Psychiatry at a Crossroads?
by Chuck Ruby, Ph.D.
Ronald Pies, M.D., who is notorious for claiming more than a decade ago that psychiatry’s long-peddled chemical imbalance theory was "never a theory seriously propounded by well-informed psychiatrists," recently introduced his new book, Psychiatry at the Crossroads: Can Psychiatry Find the Path to a Truly Humanistic Science? He explains the main themes of the book in a March 25, 2023 guest post on Awais Aftab’s "Psychiatry at the Margins" substack.
Dr. Pies' longing for a humanistic psychiatry is laudable. However, the devil is in the details, as his notions about psychiatry at a very fundamental level ironically preclude the possibility that it actually becomes a humane science. Instead, when the rubber meets the road, his longing is for a psychiatry that broadens and solidifies its control over people's lives.
The primary problem with his ideas (presumably also contained in the book) is that he says "disease" should be defined as any form of human suffering. This is an even more expansive strategy than others who at least attempt to differentiate between illness (as any form of suffering) and disease (as dysfunction in the body).
I think in order to ensure a humane system of care, though, the definitions of illness and disease must be limited to dysfunctions or defects of bodily processes. Including "suffering" as disease expands the medical professions' reach to an absurd level where there are no limits to the medicalization of life, and where personal values, preferences, and meaning-making become the targets of medical treatment. In essence, he wants psychiatry to subject individual and personalized experiences to medical intervention.
Still, Dr. Pies assumes that any human suffering is psychiatric disease or illness and the legitimate target of medical forms of assessment and care. He says psychiatry‘s goal is the “relief of suffering and incapacity” of thought, behavior, and feelings (for now, let’s set aside the questionable notion of thought, behaviors, or emotions being literally incapacitating as is the case with blindness and paralysis). But if this has been psychiatry's goal, the profession certainly has done a poor job, owing primarily to their idea that the suffering is due to some phantom dysfunction in the individual to be corrected (perhaps the chemical imbalance that was never seriously propounded?).
If history is an accurate portrayal, I think we can say with near certainty that this has not actually been psychiatry‘s goal. Instead, its goal has been to control those who are deemed unusual, inconvenient, and bothersome, not necessarily to relieve their suffering, but to relieve the profession's and the public's suffering of witnessing their existence.
Moreover, in reviewing Dr. Pies’ comments, we find that he only respects criticisms of psychiatry that attempt to "remedy its shortcomings without disparaging its successes." But what exactly does this mean for a presumed medical specialty that has no reputable theory about the alleged internal dysfunction that causes mental illness, that has no biomarkers with which to diagnose those illnesses, that has no treatments that correct deficiencies of bodily systems responsible for those illnesses, yet that has a long history of coercing people to act, think, and feel in accordance with an ill-defined and ever-changing set of moral standards?
The term “shortcomings” doesn’t come close to describing these failures and the only way to remedy them is to abandon the medical model of human distress, as it is why psychiatry has failed over the years. Instead, Dr. Pies wants to broaden the medical model and, in what appears to be an attempt to protect the profession from real and substantial criticism, he only respects psychiatry's critics if they overlook these most serious challenges to the profession's foundational assumptions. Anyone not in compliance with this is often caste aside with the simple-minded and marginalizing charge of being a member of “antipsychiatry.”
Regarding psychiatry’s successes, where are they? Many have claimed the proof rests in professionals' and patients' anecdotal stories of lives being saved by prescribed drugs and ECT. I'm sure there are some people who have undergone such treatment and genuinely believe it was life-saving. However, research that conforms to proper design, methodology, and analysis to tease out confounding variables of effect and increase confidence in the results, has shown that traditional psychiatric treatment is either ineffective, only marginally effective, only temporarily effective, is "treatment that works," or is "efficacious in reducing symptoms." The latter two outcomes are examples of the ubiquitous medicalese commonly used by the mainstream to portray psychiatry's work as medical science. But in the case of prescribed drugs and ECT, the medicalese merely describes the psychoactive effects of chemicals and electricity and how they can act as tranquilizing (or energizing) agents, pushing someone to the point of not being as troubled by real life problems and, thus, not complaining about those problems, giving the false impression of some type of resolution.
Furthermore, those “successes” are presented in isolation, without the context of the longer term harm brought on by repeated treatment of that sort, just like what happens with long term illicit and recreational drug use. A quick snort of cocaine can rejuvenate an exhausted soul, a stiff drink can settle one's angst after a grueling week, and LSD can open up new possibilities. But daily lines of cocaine, stiff drinks, and acid trips can ruin lives, while they do little to address the important human challenges that we all face.
Nevertheless, Dr. Pies justifies psychiatric treatment by saying it is “at least as effective as treatments in general medicine.” This is nothing to write home about, as it reveals problems with the drug industry in general and their shenanigans in presenting their cures as a panacea. This is especially problematic if we keep in mind that psychiatric treatment does not target specific dysfunctions in the individual’s chemical/mechanical make up. Remember, he suggests that disease be defined as suffering. Therefore, by definition, treatment of the disease of suffering can only be on the surface and palliative; there's nothing below the surface to correct.
Dr. Pies repeats an exhortation we've heard many times before. He suggests that psychiatry take the road of "holistic and comprehensive care" that is guided by the biopsychosocial model. That model has been historically ignored by psychiatry, and translated into a bio-bio-bio model. The token nature of that model makes sense if one considers that psychiatry has always viewed the psychological and social factors in a person's life as secondary to the biological factors. This is reflected in the DSM definition of mental disorder as a “dysfunction in the individual,” as well as how psychiatry has always considered the psychologically and socially oriented non-medical mental health professionals of psychology, social work, and counseling as second class. Why hasn’t the bio part in the biopsychosocial model ever been second or third in line? Can you imagine the implications of the social-psycho-bio model and psychiatry's resistance to adopting it?
Mainstream psychiatry is not at a crossroads, it is at a dead end, as long as it follows the same rules of the road that it has been using for over two centuries - constantly searching for but never finding an internal dysfunction, yet assuming one exists, and ignoring the fact that so-called mental disorder is really about moral proscriptions and prescriptions.
Still, I do think psychiatry can have a role and can be redeemed if it stays within the boundaries of medical science, using that science to identify physiological dysfunctions that have emotional, behavioral, and cognitive symptoms, handing off the treatment to those real medical specialties that target those physiological dysfunctions. Psychiatrists can also have an important role in the short term and limited use of chemicals in acute situations and in helping people wean off of prescribed psychiatric drug cocktails.
Once psychiatrists leave medical science and enter into the arena of “talk therapy,” they are no longer medical specialists, but hopefully they become compassionate assistants for people struggling with life, ever respecting the other’s worldview, instead of paternalistically cajoling people into the "proper" ways of being. But I'm not holding my breath.
Dr. Pies concludes his comments in the substack by suggesting the grandiose idea that the medical specialty of psychiatry could have a role in addressing the “breakdown of civility“ in the world as well as the serious problem of gun violence and “the spiritual needs of our patients.” But he simultaneously fears the risk that “psychiatry will overreach [I agree] and imagine that a mere medical specialty has the means to reform and repair our terribly troubled world.”
But this is what happens when you define your medical target of treatment as all of human suffering.
Chuck Ruby, Ph.D., is a psychologist who has been in private practice for the past 25 years, after a 20-year career with the U.S. Air Force. You can read more about him at his personal website. He is the author of Smoke and Mirrors: How You Are Being Fooled About Mental Illness - An Insider's Warning to Consumers. Dr. Ruby is the past Chairperson of the Board for ISEPP and has been the Executive Director since 2015.