Psychiatry at the Crossroads: The Central Themes

Guest post by Ronald Pies

Ronald W. Pies, MD is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities at SUNY Upstate Medical University; and Clinical Professor of Psychiatry, Tufts University School of Medicine. He is also Editor-in-Chief Emeritus of Psychiatric Times. Dr. Pies has published in the areas of philosophy, medical ethics, and comparative religion. He is the author or co-author of several textbooks on psychiatry and psychopharmacology, and has published works of poetry and fiction. He lives with his wife, Nancy, outside of Boston.

In this guest post, he introduces his new book Psychiatry at the Crossroads: Can Psychiatry Find the Path to a Truly Humanistic Science? (2023)

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What do we mean when we apply the term “disease” or “illness” to some person or condition? Is there an “essential” definition of these terms, or does their meaning depend on their use and function in a particular context? What is the place of psychiatry among scientific disciplines in general and medical science in particular? If psychiatry is legitimately deemed a science, what sort of science is it? What is the central and preeminent goal of psychiatric treatment? How does psychiatry view the role of medication, as contrasted with “talk therapy”, and how does psychiatry seek to integrate somatic and psychosocial treatments? How successful has psychiatry been in applying its treatments? Finally, what role should psychiatry play in addressing broad societal problems, such as the widespread denigration of science; the breakdown of civil discourse and communal values; the proliferation of “conspiracy theories”; and the burgeoning rates of mass violence in the U.S., especially gun-related violence?

These questions and my tentative answers comprise the nucleus of my book, Psychiatry at the Crossroads. Having spent the past four decades in psychiatry, I bring to the table both my own clinical experience and—to be sure—my own biases. And while I regard psychiatry as the most comprehensive and humanistic of the medical specialties, I am keenly aware that my profession is the focus of intense controversy—and sometimes, the target of acrimonious attacks. It should not be surprising that my book represents a spirited defense of psychiatry—but one, I hope, that is not reflexively defensive. And while I take sharp exception to the voices of “antipsychiatry”—a term my colleague, Dr. Aftab, has astutely anatomized—I respect the constructively critical voices that seek to remedy psychiatry’s shortcomings without disparaging its successes.

Perhaps a word of explanation is in order, regarding the title of my book. The image of the “crossroads” is intended to convey the difficult, even momentous, decisions now facing psychiatry. As one dictionary nicely puts it,

“If you say that something is at a crossroads, you mean that it has reached a very important stage in its development where it could go one way or another.” [1]

Indeed, I believe that psychiatry, over the next few decades, could go in one of two directions. It could take the road of biological reductionism, relegating psychiatrists to the ranks of highly skilled pill dispensers. Or, it could take the road of holistic and comprehensive care, on which path the much-vaunted (and often neglected) biopsychosocial paradigm will become our guiding beacon [2]. My book may be read, on one level, as a warning against taking the first road, and a heartfelt plea for taking the second.

The foundation of virtually everything I have written over the last 40 years may be summarized in short order:

(1) “Disease” (dis-ease) is best understood as a state of severe or prolonged suffering and incapacity, not owing to an obvious external factor, such as a bullet wound;

(2) The most serious conditions the DSM-5 calls “psychiatric disorders”—including schizophrenia and bipolar disorder—unquestionably fit the general criteria for disease states;

(3) Most serious psychiatric diseases are best understood as stemming from the confluence of biological, psychological, and social causes and risk factors;

(4) Psychiatry’s overarching and preeminent goal is the relief of suffering and incapacity in the behavioral, emotional, and cognitive realm;

(5) Optimal psychiatric treatment usually involves integrating biological and psychosocial treatment modalities;

(6) In recent decades, the pendulum in the U.S. has swung too far toward biological/somatic modalities, driven in large part by market forces; and

(7) The direction psychiatry needs to take in order to remain true to its primary mission is that of a holistic, biopsychosocial approach to diagnosis and treatment.

Psychiatry as a Calling

I use the term “mission” fully aware of this term’s quasi-religious connotations. Indeed, the term originated in the 16^th and 17^th centuries, with the rise of the Jesuits, who were sent out to “spread the faith.” I suspect that my use of the term will sound either archaic or grandiose—or perhaps both!—to those who already regard psychiatry as paternalistic and dogmatic. But I make no apologies here. For me, choosing psychiatry has always seemed a calling, and never merely a business or a vocation. The calling begins with the recognition of the suffering endured by those with severe psychiatric illness—and my family has experienced this first-hand, with the loss of at least two family members to suicide. And, no doubt, my late mother’s career as a psychiatric social worker helped shape my own choice of psychiatry as a medical specialty, long before I entered residency.

But How Are We Doing as a Profession?

The question may reasonably be asked: if psychiatry’s “mission” is, as I believe, to reduce suffering and incapacity in the realm of behavior, emotion, and cognition, how successful has it been? Here, psychiatry’s critics are quick to pounce, arguing that psychiatry still has no unifying “model of the mind”; no deep etiological understanding of the major mental illnesses; and few, if any, robustly effective treatments that are demonstrably “disease-modifying” rather than merely symptom-modifying or palliative. These critics often push their case further, arguing that psychiatric medications “do more harm than good”, and cause side effects that are sometimes worse than the disease.

These criticisms are not entirely without merit, though the grains of truth they contain are minuscule, beside the bushel baskets of oversimplification and misunderstanding. This is not the place for a detailed rebuttal of the aforementioned charges, as I deal with most of them in my book. Suffice it to say that, in my view, psychiatric treatment—properly and diligently carried out—is at least as effective as treatments in general medicine. In particular, psychiatric medications, according to a meta-analysis by Leucht et al. [3], are about as effective as many drugs used in general medicine. Yes, I’m aware that the Leucht et al. study has several shortcomings, and has been criticized on methodological grounds [4, 5]. But in my estimation, its overall conclusion has not been convincingly overturned.

This is not to deny the substantial side effect burden and limited long-term efficacy of many psychiatric medications, particularly the antidepressants [5, 6]. But as I argued recently, we must weigh the limited effectiveness of our medications against the devastation caused by the diseases we treat [7]. Having treated hundreds of severely depressed and psychotic patients over the course of more than 25 years, I would never minimize the benefits of even short-term relief of disease symptoms.

Furthermore, I would add the term “life-modifying” to the designation “disease-modifying”, in assessing the benefits of psychiatric medications. For example, the under-utilized antipsychotic clozapine is associated with improved psychosocial functioning and subjective life satisfaction (“quality of life”), beyond its direct, beneficial effects on psychotic symptoms [8]. Having run one of the earliest clozapine clinics in Massachusetts, circa 1987, I was amazed to see how this medication turned around the lives of many suffering patients, some of whom had been institutionalized for years. I reported on one of these near-miraculous responses in a piece for the New York Times [9].

What About Psychotherapy?

Thus far, I have been discussing only psychiatric medications. It sometimes surprises the general public to learn that psychiatrists still provide psychotherapy, and that “talk therapy” remains an important focus of a psychiatry resident’s training—at least in some residency programs [10]. And yet, the perception that psychiatrists no longer provide psychotherapy is quite understandable, even if inaccurate. For example, more than half of U.S. psychiatrists in a representative survey said they do not provide psychotherapy of any kind, and the weighted percentage of visits involving psychotherapy declined significantly from 44.4% in 1996–1997 to 21.6% in 2015–2016 [11]. To be sure, these are alarming trends that do not bode well for U.S. psychiatry, if they continue. However, these data are not universally applicable. For example, in British Columbia, over 80% of surveyed psychiatrists reported practicing psychotherapy, and the authors of the study concluded that, “Psychiatrists in British Columbia continue to integrate psychotherapy and pharmacotherapy in clinical practice, thus preserving their unique place in the spectrum of mental health services.” [12] Furthermore, the authors opined that,

“The persistent decline of psychotherapy by psychiatrists observed in the United States during the past 2 decades should not be interpreted as a general undervaluing of psychotherapy by the discipline of psychiatry, but as the result of constraining social and financial forces that may not have had the same impact on psychiatric practice in other countries such as Canada.” [12].

Conclusion

In the interest of brevity, I have not discussed here the broader, societal issues I take up at length in my book, such as psychiatry’s role in addressing the breakdown of civility [13] and the increasing rates of gun-related violence in the U.S. [14]. The risk, of course, is that psychiatry will overreach and imagine that a mere medical specialty has the means to reform and repair our terribly troubled world.

However, I do believe that psychiatry has an important role to play in the larger context of culture and society, including addressing the spiritual needs of our patients. As I wrote recently, addressing “the dark night of the soul,”

“We need not be observantly religious to help our patients through their dark night, nor need we enter into the mystical world of John of the Cross. Rather, we can act as midwives to our patients’ inner transformation—supporting and encouraging them as they struggle to give birth, often painfully, to new meaning in their lives.” [15]

And so, we come full circle to the image of the cross—not that of the Christian mystics, but the crossroads facing our profession. I hope that in this short piece, and more so in my book, I have provided a beneficial road map for where, in my view, psychiatry needs to go.  

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Acknowledgment: I wish to thank Dr. Aftab for his kind invitation to present my views in this space. I also wish to thank the contributors to my book, and the writers and editors at Psychiatric Times.

References

1.    https://www.collinsdictionary.com/us/dictionary/english/crossroads

2.    Pies RW. Can we salvage the biopsychosocial model? Psychiatric Times. Jan. 22, 2020. https://www.psychiatrictimes.com/view/can-we-salvage-biopsychosocial-model

3.    Leucht S, Hierl S, Kissling W, Dold M, Davis JM: Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses. Br J Psychiatry. 2012, 200: 97-106. 10.1192/bjp.bp.111.096594.

4.    Seemüller, F., Möller, HJ., Dittmann, S. et al. Is the efficacy of psychopharmacological drugs comparable to the efficacy of general medicine medication?. BMC Med 10, 17 (2012). https://doi.org/10.1186/1741-7015-10-17

5.    Ghaemi SN. Symptomatic versus disease-modifying effects of psychiatric drugs. Acta Psychiatr Scand. 2022 Sep;146(3):251-257. doi: 10.1111/acps.13459. Epub 2022 Jun 25. PMID: 35653111.

6.    Pies RW. Antidepressants: Conundrums and Complexities of Efficacy Studies. J Clin Psychopharmacol. 2016 Feb;36(1):1-4. doi: 10.1097/JCP.0000000000000455. PMID: 26658086.

7.    Pies RW. Antidepressants, Placebos, and Lithium—Some Parting Thoughts. Psychiatric Times. Nov 9, 2022. https://www.psychiatrictimes.com/view/antidepressants-placebos-and-lithium-some-parting-thoughts

8.    Kim S, Kim S, Choe AY, Kim E. Associations of Clozapine Use With Psychosocial Functioning and Quality of Life in Patients With Schizophrenia: A Community-Based Cross-Sectional Study. Psychiatry Investig. 2021 Oct;18(10):968-976. doi: 10.30773/pi.2021.0190. Epub 2021 Oct 8. PMID: 34619819

9.    Pies R. A Guy, A Car: Beyond Schizophrenia. New York Times. May 4, 2009. https://www.nytimes.com/2009/05/05/health/05case.html

10. Manring J. No, Psychiatry Has Not Lost Its “Mind”: Here, Psychotherapy Training Thrives. Psychiatric Times. June 2, 2010. https://www.psychiatrictimes.com/view/no-psychiatry-has-not-lost-its-mind-here-psychotherapy-training-thrives

11.Tadmon D, Olfson M. Trends in Outpatient Psychotherapy Provision by U.S. Psychiatrists: 1996-2016. Am J Psychiatry. 2022 Feb;179(2):110-121. doi: 10.1176/appi.ajp.2021.21040338. Epub 2021 Dec 8. PMID: 34875872.

12.Hadjipavlou G, Hernandez CA, Ogrodniczuk JS. Psychotherapy in Contemporary Psychiatric Practice. Can J Psychiatry. 2015 Jun;60(6):294-300. doi: 10.1177/070674371506000609. PMID: 26175328

13. Pies RW. Campus Protests, Narcissism, and the Dearth of Civility. Psychiatric Times, Feb. 2, 2016. https://www.psychiatrictimes.com/view/campus-protests-narcissism-and-dearth-civility

14. Pies RW. Is the Plague of Mass School Shootings in the US Here to Stay? Psychiatric Times. May 26, 2022. https://www.psychiatrictimes.com/view/is-the-plague-of-mass-school-shootings-in-the-us-here-to-stay-

15. Pies RW. Psychiatry and the Dark Night of the Soul. Psychiatric Times. Dec 14, 2020. https://www.psychiatrictimes.com/view/psychiatry-dark-night-soul