Avoiding the Path of Least Resistance

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CLINICAL CONVERSATIONS

Psychiatric Times’ Editor-in-Chief Emeritus Ronald W. Pies, MD, has never shied away from controversial topics and supporting the field of psychiatry and its practitioners. Dr Pies has consistently encouraged the consideration of the ethical, psychosocial, and humanistic aspects of psychiatry, in addition to the biological and pharmacological aspects of the field. His latest book draws from previous commentaries and columns published with Psychiatric Times to reflect on the current status of psychiatry and possible paths for the future.

Howard Forman, MD: We have all heard "don't judge a book by its cover," so I want to ask you about the question chosen for the cover of your newest book, Psychiatry at the Crossroads: Can Psychiatry Find the Path 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 that regard. Just to put your question in historical context, US psychiatry had its heyday during the 1950s and ’60s when the psychoanalytic era was in full flower, but when biological approaches to mental illness were generally very limited or rudimentary. The 1980s and ’90s saw the great biological turn in psychiatry, which began with a great deal of promise but ended with some disappointment. That’s not to say that our biological treatments were not helpful or that we didn’t learn a great deal about the brain during that period. But despite our best efforts and intentions, the field fell short of integrating basic biological research into clinical practice—so-called translational psychiatry. For example, despite excellent research in the areas of brain imaging and neurochemistry, psychiatry never really developed office-ready biological tests for the major mental illness categories, though we have a few promising contenders.

Furthermore, during the so-called Decade of the Brain (ca. 1990-1999), I think psychiatry lost much of its historical connection to psychosocial factors in mental illness and to the rich tradition of psychotherapy. Ever since then, I think the profession has continued to pivot toward mainly biological approaches and treatments, somewhat to the detriment of a full, humanistic understanding of psychiatric illnesses and their treatment. I say this as someone who more or less paid the rent doing psychopharmacology consultation for more than 25 years, and who firmly believes in the benefits of psychiatric medication and somatic treatments. But, during 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 with psychosocial knowledge into a single, humanistic science.

Now back to your question and to 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 with 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 must find a way to put it all together. At the same time, market pressures and the general derogation of psychiatric expertise—we are now mere providers—are powerful forces working against us. US psychiatrists are still doing psychotherapy, but substantially less often than in the 1970s and 1980s, and this has played into the hands of third-party payers who want us merely to “write scripts.” I think we, as a profession, need to find the will and the way to resist this kind of pressure. If we do so, we have a shot at becoming a truly humanistic science.

Forman: When I attended the 2023 American Psychiatric Association Annual Meeting in San Francisco, I was struck by the contrasting large banners celebrating the success of psychiatry amid a city whose streets are filled with homeless individuals, many of whom are in the throes of active illness. Where has psychiatry failed these individuals? Where has society failed in allowing psychiatry to help?

Pies: You are highlighting one of the great tragedies of our American health care system, which is really no system at all! In the US, medical care in general—and psychiatric care in particular—is like a big, tattered patchwork of poorly-integrated, regional fiefdoms. This is especially the case when we look at dual diagnosis treatment, and I would wager that many of the homeless folks you saw on the streets of San Francisco fall into the category of comorbid psychiatric/substance abuse disorders. As our colleague, Allen Frances MD, once commented in Psychiatric Times:¹

It is heartbreaking to me that 600,000 of our most severely ill patients are either in jail or homeless and that we have done so little to advocate for the community mental health centers and affordable housing that would have freed them from confinement and ended the shameless neglect.

But, I think there is plenty of blame to go around. Society—as represented by our national and state legislatures—never built or financed the kind of community support system needed to deal with the thousands of seriously ill, deinstitutionalized patients with psychiatric disorders who were essentially put out on the streets, during the period of roughly 1955-1980. As a 2007 Kaiser Commission noted:²

Not until 1993 were more state-controlled mental health dollars allocated to community care than to the state institutions… [and] policy in large federal programs was not controlled by those responsible for mental health care…
 

Forman: You have a quote by William Alwyn Lishman, MD, FRCP, FRCPsych (Hon) – PMC: "All psychiatrists should be all types of psychiatrist." Do you see a loss in the movement away from the general psychiatrist to the highly subspecialized psychiatrist?

Pies: Yes, indeed I do. I’m glad you cited Dr Lishman’s comment. His classic work, Organic Psychiatry: The Psychological Consequences of Cerebral Disorder (1987) was a very important resource for me over the course of my career. Despite the term organic in the title of his book, the late professor believed that psychiatrists need to take a diversified, pluralistic, biopsychosocial approach to their work, and I certainly agree. I think it’s worth sharing the entire quote you reference:³ 

You have got to have a finger in every pie in psychiatry, and be ready to turn your hand to whatever is the most important avenue: an EEG one day, a bit of talking about a dream another day. You just follow your nose. All psychiatrists should be all types of psychiatrist.

Forman: When I worked for economists, they would joke, "the field of economics advances one funeral at a time." Although I hope psychiatrists will continue to learn and adapt throughout their careers, certainly residency training provides the largest pool of impressionable future psychiatrists. If given the power, what would you change about the training of psychiatrists today?

Pies: 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, 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 neurology and psychotherapy components of residency training, because I see these as being of equal importance. I would like to see our residents become Renaissance clinicians, with a working knowledge of the social, cultural, and spiritual aspects of psychiatric diagnosis and treatment. And, as if I haven’t heaped on 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 elucidated so well.⁴

Forman: Where do you see this most recent book fitting into your larger collection of books, which so many of us have enjoyed. Although you indicate it is a sequel of sorts to Psychiatry on the Edge, where do you place it in the larger context of your written works?

Pies: Thanks for asking. In a sense, I think Psychiatry at the Crossroads is of a piece with my other writing, in that it contains everything from hard science (for example, articles on serotonin and antidepressants) to psychiatric ethics to philosophical/spiritual pieces,and even to some poetry and fiction. I want to give an appreciative nod to my colleagues who contributed to these features of the book: 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 tip my hat to Mark L. Ruffalo, MSW, DPsa, for his kind reading of the book. All of which brings to mind the quip by one of my mentors in residency, the late Bob Daly, MD, who used to say, “With psychiatry, you can do biology in the morning and theology in the afternoon!” Indeed, I have found to my deep satisfaction that this is so.

Dr Forman is director of the Addiction Consultation Service at Montefiore and assistant professor in the department of psychiatry and behavioral sciences at Albert Einstein College of Medicine. He serves as Psychiatric Times Book Review Editor.

Dr Pies is Professor Emeritus of Psychiatry and Lecturer on 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 several books, including, most recently, the novelette, The Unmoved Mover.

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 Precursor to LongTerm Care Reform. August 2007. Accessed August 11, 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 "Philosophy of Psychiatry" for Psychiatry Residents. Acad Psychiatry. 2018;42(4):559-563.