CLINICAL CONVERSATIONS
Psychiatric times Editor-in-Chief Ronald W. Pies, MD, has never shied away from controversial topics and championed the field of psychiatry and its practitioners. Dr. Pies has consistently encouraged consideration of the ethical, psychosocial and humanistic aspects of psychiatry, in addition to the biological and pharmacological aspects of the field. His latest book builds on previous comments and columns published with Psychiatric times to reflect on the current state of psychiatry and possible paths for the future.
Howard Forman, Physician: We’ve all heard the saying “don’t judge a book by its cover,” so I want to ask what is the question chosen for the cover of your latest book, Psychiatry at the Crossroads: Can psychiatry find its way to a truly humanistic science? Compared to other eras, how close is our current era to psychiatry achieving this goal?
Ronald W. Pies, MD: I think there is both good news and bad news in this regard. Just to put your question into historical context, American psychiatry had its heyday in the 1950s and 1960s when the psychoanalytic era was in full bloom, but when biological approaches to mental illness were generally very limited or rudimentary. The 1980s and 1990s saw the great biological breakthrough in psychiatry, which began with much promise but ended in some disappointment. That’s not to say that our biological treatments weren’t helpful or that we didn’t learn a lot about the brain during that time. But despite our best efforts and intentions, the field has failed to integrate basic biological research into so-called clinical practices translational psychiatry. For example, despite excellent research in the areas of brain imaging and neurochemistry, psychiatry has never really developed office-ready biological tests for major categories of mental illness, even though we do have some promising contenders.
Furthermore, during the so-called Decade of the Brain (c. 1990-1999), I think psychiatry lost much of its historical link with the psychosocial factors of mental illness and with the rich tradition of psychotherapy. Since then, I think the profession has continued to move towards predominantly biological approaches and treatments, somewhat at the expense of a full, humanistic understanding of psychiatric illnesses and their treatment. I say this as someone who has more or less paid his rent in psychopharmacological counseling for over 25 years and who is a firm believer in the benefits of psychiatric medications and somatic treatments. But, throughout my 40 years in psychiatry, I have always advocated a biopsychosocial approach to psychiatric illness. In fact, my 1994 book Clinical Manual of Psychiatric Diagnosis and Treatment was subtitled: A biopsychosocial approach.
Psychiatry, to the extent that we can generalize about such a diverse field, now has a golden opportunity to integrate biological and psychosocial knowledge into a single humanistic science.
Now back to your question and the good and bad news. I think psychiatry, to the extent that we can generalize about such a diverse field, now has a golden opportunity to integrate biological and psychosocial knowledge into a single humanistic science. We know that a purely biological or purely psychosocial approach to the most serious psychiatric disorders is far from adequate. So we really have to find a way to put it all together. At the same time, market pressures and the general derogation from psychiatric expertise are now straightforward providersthey are powerful forces working against us. American psychiatrists still do psychotherapy, but substantially less often than they did in the 1970s and 1980s, and this has played into the hands of third-party contributors who simply want us to write scripts. I think we, as a profession, have to find the will and the way to resist this kind of pressure. If we do, we have a chance of becoming a truly humanistic science.
For men: When I attended the American Psychiatric Association’s 2023 Annual Meeting in San Francisco, I was struck by the large, contrasting banners celebrating the success of psychiatry in a city whose streets are filled with the homeless, many of whom are in the throes of disease active. Where has psychiatry failed with these individuals? Where has society failed to allow psychiatry to help?
Cakes: You are highlighting one of the great tragedies of our American healthcare system, which is actually no system at all! In the United States, medical care in general and psychiatric care in particular are like a large, threadbare patchwork of poorly integrated regional fiefdoms. This is especially true when we look at dual diagnosis treatment, and I’d wager that many of the homeless people you’ve seen on the streets of San Francisco fall into the comorbid psychiatric disorder/substance abuse category. As our colleague, Allen Frances MD once commented Psychiatric times:1
It is heartbreaking to me that 600,000 of our most critically ill patients are in prison or homeless and that we have done so little to support community mental health centers and affordable housing that would free them from confinement and end this blatant negligence.
But I think there are many faults around. The society represented by our national and state legislatures never built or funded the kind of community support system needed to address the thousands of critically ill and deinstitutionalized patients with psychiatric disorders who were essentially put on the streets, during the period between 1955 and 1980. As a 2007 Kaiser Commission noted:2
Only in 1993 did state-controlled mental health funds go to community care rather than state institutions [and] policy in large federal programs was not controlled by mental health care managers
For men: You have a quote from William Alwyn Lishman, MD, FRCP, FRCPsych (Hon) PMC: “All psychiatrists should be all kinds of psychiatrists.” Do you see a loss in the movement away from the general psychiatrist towards the highly subspecialized psychiatrist?
Cakes: Yes, indeed I do. I’m glad you quoted Dr. Lishman’s comment. His classic work Organic psychiatry: the psychological consequences of brain disorders (1987) has been a very important resource for me throughout my career. Despite the term biological in the title of his book, the late professor believed that psychiatrists should take a diverse, pluralistic, biopsychosocial approach to their work, and I certainly agree. I think the entire quote you refer to is worth sharing:3
You have to have a finger in every pie in psychiatry and be ready to put your hand down whichever avenue is most important: an EEG one day, a little dream talk another day. Just follow your nose. All psychiatrists should be all kinds of psychiatrists.
For men: When I worked for economists, they joked, “the field of economics advances one funeral at a time.” While I hope psychiatrists continue to learn and adapt throughout their careers, certainly in-house training provides the largest pool of future impressionable psychiatrists. If you were empowered, what would change in the education of psychiatrists today?
Cakes: I doubt this idea will be popular with many residents, but I would like to see psychiatric residency become a 5-year program. After all, a surgical residency can last 5 years or more, and we need to know at least as much as surgeons. I would like to see an expansion and deepening of both the neurological and psychotherapeutic components of internal training, because I consider them to be of equal importance. I would like to see our residents become Renaissance physicians, with a working knowledge of the social, cultural and spiritual aspects of psychiatric diagnosis and treatment. And, as if that wasn’t enough, I believe our residents need a strong background in the philosophy of psychiatry, as my colleagues Awais Aftab, MD, and Nassir Ghaemi, MD, MPH, have made so well clear.4
For men: Where do you see this newest book fit into your larger book collection, which so many of us have enjoyed? Even if you indicate that it’s sort of a sequel to borderline psychiatry where do you place it in the larger context of your written works?
Cakes: Thank you for asking me. In a way, I think Psychiatry at the crossroads it lines up with my other writing, as it contains everything from hard science (eg, articles on serotonin and antidepressants) to psychiatric ethics, philosophical/spiritual pieces, and even some poetry and fiction. I want to give a nod of appreciation to my colleagues who contributed to these book features: Cindy Geppert, MD, PhD, MA, MPH, MSBE, DPS, MSJ, Mark S. Komrad, MD, Annette Hanson, MD, Steve Moffic, MD, Alan Blotcky, PhD, James L. Knoll IV, MD, David Osser, MD, Joe Pierre, MD, George Dawson, MD, and Richard Berlin, MD. I also want to compliment Mark L. Ruffalo, MSW, DPsa, for his kind reading of the book. All of which reminds me of a line from one of my graduate mentors, the late Bob Daly, MD, who said: With psychiatry, you can do biology in the morning and theology in the afternoon! Indeed, I have discovered with deep satisfaction that this is the case.
Doctor Forman is director of the Montefiore Addiction Counseling Service and an assistant professor in the department of psychiatry and behavioral sciences at the Albert Einstein College of Medicine. He serves as Psychiatric times Book review editor.
Doctor Pie is Professor Emeritus of Psychiatry and Lecturer in Bioethics and Humanities, SUNY Upstate Medical University; Professor Emeritus of Psychiatry, Tufts University School of Medicine; and editor-in-chief emeritus of Psychiatric times (2007-2010). Dr. Pies is the author of numerous books, most recently the novella, The motionless engine.
References
1. Aftab A. Conversations in Critical Psychiatry: Allen Frances, MD. Psychiatric times. 2019;36(10):17-23.
2. Koyanagi C. Learning from history: deinstitutionalization of people with mental illness as a precursor to long-term care reform. August 2007. Accessed 11 August 2023. Available at: https://www.kff.org/wp-content/uploads/2013/01/7684.pdf
3. Poole NA. Interview with Professor William Alwyn Lishman. The psychiatrist. 2013; 37(10) 343-344.]
4.Aftab A, Nassir Ghaemi S, Stagno S. A didactic course on the “Philosophy of Psychiatry” for psychiatry residents. Psychiatry Acad. 2018;42(4):559-563.
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