BACKGROUND
A couple of weeks ago (March 23), the New York Times did a feature on “Defining Mental Illness.” They invited Ronald Pies, MD (a psychiatry professor at SUNY Upstate Medical University and Tufts University) to submit a brief paper on this topic. Various people with opposing views were allowed to respond, and finally Dr. Pies presented a much longer summary and rebuttal. You can see the entire print version here.
The material is interesting in its own right, but what struck me most forcibly was Dr. Pies’ mastery of the art of spin. He is probably the best psychiatric spin-doctor I’ve ever come across.
My definition of spin, incidentally, is: the art of deflecting legitimate criticism and of presenting oneself or one’s organization in a favorable light at the expense of the facts.
PSYCHIATRIC “DIAGNOSIS” AND STIGMA
Dr. Pies’ opening piece notes that “…many …argue that current psychiatric diagnoses often ‘stigmatize’ or ‘dehumanize’ people struggling with ordinary grief, stress or anxiety.”
There are two issues here. First is the stigmatizing nature of psychiatric “diagnoses.” Second is the well-established phenomenon of diagnostic creep, through which an increasing number of problems previously considered normal life issues have become “mental illnesses.” Dr. Pies dismisses the latter issue in a single sentence. “We can certainly debate the legitimate boundaries of disease and ‘normality’…”, effectively brushing aside the wholesale erosion of these “legitimate boundaries” by psychiatrists for the past four or five decades. This is not a matter of debate. It is a matter of history.
DENY
He then goes on to address the stigma issue with a simple denial: “But there is nothing inherently dehumanizing or ‘stigmatizing’ about a psychiatric diagnosis.”
As any politician can tell you, the first rule of spin is: deny! And the second rule of spin is: blame it on the opposition. In this Dr. Pies does not disappoint us. “Ironically, such inflammatory charges only worsen society’s animus and prejudice toward those with mental illness, by implying that having a psychiatric disorder is grounds for shame.”
So look what he’s done. He has neatly sneaked in the notion that any statement on the stigmatizing effect of mental “diagnoses” is by its very nature inflammatory.
BLAME THE OPPOSITION
But more importantly, he goes on to assert that it is his opponents who are to blame for any stigma that may attach to a psychiatric “diagnosis,” because – we imply that having a “…psychiatric disorder is grounds for shame.”
I have long lost track of how many books, articles, and blogs I’ve read that were critical of psychiatric “diagnoses,” but I don’t recall a single one that implied, by any stretch of the imagination, that the behaviors embraced by these so-called diagnoses were a cause for shame. Indeed, the truth is exactly the opposite. Almost everyone on this side of the debate, including myself, conceptualizes these behaviors as essentially understandable reactions to adverse or unusual life events. How unstigmatizing can we get?
SPURIOUS MEDICALIZATION OF PROBLEMS INCREASES STIGMA
In addition, there is a large and growing body of research that indicates very clearly that relabeling human problems as mental illnesses actually increases the level of stigma associated with the behaviors in question. You can find a good summary of this research in Anne Cooke’s chapter “Problems associated with the use of the concept ‘mental illness’.” [In T. Stickley and T. Basset, eds., Learning About Mental Health Practice, pp. 329-346. Wiley: March 2008]. There is also a comprehensive study review by Angermeyer, M.C. et al “Biogenetic explanations and public acceptance of mental illness: systematic review of population studies.” They concluded that “…biogenetic causal belief or interventions are negatively associated with expectations of recovery and good prognosis,” and that “… there seems to be a danger that biogenetic illness concepts increase rather than decrease public stigma of mental illness.”
Dr. Pies is also choosing to ignore the growing and well-publicized commentary from psychiatric survivors who point out clearly and graphically how they were stigmatized and dehumanized by psychiatric “diagnoses.”
PSYCHIATRIC ‘DIAGNOSES’ vs. REAL DIAGNOSES
Dr. Pies mentions the fact that his opponents often criticize psychiatric diagnoses on the grounds that they are not based on the kind of objective criteria (e.g. blood tests) that are used in general medicine. He counters this by saying, ” But in truth, numerous medical and neurological diagnoses, such as migraine headache, are based on the same type of data that psychiatrists use: the patient’s history, symptoms and observed behaviors.”
This is spin of a very high order. It is indeed the case that those of us on this side of the argument do indeed compare psychiatric “diagnoses” negatively with real medical diagnoses. And it is true that the lack of objective tests is frequently mentioned in this context. But the fundamental source of our criticisms is that while general medical diagnoses constitute genuine explanations of the symptoms, psychiatric explanations are nothing more than a shorthand label for the “symptoms,” and a not very reliable label at that (as the DSM-5 field trials clearly revealed)
For example, if you’re very tired, and coughing up lots of awful-looking phlegm and go to your doctor, he will examine you, ask some questions, and send some phlegm to the lab. Then he comes back and tells you that you’ve got pneumonia (assuming that that is what he’s found), and he’s going to start you on an antibiotic and admit you to the hospital for a couple of days. Essentially what the doctor has done is provided you an explanation of the symptoms and a treatment plan. But imagine if instead he had said: “You’ve got an illness called phlegmy cough. I’m prescribing a cough suppressant.” This latter is a precise analogy for psychiatric “diagnosis” and “treatment.”
At this point Dr. Pies delivers another masterly stroke: “I believe that psychiatric diagnoses are castigated largely because society fears, misunderstands and often reviles mental illness.” So, psychiatric “diagnoses” are taking a bad rap – not because they’re spurious, destructive and stigmatizing – but because “society fears, misunderstands and reviles mental illness.” In other words, the diagnoses get beaten up because of societal prejudice against the “mentally ill.” But earlier he had said that it is our attacks on the diagnoses that cause the societal prejudice.
If you find these positions contradictory, you would be correct. But you would also be missing the point. This is pure spin. The facts are irrelevant. Dr. Pies’ objective is to deflect criticism from psychiatric diagnoses. In the first statement he does this by attacking his critics. In the second he achieves a similar effect by portraying these “diagnoses” – and by extension psychiatry – as innocent victims of bigotry and prejudice.
In his summary and rebuttal, Dr. Pies continues the spin in essentially the same vein. But this article is already too long. Perhaps I will manage to pick up the rebuttal at a later date.
The real problem with all this, of course, is that the mainstream media buy the spin, and continue to promote the spurious mental illness philosophy as scientific reality. Progress has been made, of course, but ultimately we need to become more effective in challenging spin, and in presenting our message to the media, the politicians, and the general public.
By the way, as far as I can ascertain, Dr. Pies takes no money from pharma. Perhaps he just believes his own spin.