Review of 'Psychiatry on the Edge' by R. W. Pies. Double D
PsycCRITIQUES
January 26, 2015, Vol. 60, No. 4, Article 4
http://dx.doi.org/10.1037/a0038619
© 2015 American Psychological Association
This article may not exactly replicate the final version published in the APA journal. It is not the copy of record.
Mastering
the Critique
of Psychiatry
A Review of
Psychiatry
on
the
Edge
by Ronald William Pies
Reviewed by
Duncan
Double
Ronald William Pies was editor-in-chief of
Psychiatric
Times
from 2007 through 2010. He is a professor in the psychiatry departments of State University of New York (SUNY) Upstate Medical University and Tufts University School of Medicine.
Psychiatry
on the Edge
contains slightly modified versions of several of his articles published in
Psychiatric
Times
from 2006.
In an interview (
Psychiatric
Time
s
, 2005), Pies explained that he is a general psychiatrist with a “very strong interest in the biological functions that underlie thinking and feeling” (p. 2). He has promoted “encephiatrics,” which means psychiatrists becoming “healers of the brain.” This doesn’t just mean providing psychopharmacology; it includes talk therapy. He believes that neurology and psychiatry should reunite, and should never have been separated, although, if this happened, there would be a need for “certain kinds of linguistic and philosophical ‘bridging devices’” (Pies & Daly, 2010, para. 9 of Pies statement in support of resolution).
In the book, Pies says brain imaging in the last 30 years has improved biological understanding of mental illness. Although for a variety of practical and theoretical reasons, biological markers have not found a useful place in everyday psychiatric practice, he sees progress as having been made in this regard with tests such as abnormal smooth pursuit eye movements in schizophrenia and derangements of hypothalamic-pituitary-adrenal function in melancholic major depression (p. 154). Over the same period, he notes that cognitive behavioral therapy (CBT) for anxiety and depression has grown. Clozapine has been developed as what he considers “the most effective medication for schizophrenia” (p. 153). As far as he is concerned, electroconvulsive therapy (ECT) still maintains efficacy in treatment of severe depression. He also points to the increasing use of transcranial magnetic stimulation and ketamine infusion for the treatment of depression and other disorders. He is, therefore, quite biological in his approach to psychiatry.
However, he says he is agnostic about whether mood disorder is caused by a “chemical imbalance,” which is a term that is “simplistic and a bit misleading” (p. 32). He believes the chemical imbalance notion “was always a kind of urban myth” and never “seriously propounded by most well-informed psychiatrists” (p. 30). Doctors know it’s an oversimplification, he says, but use it so patients don’t feel so blameworthy. He does agree this is “a little lazy” (p. 33) on the doctors’ part and doesn’t excuse their behavior, but says they are very pressed for time with so many patients to see. He recognizes a problem with the hypothesis in that patients may come to think they have no control over their illness. However, he’s clear that the catecholamine hypothesis of depression was only ever a hypothesis and not a developed theory. In fact, he emphasizes that it merely proposed an association rather than a causal relation. If there is a biochemical abnormality, this imbalance could just as easily be caused by environmental and psychological factors as genetic and constitutional processes. This isn’t a reductionist hypothesis as far as he is concerned; instead, he calls it a holistic model.
Pies endorsed the removal of the bereavement exclusion from the definition of major depression in the
Diagnostic
and Statistical
Manual
of Mental Disorder
s
, 5th edition (
DSM-5
; American Psychiatric Association, 2013), and a whole chapter of the book is devoted to this topic. Allen Francis, chair of the
DSM-IV
Task Force, amongst others, has been concerned about the overmedicalization of mental disorder and sees the removal of the bereavement exclusion as a step too far. However, Pies does recognize the distinction between grief and major depression. He also requires a sound foundation to psychiatric classification. His argument is that context does not determine mental disorder. He appreciates that careless diagnosis and overdiagnosis do occur, but generally he regards “medicalization” in psychiatry as a myth, because whether a presentation is understandable or not shouldn’t determine whether it is a mental disorder. From my point of view, he may not do enough to avoid the reification of diagnostic concepts, but like him, I am not wanting to totally abolish psychiatric diagnosis, merely recognize it for what it is (Double, 2002). I think, though, that Pies may not fully acknowledge how much the
DSM
process has been taken over by biomedical assumptions. I find this difficult to gauge fully, however, from the book, without knowing more about his clinical practice. His biological approach and emphasis on psychopharmacology suggest to me that he is not psychosocial enough in his assessment and treatment of patients.
Pies makes a case for a “polythetic pluralism” in psychiatry, by which he means using “several different approaches to diagnosis and treatment, sharing some features in common, no one of which defines the ‘essence’ of psychiatry” (p. 41). He sees himself as one of a number of “pluralistic unifiers” in psychiatry, including several
Psychiatric
Times
colleagues. This position is advocated as a response to critiques of psychiatry, which he is happy to lump together as manifestations of “anti-psychiatry.” Although he accepts that the critiques contain “at least a grain of truth —and some contain a few drams” (p. 153), he doesn’t accept their claims about what is wrong with psychiatry.
As someone who is critical of the biomedical model in psychiatry, my problem is the validity of Pies’ polythetic pluralism. I do think it would be an advance if psychiatry was more pluralistic than the current biomedical dominance in psychiatric practice. Pies wants to avoid remaining “ensnared by the terms ‘mind’ or ‘brain’” (p. 31), and says we would be better served by using the term “brain-mind.” Of course, the brain is the origin of the mind, and I agree mind and brain should be integrated, not separated. However, Pies hasn’t solved the mind-body problem. Minds are enabled but not reducible to brains. I don’t think “polythetic pluralism” acknowledges this conceptual position sufficiently.
The split between biomedical and psychosocial understandings has been present since the origins of modern psychiatry. It can’t be overcome by supposing both medication and psychotherapy are effective in psychiatric treatment. In fact, I think that Pies is still essentially trying to justify a biomedical approach to psychiatry by adding the personal dimension and calling it “polythetic pluralism.” But, I don’t think he is person-centered enough in his approach. This is evidenced, for example, as I have mentioned above, in his belief in biological markers and his failure to reject firmly the notion of “chemical imbalance.” He sees psychiatry standing “‘on the edge’—of promise and peril, progress and regress” (p. xi). I suspect he would regard my questioning of whether the neural substrate in mental illness is any different from our “normal” behavior as “over the edge”! He might also designate my position as what he calls “anti-psychiatry.” However, I think that having a proper conceptual understanding of mental illness is the only way to make true progress in psychiatry.
A strength of this book is that it is an attempt to engage with the critique of psychiatry. Collecting together various articles that have been published on different topics over the years may not make a very coherent apology for psychiatry. Pies’ theoretical position, however, does show through in the various essays. I remain to be convinced that he is successful in defining a valid response, but he makes an attempt to master the critique of psychiatry. It’s worth looking at the book to understand how he tries to do this. I would
have preferred that he took on board more of a critical perspective, rather than, in my view,
still essentially defending biomedical psychiatry.
References
American Psychiatric Association. (2013).
Diagnostic
and statistical
manual of mental disorders
(5th ed.). Washington, DC: Author.
Double, D. B. (2002). The overemphasis on biomedical diagnosis in psychiatry.
Journal
of Critical
Psychology,
Counselling
and Psychotherap
y
,
2
, 40–47. Retrieved from
http://www.critpsynet.freeuk.com/Overemphasis.htm
Pies, R. W., & Daly, R. (2010, March 4). Should psychiatry and neurology merge as a single discipline?
Psychiatric
Time
s
. Retrieved from
http://www.psychiatrictimes.com/
neuropsychiatry/should-psychiatry-and-neurology-merge-single-discipline
Psychiatric
Time
s
. (2005, November). Through the times with Ronald Pies, M. D. Retrieved from
http://www.psychiatrictimes.com/articles/through-times-ronald-pies-md/page/0/1