Since about the mid 1960’s, the great majority of psychiatrists have abandoned any form of psychosocial perspective, and have insisted that the various items listed in successive revisions of the DSM are “real illnesses”. The usual justification for this is based on the assertion that the “symptoms” of these items are caused by neurological malfunctions (e.g., chemical imbalances, neural circuitry aberrations, etc.). Although there is no evidence to support these claims, psychiatrists continue to promote them. I have written about these promotions (e.g., here, here, here, and here). Many other anti-psychiatry writers have also criticized these simplistic, unproven theories.
A small minority of psychiatrists, including some who formerly supported the infamously spurious chemical imbalance theory, seek to preserve the “real illness” deception by altering the definition of illness/disease. The defining features of illness/disease, they now tell us, are distress and/or impairment. And, since distress and/or impairment are written into the DSM criteria for each so-called mental disorder, it is clear, from the tenets of psychiatric logic, that every DSM catalog item is an illness/disease.
This, of course, is the very epitome of inanity, because, as everybody who lives in the real world knows, the essential definition of illness/disease is the presence of characteristic biological pathology. The problem for psychiatry, however, is that none of their “diagnoses”, with the exception of those clearly caused by general medical conditions (e.g. brain damage), have ever been linked definitively with a characteristic biological pathology. So they have only two options. They can come clean, and acknowledge that the entire disease notion was a hoax, which would be professional suicide, or they can double down by promoting the spurious distress plus impairment “definition” of illness.
One of the leading proponents of the distress/impairment deception is the illustrious Ronald Pies, MD, whose adherence to this nonsense is well documented in his various essays and books. As my regular readers are well aware, Dr. Pies is a talented and gifted thinker, and it has always seemed strange to me why a person of his great intellectual stature would embrace a notion that is so patently absurd, and so much at variance with ordinary well-established linguistic usage. Why is there this blind spot? Or to put the matter more precisely, if he wants to use this non-standard definition of illness/disease, why doesn’t he present it more honestly. For instance, he could write something like: major depression is an illness, not in the usual sense of having a characteristic biological pathology, but only in the peculiarly psychiatric sense of entailing distress and impairment. But of course that would give the game away to even the most stalwart of psychiatric supporters.
So, the mystery remains: why would a person of Dr. Pies’ great learning and scholarship embrace and promote such an obviously spurious and confusing notion?
THE MYSTERY IS RESOLVED
Well, recently I came across two papers that I think might shed some light on this paradox.
The first paper is a thoughtful article by Carl I. Cohen, MD, professor of geriatric psychiatry at the SUNY Health Center in Brooklyn. It was published in Psychiatric Services, January 2000, Vol 51, No. 1, and was titled Overcoming Social Amnesia: The Role for a Social Perspective in Psychiatric Research and Practice. Here’s the abstract:
“Psychiatry’s reliance on biological models has resulted increasingly in the social realm’s being dismissed or trivialized. The author examines the adverse consequences of this situation for psychiatric research and practice and suggests methods for addressing the problem. He describes how the social perspective has been extruded from discussions about the definition, future, and accomplishments of psychiatry, and he reviews four areas in which the biological model has produced unvalidated assumptions about the etiology, course, and prevention of mental disorders. The author shows how the social realm is intrinsic to concepts of mind and mental illness, and he describes seven ways in which a social perspective can provide a complement or a corrective to the prevailing assumptions of biological models, indicate new points of departure, and suggest methods for psychiatry’s expansion.” (p 72)
Here’s the final sentence of the article:
“Bringing the social back into research and practice in a serious way will make psychiatry more relevant and scientifically robust.” (p 77)
And here are two quotes from the body of the article:
“Diagnoses in psychiatry are starkly different from diagnoses in physical medicine…” (p 73)
“Biology does not necessarily have priority over social perspectives in explaining mental disorders.” (p 74)
Dr. Cohen’s article is interesting, cogent, and pertinent, but it is not anti-psychiatry. Rather, it is an exhortation to his psychiatric colleagues to inject a social perspective as a “complement or corrective to the prevailing assumptions of the biomedical model.” (p 77) Over the years various psychiatrists have proposed and promoted these kinds of correctives, but none has ever made the slightest dent in the pill-for-every-problem paradigm that has characterized almost all psychiatric activity for the past fifty years or so. Anyway, although it is twenty years old, Dr. Cohen’s article is worth a read.
What’s particularly interesting, however, is Dr. Pies’ reaction to Dr. Cohen’s paper. In the April 2000 issue of Psychiatric Services, Dr. Pies published a letter to the editor titled A Social Perspective in Research and Practice. (p 532) Here are Dr. Pies’ first two paragraphs:
“The thoughtful and important piece by Carl I. Cohen, M.D. (1), in the January 2000 issue articulates what many of us have urged for years: a broad-based biopsychosocial view of psychiatric illness. The author rightly emphasizes the social perspective as one that enriches and complements the biomedical model.
However, Dr. Cohen’s claim that ‘diagnoses in psychiatry are starkly different from diagnoses in physical medicine’ is just the sort of statement some health maintenance organizations will seize on in order to extrude psychiatry from the realm of general medicine and to discriminate against both psychiatric patients and their clinicians. Furthermore, despite Dr. Cohen’s evident distaste for Cartesian thinking, his statement erects a conceptual wall between psychiatric and physical illness, which is both a tactical and a philosophical error. Indeed, the difference between psychiatric diagnosis and diagnosis in other areas of medicine is far less stark than Dr. Cohen’s analysis suggests.”
In other words, stressing the differences between psychiatric “diagnoses” and the real diagnoses in general medicine could encourage some HMOs [Health Maintenance Organizations] to continue their efforts to deny reimbursements to psychiatry. Note that Dr. Pies describes stressing these differences as a tactical and a philosophical error. Clearly the tactical error consists of providing ammunition to the HMOs in their cost-cutting efforts.
And if I may offer a clarification of Dr. Pies’ language, discriminating “against both psychiatric patients and their clinicians” is psychiatric code for: refusing to reimburse us for the services we provide.
So the paradox is made clear. They’re in it for the money, and the ungrounded insistence that they are treating “real illnesses” is more a kind of battle cry to rally the troops than a statement of fact.
Psychiatrists desperately need to maintain the fiction that they are treating real illnesses in order to qualify for reimbursement from insurance companies for the dubious services that they provide.
Psychiatry’s need for “real illnesses” is essentially a financial matter, and only became critical when employers began to provide medical insurance to their workers in larger numbers during the 1950’s and 1960’s. Psychiatry simply couldn’t afford to miss out on this bonanza.
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THE SLIPPERY SLOPE GETS EVEN SLIPPERIER
In fairness to Dr. Pies, it should be noted that he is not the only psychiatrist to stress the importance of tactical considerations in these areas.
Here’s a quote from a March 2014 article, written by Joseph Pierre, MD, a prominent Los Angeles psychiatrist. The article is titled A Mad World, and was published by Aeon, a “digital magazine publishing some of the most profound and provocative thinking on the web.”
“The truth is that while psychiatric diagnosis is helpful in understanding what ails a patient and formulating a treatment plan, psychiatrists don’t waste a lot of time fretting over whether a patient can be neatly categorised in DSM, or even whether or not that patient truly has a mental disorder at all. A patient comes in with a complaint of suffering, and the clinician tries to relieve that suffering independent of such exacting distinctions. If anything, such details become most important for insurance billing, where clinicians might err on the side of making a diagnosis to obtain reimbursement for a patient who might not otherwise be able to receive care.” [Emphasis added]
Erring “on the side of making a diagnosis to obtain reimbursement for a patient who might not otherwise be able to receive care” is a crime. It is insurance fraud, and is punishable by large fines and long prison sentences. It is also worth pointing out that Dr. Pierre implies that many, perhaps most, psychiatrists engage in this kind of criminal activity.
“…psychiatrists don’t waste a lot of time fretting over whether a patient can be neatly categorised in DSM, or even whether or not that patient truly has a mental disorder at all.” [Emphasis added]
If Dr. Pierre’s assertions are correct, then the entire DSM system is a fraudulent charade: window dressing to persuade the insurance companies to pay psychiatrists for their “skilful” diagnosing and for the vital pills and electric shocks that they prescribe for their hapless clients.
Dr. Pierre mispresents this criminal activity as a favor that he (and other psychiatrists) afford their customers. But in fact, since the reimbursements come to the psychiatrists, it is they who benefit from the fraud. The customer is merely the dupe who agrees to a disempowering and stigmatizing “diagnosis” and “treatment”, for the financial benefit of the psychiatrist. And when we recall that Aeon is an e-zine aimed at the general public, it is clear that Dr. Pierre is broadcasting this fraudulent scheme to a wide readership. His essential message to Aeon’s readers is that if they are experiencing an ill-defined measure of “suffering”, they can consult a psychiatrist and receive psychiatric “treatment” at their HMO’s expense even if they don’t meet the criteria specified in their insurance contracts.
And to reinforce his message, Dr. Pierre continues:
“Ultimately, availability of medications that enhance brain function or make us feel better than normal will be driven by consumer demand, not the Machiavellian plans of psychiatrists. The legal use of drugs to alter our moods is already nearly ubiquitous. We take Ritalin, modafinil (Provigil), or just our daily cup of caffeine to help us focus, stay awake, and make that deadline at work; then we reach for our diazepam (Valium), alcohol, or marijuana to unwind at the end of the day. If a kind of anabolic steroid for the brain were created, say a pill that could increase IQ by an average of 10 points with a minimum of side effects, is there any question that the public would clamour for it? Cosmetic psychiatry is a very real prospect for the future, with myriad moral and ethical implications involved.”
The message here is perfectly clear: because consumers have been demanding, and continue to demand, psychiatric drugs for “cosmetic” purposes, psychiatrists will continue to provide them at the insurance companies’ expense, and won’t be overly conscientious as to whether the consumer meets the criteria for a “diagnosis of mental disorder.” How is this different from street corner drug dealing, other than being more expensive?
Those of us in the anti-psychiatry movement won’t be too surprised by these revelations. Psychiatrists, however, are usually a good deal more circumspect concerning their true motivations, and it is unusual for them to fly their colors quite so openly.
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It’s a hoax, folks, and a profitable hoax at that. And the deception that mental disorders are “real illnesses” is the very center of the hoax. Psychiatrists embrace and promote the hoax for the increased earnings and for the prestige that it affords them. They promote their pills as safe and effective, while downplaying the adverse effects, including akathisia, suicide, aggression, etc. And the DSM, which was supposed to make their “diagnoses” more valid and reliable, is now nothing more than an “exacting distinction”, to be dispensed with at the psychiatrist’s discretion.
And Dr. Pierre, while not as illustrious and scholarly as the venerable Dr. Pies, is no slouch. Here’s a list of his positions and achievements from his UCLA healthsciences database biography:
- Acting Chief of Community Care Systems at the VA West Los Angeles Healthcare Center
- Health Sciences Clinical Professor in the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA.
- Extensive clinical experience working with individuals with psychotic disorders, substance abuse, and those with “dual diagnosis.”
- Considerable experience as a clinical researcher, participating as a primary investigator and collaborator for clinical trials in schizophrenia and early intervention for young persons at high risk for psychosis.
- In 2005, he received Young Investigator Awards from both the International Congress of Schizophrenia Research and the American College of Neuropsychopharmacology.
- Has authored over 100 papers, abstracts, and book chapters related to schizophrenia, antipsychotic medications, substance-induced psychosis, delusions and delusion-like beliefs, auditory hallucinations and voice-hearing, and a variety of other topics including the neuroscience of free will and culturally sanctioned suicide.
- Writes the Psych Unseen blog at Psychology Today
- Has presented research findings and lectured to audiences both nationally and internationally and has served as an expert witness consultant in forensic/legal cases involving schizophrenia, the intersection of psychosis and religion, delusion-like beliefs and conspiracy theories, and the side effects of antipsychotic therapy.
- Is highly involved in resident and medical student education and has received several awards for excellence in teaching including the 2012 UCLA NPI Housestaff Teaching Award.
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Psychiatry, whatever it might or might not have been in the past, is now little more than a parody of real medicine. It invents its “diagnoses”, works hand-in-glove with pharma in the promotion of its products, and has even engaged the services of a PR firm to improve its image. But one can’t make a silk purse from a sow’s ear. It’s still a hoax.