On June 30, 2020, Awais Aftab, MD, psychiatrist, published an interview with Ronald W. Pies, MD, also a psychiatrist, in Psychiatric Times.
As an interview, the piece is somewhat unusual in that Dr. Aftab, as interviewer, does not confine his role to asking questions, but actually contributes substantially to the dialogue. So the piece is more like a conversation than an interview, and both parties express their positions fairly freely on the topics discussed.
Dr Pies will be no stranger to my readers. I have critiqued various aspects of his work here, here, here, here, here, here, here, here, here, here, here, here, here, here, here, here, here, here, here, and here. We go way back.
I critiqued one of Dr. Aftab’s essays (Mental Illness vs Brain Disorders: From Szasz to DSM-5), here on March 14, 2014.
The title of the present interview/conversation is The Battle for the Soul of Psychiatry: Ronald W. Pies, MD.
“The Battle” is a lengthy piece, and for this reason, I will confine this critique to the more salient/egregious contentions.
CRITICISM OF PSYCHIATRY
Early in the conversation, the two eminent doctors express general agreement that some criticisms of psychiatry are legitimate, while others are not. Dr. Aftab describes the latter as “hostile, ill-conceived, rhetorical, sentimental, and divorced from any meaningful science.” Dr. Pies, in general agreement, points out that:
“…there are ‘critics’ whose hostile and vituperative rhetoric is clearly aimed at discrediting psychiatry as a medical discipline. These critics, in my view, fall under the rubric of ‘anti-psychiatry,'”
Dr. Pies continues by deploring “how little they [the “hostile” critics] understand of general medical nosology and praxis, or of the history of medicine—which leads them fallaciously to marginalize psychiatry from the other medical disciplines.”
I suppose this interaction between the two eminent psychiatrists could be construed as a kind of pre-conversation bonding exercise, and as such, probably serves some ill-defined emotional need. But what strikes me most forcibly is why neither participant makes any attempt to identify the cads in question or to address any of the issues that these dreadful people raise. If their contentions are simply expressions of vituperative ignorance, why not address these contentions and demolish them out in the open for all of us to see. Why not educate us so that we can identify these miscreants and not be misled by their hateful rhetoric, their lack of science, and their ignorance of medical nosology? Give us their names and websites so that we may assess for ourselves the validity or otherwise of their assertions.
It takes no great effort or courage to denounce one’s unnamed critics in vague, generalized terms and to insinuate questionable motives to their contentions. But by the same token, little is gained by the process. So, I encourage Dr. Pies and Dr. Aftab to have the courage of their convictions and to denounce these ignorant wretches by name, and with clear details of their nefarious endeavors.
CHEMICAL IMBALANCE
With the bonding exercise complete, Dr. Aftab loses no time in raising the issue of the chemical imbalance, beloved brainchild of psychiatrists everywhere.
“I think you are right that the 1970s and 1980s—the period when psychiatrists of your generation were trained—were probably the ‘golden’ years of AJE [Alexandrian-Jasperian-Engelian] tradition, but I think the agenda was hijacked pretty quickly afterwards. The explosion of pharmaceutical development in the 1990s and early 2000s with the development of SSRIs and atypical antipsychotics resulted in the reductionistic, caricaturish portrayal of psychiatric disorders as ‘chemical imbalance’ in the public imagination; there was a large influx of money into neuroscience research with an undelivered faith that neuroscience will soon revolutionize the field, and then managed care knocked out whatever wind was left in clinical practice. When I see bio-psycho-social thinking described as the ‘solid center,’ I cannot help but think of the famous phrase from W.B. Yeats, ‘The center cannot hold.’ Do you also share this sense that the solid center has somehow fallen apart?” [This question is addressed to Dr. Pies]
Dr. Aftab’s paragraph is complicated, so let’s open it up. The “explosion” of pharmaceutical development began much earlier than the 1990’s and 2000’s. The production of the major tranquilizers in the 1950’s and the benzodiazepines in the 1960’s were every bit as significant as the second generation neuroleptics and the SSRI’s in later decades. In this regard, it needs to be noted that although pharmaceutical advertizing promoted the benzodiazepines as adjuncts to therapy, it didn’t take psychiatry long to embrace them as therapeutic agents in their own rights. It is also noteworthy that psychiatrists routinely dismissed, and in many cases actually denied, the obvious reality that these products are highly addictive. Given that the damage done by this blatant falsehood is still with us, it is understandable that Dr. Aftab might want to brush it aside.
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“…resulted in the reductionistic, caricaturish portrayal of psychiatric disorders as ‘chemical imbalance’ in the public imagination…”
Gaze in awe, my dear readers, at the exquisite side-shuffle: the development of the antipsychotics “…resulted in…”. It just sort of – you know – happened. Pharma developed the drugs and voila, out of nowhere came this
“reductionistic, caricaturish portrayal of psychiatric disorders as ‘chemical imbalance’ in the public imagination…”
So the chemical imbalance theory – using the word “theory” in the dictionary-endorsed sense of guess or conjecture, or in this special case, deception – somehow resulted from pharma developments – and despite its reductionistic and caricaturish features, became embedded in the public imagination, without any help from psychiatry. Just ol’ John and Jane Q. Public and their over-active imaginations. Well isn’t that the most convenient thing you ever heard of! Nobody’s to blame. It just happened. One of the most successful and most deceptive marketing devices in history just happened. Once pharma had developed the drugs in question, the drugs developed a life of their own. What could psychiatry do? What could anyone do?
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And there’s more:
“…there was a large influx of money into neuroscience research with an undelivered faith that neuroscience will soon revolutionize the field…”
Well there was indeed a large influx of money – mostly from pharma. Dr. Aftab is silent as to the recipients of this money, though he must surely know that most of it went to research psychiatrists and their departments. And there was indeed a profound – almost religious – belief that research would soon provide proof of the chemical imbalance theory (i.e., guess, conjecture, deception). But – and this is critical – psychiatry was pushing the chemical imbalance theory on their clients, the media, and government entities almost since the theory was first proposed, and in many contexts, continue to do so today. They didn’t wait to see what the evidence would say. Who needs evidence when one already knows “the truth”? For an excellent account of this whole matter, see Terry Lynch’s book Depression Delusion, (2015)
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“…and then managed care knocked out whatever wind was left in clinical practice.”
It’s not clear what this means, but here’s my best guess: we psychiatrists would really like to be providing therapy and devoting adequate time to each customer because we’re really good guys and gals, but managed care prevents us from doing so. If this is Dr. Aftab’s intended meaning, then it’s nonsense. It was psychiatric endorsement of the all-mental-problems-are-brain-illnesses-and for every-brain-illness-we-have-a pill-or-a-shock-machine perspective that enabled pharma and the managed care companies to exert the influence that they do. Psychiatrists needed the pills and the shock machines to establish themselves as real doctors. Pharma provided the pills, and psychiatry sold the package to managed care as a more efficient way to “treat mental illness”. Besides, psychiatrists who wish to opt out of these systems can do so, but it will impact their earning potential significantly.
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Dr. Pies’ response to all this is interesting, though largely predictable.
“…I have argued repeatedly that the so-called ‘chemical imbalance theory’ was never a bona fide ‘theory’ in the strict, scientific sense.”
Dr. Pies trots out this gem of pedantic irrelevancy whenever this topic is raised. But in fact, it makes no difference whether the chemical imbalance theory is a “bona fide theory in the strict scientific sense of the term” or not. It was never more than a guess or conjecture or speculation, all of which can be found in most dictionaries as synonyms for the word “theory”. Laboring the precise “scientific” meaning of the term serves no purpose except to demonstrate how wise and eminent Dr. Pies is – a contention that, as far as I am concerned, was never in dispute. I have stated many times that Dr. Pies is probably one of the wisest and most eminent psychiatrists in the US.
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“Nor was it a model embraced by most academic psychiatrists or, importantly, by the pioneers of the biogenic amine hypothesis.4“
Reference 4 is Schildkraut and Kety (Science, 1967), whom Dr. Pies routinely, and mistakenly, considers the pioneers of the biogenic amine hypothesis. In fact, the theory/guess/conjecture was first suggested in 1958 by two groups of researchers acting, as far as I know, independently. The first group was Guy Everett, PhD, James Toman, PhD, and several assistants from Chicago. The second group was John Saunders, MD, Nathan Kline, MD, Maurice Vaisberg, MD, et al from Rockland State Hospital, Orangeburg, New York. Each group presented a paper at the scientific sessions of the Society of Biological Psychiatry, San Francisco, May, 1958. The proceedings were published under the title “Biological Psychiatry”, by Grune & Stratton (1959), edited by Jules H. Masserman, MD, who at the time was president of the society. The Everett and Toman proposal can be found in Chapter 6: “Mode of Action of Rauwolfia Alkaloids and Motor Activity”. Saunders, Kline, Vaisberg et al is Chapter 24, titled “Psychic Energizers”. “Psychic energizers” was the original name for anti-depressants.
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It is also noteworthy that in other writings, Joseph Schildkraut expressed a great deal more support for the chemical imbalance theory/guess/conjecture than Dr. Pies suggests was the case. For instance:
“Thus, although lacking direct experimental confirmation, the catecholamine hypothesis [AKA chemical imbalance theory/guess/conjecture] currently seems to be the strongest and most useful pathophysiological hypothesis of affective disorders. It must be stressed, however, that this hypothesis is undoubtedly, at best, a reductionistic over-simplification of a very complex biological state and that the simultaneous effects of the indoleamines, other biogenic amines, hormones and ionic changes will ultimately have to be included in any comprehensive formulation of the biochemistry of the affective disorders. In our present state of knowledge, however, the catecholamine hypothesis is of considerable heuristic value, providing the investigator and the clinician with a frame of reference integrating much of our experience with those psychopharmacological agents which produce alterations in human affective states.” (p 517) [Emphasis added] (The Catecholamine Hypothesis of Affective Disorders: A review of supporting evidence. Am J Psych, 1965 Nov: 122(5): 509-22)
Note in particular the caveat:
“…lacking direct experimental confirmation…”
but also:
“…a reductionistic over-simplification of a very complex biological state and that the simultaneous effects of the indoleamines, other biogenic amines, hormones and ionic changes will ultimately have to be included in any comprehensive formulation of the biochemistry of the affective disorders.” [Emphasis added]
all of which strikes me as downplaying the caveat, and stressing that other biochemical matters will need to be integrated into the guess/conjecture. In other words, the chemical imbalance theory (guess/conjecture/deception) is too simple. We need to add lots more bio-chemicals into the mix if we want to have a “comprehensive formulation of the affective disorders”. So it’s not really any different. There’s no recognition of the obvious fact that people – living sentient beings – feel sad because sad things happen to them. Rather, it is contended that their sadness, provided it meets certain arbitrary and intrinsically vague thresholds of duration, degree, and impact, is caused by a complex interplay of pathophysiological processes.
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Then Dr. Pies makes what seems an unusual admission:
“I think it is incontestable that, since the heyday of psychoanalysis (ca. late 1950s-1960s), the field of psychiatry took a fairly sharp turn toward the ‘biological’ in the period from roughly 1978 to 1998, which, to a considerable degree, persists to this day.”
I would have said an extremely sharp turn, but we can let that go, because Dr. Pies’ next two sentences effectively exculpate psychiatry:
“But we were far from alone in taking this turn, as witnessed by U.S. President George H.W. Bush’s proclaiming the decade from 1990-1999, ‘The Decade of the Brain.’ And there is no question that the movement toward the biological/biochemical has been heavily influenced by the pharmaceutical industry.”
So there it is: from ’78 to ’98, psychiatry took a fairly sharp turn toward the “biological” (which for some unknown reason Dr. Pies puts inside quotation marks) which, to a considerable degree persists to this day. [Emphasis added]
But psychiatry, he assures us, isn’t wholly to blame for this because:
- The US President himself proclaimed the nineties as the Decade of the Brain, and
- The move was “heavily influenced” by the pharma industry.
So there you have it. What could the poor misfortunate psychiatrists do? Poor lambs, they had to just – you know – go along with all this pressure. Who could resist the combined pressure of a US President and the pharma industry?
Are we really being asked to take this contention seriously?
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Nevertheless, Dr. Pies isn’t ready to throw in the towel completely. He can still cheer-lead.
“Nonetheless,” he writes “what I have called the ‘Alexandrian-Jasperian-Engelian (AJE) integrative tradition’ has remained central to academic psychiatry, alongside Engel’s Biopsychosocial Model (BPSM). You and I and Dr Ghaemi have had a fruitful debate on the merits, demerits, and validity of the BPSM, and I won’t rehash that discussion. I will simply say that, while the AJE/BPSM framework has struggled to remain a central part of psychiatric practice—pushing back against powerful market forces that favor brief ‘med checks’ and provision of psychotherapy by non-physicians—the ‘integrative impulse’ is alive and well in our profession.”
The above paragraph is light on content, but excellent cheerleading.
Also note the limited extent of his claim:
“…the ‘Alexandrian-Jasperian-Engelian (AJE) integrative tradition’ has remained central to academic psychiatry, alongside Engel’s Biopsychosocial Model (BPSM).” [Emphasis added]
Dr. Pies’ assertion concerning the central place of “the integrative tradition” applies only to the ivory towers of academic psychiatry. But what about psychiatric practice, where the rubber, so to speak, meets the road?
“…while the AJE/BPSM framework has struggled to remain a central part of psychiatric practice…” [Emphasis added]
Struggled against what or whom?
“…pushing back against powerful market forces…”
What powerful forces?
“…market forces that favor brief ‘med checks’ and provision of psychotherapy by non-physicians…”
So psychiatry, which for decades has embraced the simplistic, deceptive chemical imbalance theory/guess/conjecture, and sold it to the general public as literal truth, is now stuck with the fact that the insurance companies are actually expecting them to live up to their promises to medicalize every significant problem of thinking, feeling, and/or behaving, and to prescribe “evidence-based” pills and electric shocks to cure these problems. Isn’t that a shame! The poor psychiatrists – stalked relentlessly by the ghosts of their own deceptions. Is there no justice?
Is there no hope? Are the long-suffering psychiatrists doomed to trudge the dreary med check gold mine for the duration of their careers?
No! Because:
“…the ‘integrative impulse’ is alive and well in our profession.”
Phew! What a relief.
But how, my dear readers, do we know that this “integrative impulse” is alive and well? Because the eminent Dr. Pies tells us so. Which is very convenient, because there has been little or no evidence of a lively “integrative impulse” in psychiatry for many, many years. And without Dr. Pies’ assurance, we would never have known.
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But almost as soon as Dr. Pies has raised our hopes concerning psychiatric practice, he dashes them again by retreating to the comfort and familiarity of his ivory towers.
“My own department at SUNY Upstate Medical University [at Syracuse, NY] emphasizes the integration of psychopharmacology and psychotherapy and explicitly endorses ‘the biopsychosocial approach.'”
And not only the State University of New York, but also:
“…at the University of Rochester, where Engel taught and practiced.”
And finally:
“In short, I believe the AJE/BPSM center is still ‘holding,’ but it is surrounded by powerful forces that threaten its integrity.” [Emphasis added]
So Dr. Pies tells us that he believes that the AJE/BPSM center is still holding, even though surrounded by “powerful forces” that threaten its integrity. And the clear implication is that Dr. Pies considers his beliefs on this matter, based as they are on his observations of two psychiatry departments in upstate New York, should carry some persuasive influence on his readers. This is the same Dr. Pies who but a few short paragraphs earlier, condemned psychiatry’s critics, whom he lacks the courage to name, for allegedly basing the opposite premise on quotes from “this or that” notable psychiatrist who used the phrase “chemical imbalance”. In fact, those of us on this side of the issue have based these kinds of statements on an enormous reservoir of personal experience in which psychiatrists who expressed even minor reservations about the chemical imbalance theory/conjecture were a tiny minority in a profession which had long since boarded the chemical imbalance bandwagon en masse.
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And even the eminent Dr. Aftab appears to align himself with the anti-psychiatry position on this matter. Here’s how he responded to Dr. Pies:
“Generally, I agree with you that the chemical imbalance was never accepted as the ‘truth’ by academic psychiatry or by our professional organizations. It was likely an advertisement strategy by pharmaceutical companies that took on a life of its own. However, I am not sure I am ready to exonerate our profession. At best, it seems like we were silent spectators, watching as this misleading idea spread like wildfire in the society (including among our patients and patient advocacy groups), doing little to nothing to correct these public misperceptions. At worst, it seems like at least some of us were participants. Ken Kendler writes in a 2019 JAMA Psychiatry commentary, ‘I would commonly see patients who would say some version of ‘my psychiatrist said I have a chemical imbalance in my brain.’’10 I have had a very similar experience myself. Either way, surely as a profession, we could have done a better job of educating our patients and the public?”
This is certainly interesting, coming, as it does, from a psychiatrist. But let’s take a closer look.
“…that the chemical imbalance was never accepted as the ‘truth’ by academic psychiatry or by our professional organizations.”
In my June 2014 post Psychiatry DID Promote the Chemical Imbalance Theory, I quoted eight eminent, academic psychiatrists who had unambiguously promoted this theory/guess/conjecture. These were:
Richard Harding, MD, University of South Carolina;
Nada Stotland, MD, Rush Medical College, Chicago;
Timothy Wilens, MD, Harvard Medical School;
Jeffrey Lieberman, MD, Columbia University;
Nancy Andreason, MD, PhD, University of Iowa;
Hagop Akiskal, MD, University of Tennessee, subsequently UC San Diego;
Andrew Leuchter, MD, University of California at Los Angeles;
and the late Morris Lipton, MD, PhD, University of North Carolina at Chapel Hill
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“It was likely an advertisement strategy by pharmaceutical companies that took on a life of its own.”
So the blatant and destructive falsehood was the fault of pharma, but was also, apparently, the fault of the chemical imbalance theory itself, which spontaneously took on a life of its own. No, Dr. Aftab, the chemical imbalance deception did not take on a life of its own. It was, rather, a deliberate and self-serving lie promoted actively by psychiatry to legitimize the harmful drugging and shocking, and to promote their prestige and financial rewards. Pharma was certainly involved in this process, but they were, at every turn, led and assisted by psychiatrists. And, by the same token, could have been stopped in their tracks at any time by a direct, honest, and concerted rebuttal from organized psychiatry and from the rank and file. But no such rebuttal was forthcoming, until the hoax was exposed by members of the anti-psychiatry movement and other critics of psychiatry. But the exposure is by no means complete. Chemical imbalance narratives are still widely endorsed by practitioners and facilities, and, tragically, are still widely accepted by psychiatry’s “patients”.
My recollections of the period in question are that the early pharma ads promoted the pills as adjuncts to psychotherapy – they would help the clients communicate with their psychiatrists. The chemical imbalance nonsense itself was initially promoted by psychiatrists, and in due course, not surprisingly, pharma climbed aboard.
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“However, I am not sure I am ready to exonerate our profession.”
H’m. A rift in paradise?
“At best, it seems like we were silent spectators, watching as this misleading idea spread like wildfire in the society (including among our patients and patient advocacy groups), doing little to nothing to correct these public misperceptions.”
“…we were silent spectators…”
In fact, psychiatrists were anything but silent in this matter. Rather, they promoted the chemical imbalance theory/guess/deception with all the guile and resources at their disposal, including vigorous ridiculing of anyone who dared to challenge this most sacred of all psychiatric doctrines. In staff meetings throughout the country, and probably overseas also, staff members who proposed psychosocial perspectives in particular cases were routinely and condescendingly told: “First we must treat the depression”; meaning, first, we must start the pills or the shocks.
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“… watching as this misleading idea spread like wildfire in the society (including among our patients and patient advocacy groups), doing little to nothing to correct these public misperceptions.”
Well, the misleading idea, which I prefer to call a blatant and destructive lie, did indeed spread widely in our society, particularly among psychiatry’s “patients” and “patient” advocacy groups. But Dr. Aftab neglects to mention (or perhaps is unaware) that these advocacy groups were, until recently, given space and endorsement on the APA website to promote this deception.
“…these public misperceptions…”
The implication here is that the public misperceived the message. In fact, there was no misperception. The message was clear, was correctly perceived by the public, by the media, and by government agencies, and has resulted in untold damage to millions of people worldwide. In addition, the deception is still very much in play in virtually all segments of society, including Dr. Aftab’s workplace website, where as of today (November 5, 2020) you can still find the assertion that “metal illnesses” are “biologically based brain disorders”.
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“At worst, it seems like at least some of us were participants.”
My recollection is that the vast majority of psychiatrists were participants.
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“Ken Kendler writes in a 2019 JAMA Psychiatry commentary, ‘I would commonly see patients who would say some version of ‘my psychiatrist said I have a chemical imbalance in my brain.’10 I have had a very similar experience myself.”
I couldn’t begin to estimate the number of times I’ve heard this.
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“Either way, surely as a profession, we could have done a better job of educating our patients and the public?”
Of course psychiatry could have done a better job of educating their “patients” and the public and the media and government agencies. They could, for instance, even now, take out full-page ads in all the major newspapers, acknowledging and apologizing for their deceptions.
But they haven’t done so, because the deception served, and continues to serve, their interests. It created the impression that they were real doctors; it legitimized the rampant prescribing of mood-altering drugs and destructive electric shocks; it enhanced the psychiatrists’ prestige, and improved their earning power. And psychiatry is drawing down the benefits of this hoax to this very day.
The purpose of the chemical imbalance theory/guess/conjecture/deception was to break down the widespread and sensible reluctance on the part of the general public to ingest pills as a substitute for dealing with life’s problems. And, tragically, it has been remarkably successful.
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At this point, Dr. Pies expresses agreement with Dr. Aftab’s position; but immediately transfers the guilt to Mad Men (i.e. the advertizing executives on Madison Avenue).
“Yes, I agree that we—all of us—could have done a better job of counteracting the so-called ‘chemical imbalance’ trope, which, as your comments imply, was more a creature of ‘Mad Men’ than of men and women who study madness!”
Notice the word “trope” – “a literary device…that consists in the use of words in other than their literal sense” (Random House College Dictionary 1990). What Dr. Pies is asserting here is that the chemical imbalance theory/guess/conjecture/deception was never meant to be taken literally. It was just an advertizing metaphor. However, in all the times I’ve heard or read of psychiatrists promoting this theory, I never heard even one explain that it was just a metaphor and was not to be taken seriously. Rather, they routinely doubled down on their assertions by claiming that “mental illnesses” were real illnesses just like diabetes; that the drugs/shocks were required to correct the “imbalances”, or “aberrant circuitry”, or other biological anomalies in the brain; and would probably need to be taken for years or even for life.
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Then Dr. Pies shifts the blame to the psychiatric “patients”:
“And, yes—we often hear anecdotes concerning patients who tell their current clinician some version of, ‘My psychiatrist said I have a chemical imbalance . . .’ But where is the evidence that this is what patients were actually told? Who has contacted the patient’s psychiatrist, or reviewed his/her case notes, to see if that was really what the patient was told? To my knowledge, there has never been a study examining the ‘other side of the story’—and, to be clear: patients are not infallible recorders of what their doctors tell them. So, we are really left to speculate, and with the knowledge that about 80% of antidepressant prescriptions are written not by psychiatrists, but by primary care physicians and family practitioners. Who knows what these doctors told their patients? So, I consider this really a fruitless debate, unless and until I see contemporaneous documentation of what patients were actually told by their psychiatrists; or, failing that, a large ‘N’ of psychiatrists confirm that they regularly used the ‘chemical imbalance’ trope to explain the nature of their patients’ problem. I will add that, in my own practice over 25 years or more, I did include a discussion of neurotransmitters in my explanations to patients, but always in the context of ‘bio-psycho-social’ causes and risk factors.“
So, “patients” can’t be trusted; nobody has done a controlled study of this matter; 80% of prescriptions are written by GP’s; we need contemporaneous documentation of what “patients” were actually told by their psychiatrists; or we need a great many psychiatrists confirming that they regularly used the chemical imbalance deception to “explain the matter to the ‘patients'”.
Note in particular:
“I did include a discussion of neurotransmitters in my explanations to patients, but always in the context of ‘bio-psycho-social’ causes and risk factors.” [Emphasis in original]
But how credible is Dr. Pies on this matter, given that in a letter to the editor of the American Journal of Psychiatry published in March 1992, he proposed his very own chemical imbalance theory (guess/conjecture/speculation) of self-injurious behavior? I have quoted his letter in full elsewhere. In the letter, Dr. Pies distinguishes two types of self-injurious behavior, type 1 and type 2. Here are two quotes from the letter:
“I hypothesize that a primary excess of dopaminergic function is the principal neurotransmitter abnormality in type I and that both D2 and D1 receptors are implicated (possibly with D2 dysfunction predominant). Dopamine agonists would tend to worsen this type of self-injurious behavior, which may respond to conventional antipsychotics.”
and
“…I postulate two principal neurotransmitter abnormalities in type II self-injurious behavior: a primary dopamine deficiency which, over time, may lead to secondary dopamine receptor hyper-sensitivity and/or a dysregulation of serotonergic systems (1-4). D1 receptors –– possibly in nigrostriatal more than in mesolimbic tracts –– are involved preferentially. Treatment with either dopamine agonists or antagonists may be helpful, depending on the point of ‘transition’ between primary dopamine deficiency and dopamine receptor hypersensitivity. Serotonergic agents (e.g., fluoxetine, clomipramine) are also helpful in this type, particularly in patients with ‘obsessive spectrum’ symptoms such as trichotillomania.”
So, we know that in 1992, Dr. Pies had developed his own chemical imbalance theory/guess/conjecture concerning self-injurious behavior, and had even fleshed out this conjecture with specific drug recommendations! Fortunately the conjecture was not well received and, to the best of my knowledge, went no further. But the question arises: did Dr. Pies ever present this conjecture to his customers? Did he prescribe the drugs in question for the problems identified? Has anybody seen his contemporaneous documentation on these matters? Has anybody surveyed a large number of his self-injurious “patients” as to what they were actually told? Is there some evidence that psychiatrists are generally more credible in these matters than their clients?
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It’s pretty clear at this point in the interview that Dr. Pies’ comments concerning the credibility of psychiatry’s “patients” have the potential to backfire, not only on himself, but on the profession generally. Dr. Aftab sees this clearly and throws Dr. Pies a lifeline.
“I understand that there is no conclusive evidence, but this is not a court of law…”
“My fear is that many patients who will read what you have said will feel ignored and invalidated, and their trust in psychiatrists may be further eroded.”
“I don’t believe that is what you intend, so I want to give you an opportunity to reassure such readers who may find your words alarming.”
We can only speculate as to how Dr. Aftab could know what Dr. Pies’ intentions were, but Dr. Pies, being the eminent and scholarly psychiatrist that he is, gets the message.
“Thank you for letting me clarify my comments, Dr Aftab. First, you are wise to take your patients’ reports and recollections seriously—and to treat such reports respectfully. Without mutual respect, the therapeutic alliance is doomed. [This from a person who has just displayed an almost total lack of respect for his own “patients.”] My somewhat testy comments regarding, ‘Where is the evidence that this is what patients were actually told?’ were offered in the context of rebutting dubious claims by various antipsychiatry blogs, websites, and organizations. In the clinical context—sitting with my patients—I would never challenge a report like, ‘My psychiatrist [family practitioner, general physician, etc.] said I have a chemical imbalance . . .’ Rather, I would likely reply by asking the patient, ‘Can you tell me more about that meeting with your doctor, and how you felt when you heard what he/she said?’ I would draw the patient out on what ‘message’ he or she took from the encounter; eg, did apparent mention of a ‘chemical imbalance’ leave the patient feeling relieved or anxious? More worried or less? etc. (Some patients react badly when given a purely ‘biochemical explanation’ of their problem). Note that an interaction of this type does not prejudge the patient’s recollection or reach a final conclusion regarding what the patient was actually told by the psychiatrist or other physician. Remember: listening seriously and respectfully is not the same as listening credulously.”
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Let’s examine this response in detail.
“My somewhat testy comments regarding, ‘Where is the evidence that this is what patients were actually told?’ were offered in the context of rebutting dubious claims by various antipsychiatry blogs, websites, and organizations.”
So his “somewhat testy comments” were not directed at his “patients”, but rather at “the dubious claims” of “antipsychiatry blogs, website and organizations”. This is a slick side-shuffle because his earlier “somewhat testy comments” were most certainly directed at his “patients”.
“…we often hear anecdotes concerning patients [my emphasis] who tell their current clinician some version of, ‘My psychiatrist said I have a chemical imbalance . . .’ But where is the evidence that this is what patients [my emphasis] were actually told?” [Dr. Pies’ emphasis]
So although he acknowledges that these “anecdotes”, which he could just as easily have called “reports” or “accounts”, are often heard, he still calls for evidence that this is what his “patients” were actually [emphasis is Dr. Pies’] told. He is clearly drawing a credibility gap between what the customers were “actually” told and what they say they were told.
In other words, they [the “patients”] can’t be trusted.
There is no hint that the untrustworthiness is meant to apply to “various antipsychiatry blogs, websites, and organizations.”
and
“Who has contacted the patient’s psychiatrist…”
The psychiatrist, of course, being the final arbiter of truth in such matters.
“…or reviewed his/her case notes…”
Case notes were written by the psychiatrist, so they must be truthful and accurate.
“To my knowledge, there has never been a study examining ‘the other side of the story'”
Actually, there has never been a study of the “patients'” side of the story either, though psychiatrists could easily have undertaken such a study any time in the past fifty years. But they chose not to, devoting their research energies instead to the search for proof of their long-cherished chemical imbalance theory/guess/conjecture/deception or other biological explanations. Proof, incidentally, that has never materialized.
. . . . . . . . . . . . . . . .
He then vents his spleen on GP’s and family doctors:
“Who knows what these doctors told their patients?”
It’s difficult not to detect a note of disdain in this rhetorical question.
. . . . . . . . . . . . . . . .
and finally:
“…I consider this really a fruitless debate, unless and until I see contemporaneous documentation of what patients were actually told by their psychiatrists; or, failing that, a large ‘N’ of psychiatrists confirm that they regularly used the ‘chemical imbalance’ trope to explain the nature of their patients’ problem.”
I would definitely call this client-bashing, and it reveals a very fundamental problem within psychiatry:
Psychiatric “patients” are widely disbelieved by psychiatrists.
It’s seldom that one sees it quite so graphically illustrated, but perhaps Dr. Pies’ “testiness” eclipsed his usually careful presentation. What he doesn’t seem to realize, however, is that clients almost always know when they are being disbelieved, and they talk about it, but not usually in the presence of the psychiatrist from a justifiable fear of retaliation.
. . . . . . . . . . . . . . . . .
At this point Dr. Pies makes an almost plaintive attempt to draw a parallel between the stigma and marginalization experienced by psychiatric “patients” and that experienced by psychiatrists themselves.
“And keep in mind that while people with mental illness have indeed been marginalized and stigmatized, so have those of us who care for them. Among other factors, derogatory portrayals of psychiatry and psychiatrists in the media have contributed to stigma against psychiatrists and mental health professionals.”
The primary source of psychiatry’s negative image stems from their deceptions; prolific drugging; and the use of electric shock machines. The primary source of the negative image of their “patients” stems from the false psychiatric assertion that they have incurable brain illnesses.
DEFINITION OF DISEASE
The remainder of the interview focuses on the concept of disease/disorder and how these concepts should be conceptualized and defined.
Dr. Pies, of course, has long insisted that the essential definition of disease is the presence of suffering and impairment to a significant degree. This is broadly in line with the notion of “disorder” as presented in successive editions of DSM from DSM III to the current DSM-5. In the interview, Dr. Aftab presents various challenges to this notion, all of which are deflected by Dr. Pies.
The discussion is interesting but the general topic has long become tiresome. The fact is that the terms “disease” or “sickness” or “disorder”, all of which are more or less synonymous, are consistently used in common speech and by real doctors to indicate the presence of a biological or anatomical pathology.
So when psychiatrists contend that an episode of depression, say, which meets or surpasses certain vague and arbitrary thresholds of intensity, duration and impact constitutes an illness, they are using the term “illness” in a strained and ambiguous fashion.
When they present this notion to their customers, they leave them with the impression that they (the customers) have some kind of neural pathology that the psychiatrists’ understand, and can effectively cure. In the past, the majority of psychiatrists reinforced this absurdity by telling the “patient” that his/her depression was a real illness just like diabetes. Since the fallacy was outed by the anti-psychiatry movement, psychiatrists have been more circumspect on these topics, but the pseudo fact was so widely disseminated and promoted that it continues to be heard and to exert a profoundly negative influence in these matters.
All of this could be cleared up very simply if psychiatrists would clean up their language. If, instead of telling their customers that they (the customers) have an illness called major depression, they said something like: you are experiencing a number of thoughts/feelings, and behaviors that we psychiatrists choose to call an illness in order to increase our prestige and earnings. But it’s not an illness in the normal sense of biological/anatomical pathology, but rather in the specific psychiatric sense of impairment and/or distress.
But they won’t do this because the notion of real illness, just like diabetes is the essential ingredient of the psychiatric hoax that has been drawing “patients” into its destructive drug-pushing web for decades.
. . . . . . . . . . . . . . . .
Here are some of Dr. Pies’ quotes from the remainder of the interview, interspersed with my comments/responses.
“The issue of bias, misrepresentation, and ‘conflict of interest’ in the medical literature is very important—but the problem is not confined to psychiatry, and the blame cannot be laid entirely at the feet of the pharmaceutical industry. As one recent review by E.H. Turner noted, the responsibility for pervasive publication bias lies with various parties such as authors, journals, academia, industry, news media.19
Turner suggests several possible remedies, including a requirement that ‘…results should be excluded from review until after a preliminary judgment of study scientific quality has been rendered, based on the original study protocol.’19 As a teacher of psychopharmacology, I think it is equally important to train our residents (and more senior clinicians) to recognize substantial biases in published papers, and to appreciate the critical importance of randomization in medical research. [Emphasis Dr. Pies’]
So Dr. Pies acknowledges that there are problems of bias, misrepresentation and “conflicts of interest” in the medical literature, and that these problems are “very important”. This strikes me as extreme understatement. Bias and misrepresentation essentially indicates falsification of findings, while conflict of interest usually refers to writing/publishing material that routinely subordinates considerations of fact to one’s own financial interests. This is a very serious admission and leaves one wondering is there anything in this literature that can be trusted.
But Dr. pies immediately attempts to rescue his beloved psychiatry from the worst of the censure:
“…but the problem is not confined to psychiatry, and the blame cannot be laid entirely at the feet of the pharmaceutical industry.”
In other words, one can find bias, misrepresentation, and conflict of interest in the literature of real medical specialties, and, apparently, Dr. Pies is of the opinion that this somehow mitigates psychiatry’s active role in these areas.
. . . . . . . . . . . . . . . .
Back to the Aftab-Pies interview: here’s a quote from Dr. Pies with respect to defining the term disease or disorder.
“…I believe our ‘ordinary language’ is as good a guide as any, with respect to defining these terms. In our ordinary parlance, when someone shows evidence of prolonged or severe suffering and incapacity that is not due to an obvious wound (eg, a bullet wound), we are perfectly justified in saying that the person is ‘ill’; has some kind of ‘disorder’; or is ‘diseased.’ No labs or imaging needed! Indeed, the concept of disease (dis-ease) arose to explain just such instances of suffering and incapacity. In short, ‘disease’ is a pre-biological, pre-scientific construct.” [Emphasis Dr. Pies’]
I think the most charitable way to interpret this passage is to remember that Dr. Pies has spent most of his career in the rarified atmosphere of psychiatry’s ivory towers, where apparently “ordinary language” is not ordinary at all.
The fact that the concept of disease might have arisen to explain instances of suffering and incapacity, has no bearing whatever on how the word is used in the present time. In former times, people, even medical practitioners, had little knowledge of the causes of diseases. Today, living as we do, in the biological and scientific era, the words “disease”, “sickness”, “disorder”, etc. entail the clearly understood denotation of biological or anatomical pathology. In some diseases, e.g. tuberculosis, kidney failure, Wegener’s Granulomatosis, etc, the disease process is well understood; in other cases, it’s not. But in all cases, the need to identify the underlying pathology is considered by real doctors to be of paramount – indeed essential – importance.
Relying on an archaic, pre-biological, pre-scientific understanding of these critical concepts is on a par with the promotion of flat Earth theories, the destruction of crops by witches, the geo-centered solar system, and references to women as the weaker sex. In short, it’s nonsense.
. . . . . . . . . . . . . . . . .
Back to Dr. Pies:
“By way of analogy: let’s imagine that an elderly man with known coronary artery disease is hiking along a woodland trail, when suddenly, a 9-foot grizzly bear appears in front of him. The man is gripped by terror and suffers a myocardial infarction. Would any physician exclude the diagnosis of myocardial infarction (MI) because it occurred in the context of ‘stress’? I don’t think so. Nor is the MI rendered a non-MI because it is ‘understandable’ under such circumstances—I have called this, ‘the fallacy of misplaced empathy’. An MI is an MI, and a major depressive episode is a major depressive episode; ie, if you have all the signs, symptoms, distress and incapacity, you own the disorder!”
This is nothing more than verbal chicanery. A myocardial infarction (heart attack) is a real illness. It is a real illness because it entails a clearly defined biological pathology. It is, unfortunately, fairly common and can be identified pre- and post-mortem with little ambiguity or error. In addition, there is a clear causal link between the pathology, and the signs and symptoms.
By contrast, here’s how Dr. Pies justifies psychiatry’s insistence that what they call “major depressive disorder” is a real illness:
“The cardiologists tell us that there are at least 5 different types of MI, including a primary coronary event, such as plaque rupture; coronary spasm, coronary embolism, and others. But all have in common the production of myocardial ischemia and myocardial-cell death. By the same token, with people who meet full DSM-5 symptom, severity, and duration criteria for a major depressive episode [MDE], we can again enumerate different etiologies and ‘contextual types’; for example, MDE arising in the context of a chronic medical illness, like cancer; in the context of a relationship breaking up; or after sudden job loss. Yet the ‘family resemblances’ (I will resist the lure of a Platonic ‘essence’) that unite these diverse contextual types consist in what you rightly call the ‘relevant pathological and clinical features.’ These are the well-known findings of depressed mood; changes in sleep and appetite; low energy; loss of interest or pleasure in usual activities; impaired concentration, etc. Often, feelings of guilt, worthlessness, or hopelessness accompany these features. Taken together, these features produce varying degrees of ‘suffering and incapacity.'”
. . . . . . . . . . . . . . . .
This is very obscure, so let’s see if we can open it up:
“…people who meet full DSM-5 symptom, severity, and duration criteria for a major depressive episode [MDE]…”
The problem here is that because of the inherent vagueness of the criteria, these people cannot be reliably identified. Cohen’s kappa for “major depressive disorder” in the DSM-5 trials was only 0.28 (here). So any statements that Dr. Pies, or any other psychiatrist, makes about these individuals are inevitably a distortion. A Cohen’s kappa of 0.28 means that the individuals using the term don’t actually know what they are talking about – literally.
“…we can again enumerate different etiologies and ‘contextual types’…”
So Dr. Pies tells us that he can enumerate different etiologies for these cases of “major depressive disorder”. But if we recall that the word etiology means the cause of a disease, it is clear that he is assuming that “major depressive disorder” is a disease in the very process of proving that this is so. His conclusion is hidden in his premise: a logical fallacy known to logicians as “begging the question”, or “assuming the conclusion”.
. . . . . . . . . . . . . . . .
“Yet the ‘family resemblances’ (I will resist the lure of a Platonic ‘essence’) that unite these diverse contextual types consist in what you rightly call the ‘relevant pathological and clinical features.’ These are the well-known findings of depressed mood; changes in sleep and appetite; low energy; loss of interest or pleasure in usual activities; impaired concentration, etc. Often, feelings of guilt, worthlessness, or hopelessness accompany these features.”
Note again how Dr. Pies has slipped in the medical words “pathological” and “clinical”. “Pathological” means altered or caused by disease. (It comes from the word pathology, which means: “…the study of the essential nature of diseases and especially of the structural and functional changes produced by them.” (Merriam-Webster). Tabers Cyclopedic Medical Dictionary (2013) defines pathology as: “The study of the nature and cause of disease which involves changes in structure and function.” Tabers defines “pathologist” as: “A medical professional trained to examine tissues, cells, and specimens of body fluids for evidence of disease.”
The word clinical simply means pertaining to a clinic. It is an informal word routinely used by psychiatrists to create the impression of disease without actually committing themselves to an outright falsehood.
So what “relevant pathological…features” of a “major depressive episode” is Dr. Pies adducing in the present interview?
“These are the well-known findings of depressed mood; changes in sleep and appetite; low energy; loss of interest or pleasure in usual activities; impaired concentration, etc. Often, feelings of guilt, worthlessness, or hopelessness accompany these features. Taken together, these features produce varying degrees of ‘suffering and incapacity.’ It is this dyad that constitutes the ‘disorder-ness’ that separates clinical depression from grief.“
Dr. Pies’ list, of course, constitutes the “symptoms” of a major depressive episode in successive editions of the DSM. By referring to these thoughts, feelings, and behaviors as pathological, Dr. Pies is once again begging the question. It is also clear that Dr. Pies is not using the word illness in its standard “ordinary language” sense. Rather, he has dragged the term “pathological features” into the discussion (as he did earlier with the term “etiological”), to convey the impression of illness where, in fact, none exists.
In the final analysis, his argument amounts to this: depression which crosses arbitrary and vaguely-defined thresholds of severity, impact, and duration is an illness because it entails suffering and incapacity. Suffering and incapacity are the defining features of illness, disorder, disease, etc. because I and “this or that” other eminent psychiatrists say so, and – most extraordinarily – because of linguistic conventions established in the pre-biological, pre-scientific era.
Nonsensical as it sounds, there is nothing more to psychiatry’s claims that they treat real illnesses.
Dr. Pies continues by stating that nosologists who claim that psychiatric “illnesses” are “really problems of living”
“…are mistakenly classifying a bona fide depressive disorder as merely a ‘problem of living,’ with no clear evidentiary justification, potentially to the detriment of their patients.”
To which I could just as readily respond that psychiatrists who classify bona fide problems of living as illnesses with no clear evidentiary justification do enormous harm to the victims of this unconscionable hoax. And let us not forget that in real science (as opposed to psychiatric science), the burden of proof lies with the party making the extreme claim.
And it needs to be stressed that neither Dr. Pies nor any other psychiatrist has ever produced evidence in support of this position. Like some modern politicians, they repeat their falsehoods over and over, as if this process carried some evidentiary weight.
Then Dr. Pies makes this noteworthy statement:
“That said, I agree with you that disorder attribution ‘serves pragmatic functions within a social context,’ which may vary from culture to culture…This reminds us yet again that medical judgments are not ‘value-free,’ even though they may draw on ‘objective,’ clinical data. Zachar and Kendler note, for example, that a central controversy in the bereavement debate revolved around the question: which is more important when assessing depression: avoiding false positives or avoiding false negatives? Ultimately, this depends on which ‘pragmatic functions’ a society wishes to promote and underwrite, and this is clearly a matter of societal values.” [Emphasis Dr. Pies’]
In other words, if I’m understanding this correctly, if the general public wants us to diagnose illnesses and prescribe pills and shocks, then that is what we will do! We will attribute disorders (i.e. we will diagnose illnesses) in accordance with which “pragmatic functions” society wishes us to promote and underwrite. This is clearly a matter of societal values, and not (though Dr. Pies fails to articulate this explicitly) a matter of science or logic. It also displays an extraordinary degree of arrogance on the part of psychiatrists to assume that they themselves have some special insights into the wishes/wants of society. Have they received some specific and valid training on these matters? Or have they, as a profession, developed a reliable body of pertinent research data?
. . . . . . . . . . . . . . . .
Dr. Aftab: “What are your hopes for the future of psychiatry?”
Dr. Pies’ response to this question is interesting, even alarming. Here’s his full response:
“One of the most perceptive and heuristically useful comments about psychiatry that I have ever heard came from one of my residency mentors, Dr Robert Daly. Bob once said that in psychiatry, ‘You can do biology in the morning and theology in the afternoon.’ That comment from nearly 40 years ago has always stuck with me. It speaks to the holistic and pluralistic nature of the psychiatric enterprise, which I wholeheartedly endorse, and which has radically shaped my entire career. So my chief hope for ‘the future of psychiatry’ is that it recover its pluralistic ‘core’—what I earlier described as the AJE tradition. I say ‘recover’ because, as I noted earlier, I believe that psychiatry’s ‘solid center’ is besieged by market-driven forces that would like to reduce us to ‘writing scripts’ and ‘turfing’ psychosocial interventions to less costly non-physicians. We need to push back hard against those trends! At the same time, I would like to see psychiatry achieve much better integration with neurology and general medicine, in what has been called ‘collaborative care.’ I also think psychiatry has to do a much better job of ‘public outreach,’ whereby we go out into the community in a proactive way, so that the general public has a better understanding of who we are and what we do. We can’t afford to let antipsychiatry define us in the public mind. The stakes for our profession and the well-being of our patients are far too high.”
This closing paragraph of the interview raises several issues:
- What does the eminent Dr. Pies mean by doing theology? Is this the same as preaching? Or discussing abstruse theological matters? Or seeking meaning in life through religion? It is clear that Dr. Pies has put great store in the expression, and that it has stuck with him for forty years. But is it what people expect when they present themselves for psychiatric “treatment”, or is Dr. Pies foisting his own agenda on his hapless victims? We can only guess.
- “It speaks to the holistic and pluralistic nature of the psychiatric enterprise, which I wholeheartedly endorse, and which has radically shaped my entire career.” Actually, depending on what Dr. Pies means by “doing theology”, it could mean the exact opposite – using his position as a psychiatrist to preach theological dogma.
- Pies clearly hopes for some revival of “doing” theology within psychiatric practice. “So my chief hope for ‘the future of psychiatry’ is that it recover its pluralistic ‘core’—what I earlier described as the AJE tradition.”
- “…I believe that psychiatry’s ‘solid center’ is besieged by market-driven forces that would like to reduce us to ‘writing scripts’ and ‘turfing’ psychosocial interventions to less costly non-physicians.” Actually, the siege is over. Psychiatry’s “solid center”, if indeed it ever existed, has long since been swept away. Writing scripts for mood-altering drugs and intra-cranial shocks is pretty much the sum total of psychiatric activity at present.
- “…I would like to see psychiatry achieve much better integration with neurology and general medicine, in what has been called ‘collaborative care.'” To some extent psychiatry has had some success in this area. Readers who are Medicare recipients will have noticed that they are being routinely screened for depression in recent years. This stems from a conscious and calculated effort on the part of psychiatry to spread its tentacles into every aspect of our lives.
- “We can’t afford to let antipsychiatry define us in the public mind. The stakes for our profession and the well-being of our patients are far too high.” Note that his concern for the profession of psychiatry takes precedence over his concern for his “patients”. And, of course, in the final analysis, psychiatry is defining itself as the arch-purveyor of chicanery and deception.
CONCLUSION
It is clear from the comments of Dr. Pies in this interview that his primary concern at the present time is to discredit and marginalize the anti-psychiatry movement. He denies the fundamental legitimacy of the movement as a vital corrective to psychiatry’s invention and promotion of bogus illnesses, and to its blatant and harmful pushing of drugs and electric shocks.
The most striking feature of Dr. Pies’ assertions in this area is his failure to understand the modern meaning of the words illness and disease, and his stubborn reliance on archaic “pre-scientific”, “pre-biological” definitions of these terms as a ploy to sell the false notion that psychiatric “illnesses” have the same ontological status as the illnesses treated by real doctors.
Like modern politicians who confuse repetition with truth, he continues to beat the same worn-out tunes on the same old drum.