybody can edit and revise. In my view, any inaccuracy there is a matter of allowing it to be that peoples’ reference. If you find anything false therein, you have the capacity, yourself, to make a correction. I have done so. What about you? People are required to cite sources, that’s about making yourself credible. I also disagree about the random high school student being more credible. As I was saying, where I have found any major mistake or misleading statement in Wikipedia I have tried to offer a correct revision. I couldn’t do such with Encyclopedia Britannica, for instance, and I am proud to be able to do so with Wikipedia.
Frank, I understand the “Biomedical Model” to be the prevailing model of medical care throughout the western world, and to have different connotations than the “Medical Model” when it is used in psychiatry.
I see it as a peoples’ reference that anybody can edit and revise.
Exactly why it’s not credible.
Watch what happens if you try to revamp their anti-psychiatry section, which was written either by a dufus or someone intent on deliberate misinformation.
The semantics of the disease vs. medicine “issue” amounts to academic nitpicking as far as I can see; one implies the other. The question should be how to stop it, however it’s defined.
I agree. The psychiatrists’ medicalization of non-medical problems is a self-serving hoax.
Generally, Steve, my understanding is that medical model goes along with biological psychiatry, and when we say medical model we mean biomedical model. Anything less biological would be out to buck the medical model in some fashion.
The question here is whether any of the problems or conditions covered by psychiatry are actually medical/biological, or whether they are psychological/social, and to what, if any, extent.
Medical implies biological, however, in psychiatry we are dealing with issues that are not, in a very many instances, biological in the slightest. Hence the need for alternatives to any strictly medical approach to such problems. Many of us are very aware of the harm that has come to people of dealing with such ‘problems in living’ as if they were medical conditions.
Generally, Steve, my understanding is that medical model goes along with biological psychiatry
Now it sounds like you’re drinking the Kool-Aid too. Psychiatry IS the medical model in and of itself and has ALWAYS been “biological.”
Szasz deconstructed the medical model independently of any biological considerations — though he also exposed the bankruptcy of what people seem intent on calling the “biomedical model,” which unnecessarily implies a distinction since the same practices date back to the ships of fools, where everyone was kept inebriated on alcohol, the medication of that day.
I know you don’t like Freud (nor do I) but he seems to not have been into the biological model of psychiatry with his theories of the subconscious and prolonged “therapeutic” talks.
I don’t have any particular antipathy towards Freud, however he apparently considered psychoanalysis to be a temporary approach pending future medical discoveries. Not that he had any particular evidence. My impression is that Freud’s beliefs tended to shift and morph over time.
Main isn’t generally painful, it’s euphoric. And it’s not so much a problem with living, either.
Encephiatrics! That’s it! This is the cure! Simply call psychiatry, the pseudo-scientific system of slavery, by a different name… and violà! Legitimacy.
Encephiatrics… what a load of nonsense! Someone better try out some encephiatrics on the brain of Ronald Pies before he invents other justifications for psychiatric torture and abuse. Why don’t we call it psychiatriatry – “the medical treatment of psychiatrists.”
Pies is a poet. He doesn’t deal in science but metaphors and imaginary words. Like the evil version of Dr. Seuss or Ogden Nash.
P.S. I don’t want to derail the conversation on this great article, but I wonder if we can gather together everyone from MIA and those who comment who are serious about the abolition of psychiatry. Who are the serious antipsychiatrists out there, and who, in particular, is serious about abolition? Thank you.
It’s all waffle, isn’t it.
A person can say anything in Psychiatry, its wide open to any kind of nonsense and any kind of abuse. The patients themselves are being chemically exterminated as readily as the Jewish people were, during the Holocaust.
There is absolutely nothing good about psychiatry!
Wow, Pies has dizzying intellect. Phil, love your articles. As always, I always look forward to reading something that you have written and this one is a doozey. It’s just been too long since the last article. I guess I’m just too stupid Phil and just a mere mortal who has no medical degree and just can’t understand the difference between a quack, 10 minute consult and prescribing the very medication that adjusts the very chemical imbalance that they say “does not exist”, nor have they ever promoted it and this bio bio bio crap he’s talking about. I’m just TOO dumb. It couldn’t ever be blamed on the fact that “shit happens” and this is normal to life as we know it. How could we be so obtuse to think that an individual going through a horrific trauma could have anything to do with unwanted behavior? And I guess he’s going to keep this scientific methodology to himself since he clearly never is going to document “what should be done”.
Alas, I have been reminded that I am but a mere mortal again. At least Pies is good for a laugh!
Yes. In my view, Dr. Pies is a kind of perfect reflection of psychiatry’s errors and self-serving notions.
Psychiatrists also contradict themselves in other ways.
For example: claiming that bad behaviors are different from “mental illness” but how do they judge whether someone is “mentally ill?” Blood work? Brain scans? Nope. Behaviors that hurt the performer, threaten others, or simply bug those around them.
Why did that guy go on a killing spree?
Because he was mentally ill.
How do you know he was mentally ill?
Because only a mentally ill person goes on killing sprees.
You can’t argue with that astounding logic. 😀
“Pies has dizzying intellect.” His ability to rationalize cruel, pointless experiments on his fellow humans is certainly breath taking. 🙂
To make change happen be an advocate not an adversary.
That’s basically why I don’t join the canary club of mad in America.
Leadership is rising above and taking the high ground with people involved in order to make realistic change occur.
Although illness and disease are thrown around casually, just to clarify a fact: DSM 5 (and really all prior DSMs) stands for Diagnostic and Statistical Manual of Mental Disorders. Emphasize DISORDERS (not diseases or illnesses) and MENTAL (not brain).
As Frank would point out, disorder is a “weasel” term for disease. Whose order, anyway?
The terms “disorder” and “illness” and “disease” are used interchangeably in general medicine and in psychiatry. Moreover, if the APA had something other than illness in mind when they coined this title in 1952, they’ve had lots of time to clarify the matter.
They certainly take no trouble to undeceive the public. I find Pies’s article about the “metaphor” psychiatry bases its authority on a snarky bit of self congratulation. He and his cronies are laughing up their sleeves at how easily the public is deceived by “well-informed” professionals in the know.
I am printing that article to show my dad. Once he knows the truth he will be furious.
Stevie, I agree what they call “mental illness” has no biological explanation. Basically it’s unhappy people coping with horrible situations by letting their imaginations work overtime.
Why, then, the emphasis that “mental illness” is a brain disease? All the mainstream resources insist it’s bad biology–not human suffering–at work.
Ronald Pies, as quoted in Phil Hickey’s piece:
“In short, the ‘chemical imbalance theory’ was never a real theory, nor was it widely propounded by responsible practitioners in the field of psychiatry.”
Then Phil Hickey:
“In reality, the vast majority of psychiatrists promoted the chemical imbalance theory, as I demonstrated clearly in an earlier post.”
The vast majority of psychiatrists are not responsible practitioners of anything.
Dr. Pies must be suffering a very severe case of cognitive dissonance. He’s contorted his brain and thought process far beyond pretzels. But seriously, how long can any sane, rational person twist, spin, and distort his thoughts and words, and still keep a straight face? We must accept that Pies is a Grand Master of psychobabble and gobbledygook. This isn’t even funny anymore. It’s just sad and pathetic. Giant slices of SAD and PATHETIC PIES….
(c)2018, Tom Clancy, Jr., *NON-fiction
Pies has driven himself crazy through continuous lying. Not a “brain” disorder. A moral one. Only instead of “creative symptoming” as Glasser called it–you see lavender gazelles to avoid the painful reality surrounding you–Pies has gone nuts trying to justify his wicked ways.
Remember the cruel Commandant in Schindler’s List? He couldn’t live with his own guilty conscience. When they executed him he had “lost it.”