A Look into a Clinician’s Perspective on Psychiatry

Dr. Wilner:
Welcome to Book Club on ReachMD.  I’m your host, Dr. Andrew Wilner.  And joining me to talk about his recent book, titled Psychiatry at the Crossroads: Can Psychiatry Find the Path to a Truly Humanistic Science? is Dr. Ronald Pies.  Dr. Pies is Professor Emeritus of Psychiatry at State University of New York Upstate Medical University and a Clinical Professor of Psychiatry at Tufts University School of Medicine. 

Dr. Pies, welcome to the program. 

Dr. Pies:
Thanks very much, Dr. Wilner.  It’s a pleasure. 

Dr. Wilner:
To get started, Dr. Pies, I’ve been reading your book, and I appreciate the clarity of thought.  I’ve even had to look up a few words.  Please tell us what inspired you to write this book. 

Dr. Pies:
Well, Andrew, I’ve been writing for Psychiatric Times since 1985, which was the first year that the paper was published.  I published a book in 2014, called Psychiatry on the Edge, which was a collection of my columns up to that point, and about a year ago, as I moved closer to full retirement from psychiatry, I decided I wanted to leave the field with a legacy, and so this latest book puts nearly all my recent columns together in one volume, so it’s a sequel to the first book.  I chose the image of the crossroads because I believe that psychiatry has some very critical and defining decisions to make in the coming years.  Specifically, does psychiatry want to become almost exclusively focused on biology and medication?  Or do we want psychiatry to become what I think it was always meant to be, which is a holistic biopsychosocial medical discipline? 

Dr. Wilner:
Okay.  So that certainly is one of my questions, and I think what you’re talking about, there’s sort of two extremes.  One is when I think of a psychiatrist, you can’t help but think of Sigmund Freud and a young patient typically lying on his couch.  And then the alternative is where the psychiatrist sees patients with depression or something, and they come in for a refill, and it’s, “How are you doing?”   “Oh, I’m still depressed.”   “Okay, we’ll up your dose.  See you in a month or two months,” and there’s really not much attention to the patient’s holistic view with all of the things that you focus on in a psychiatric history.  Is that what you’re talking about, these two extremes? 

Dr. Pies:
Yes, it is, although, I think that there are still many psychiatrists who really integrate psychotherapy into their pharmacological practice and manage to integrate medication with psychotherapy, though I will say that the percentage of psychiatrists who do psychotherapy has declined in the last 15, 20 years, unfortunately.  I think that’s mostly due to market forces, not because psychiatrists are less interested in psychotherapy at all. 

Dr. Wilner:
Okay.  So barring market forces, which of course, change and are somewhat arbitrary, what should the psychiatrist of tomorrow be doing in your view? 

Dr. Pies:
In terms of training, I think psychiatric residency needs to provide a very solid foundation in general medicine and neurology.  The resident needs to be deeply schooled in medical psychiatric differential diagnosis.  Just to give you one example, the presentation of psychosis in schizophrenia versus the psychosis due to antibodies directed against the NMDA receptor versus psychosis due to substance abuse—the residency needs to prepare the young psychiatrist to be able to distinguish these diagnoses—but I think training should also provide a very strong foundation in psychosocial treatments, including the various types of psychotherapy, cognitive behavioral, psychodynamic, and so on.  And I think that area has been somewhat neglected in recent years in some residency programs, though not the one that I was in where psychotherapy was very heavily emphasized, State University of New York Syracuse.  What I would like to see in the best of all possible worlds is also some exposure to areas like religion, spirituality, literature, and culture to produce a Renaissance psychiatrist, but I realize that unless we expand to a five-year residency program, it’s very hard to include all of those things. 

Dr. Wilner:
Now in your book you talked about a concept of the psychiatries versus psychiatry, so what do you mean by the psychiatries? 

Dr. Pies:
Right.  Good question.  Many people talk about psychiatry as if it’s this monolithic entity like one of these dolmens that you see, these upright stones sitting at Stonehenge.  Psychiatry is not a monolithic entity.  It’s really more like a collection of subspecialties.  For example, forensic psychiatry, psychopharmacology, geriatric psychiatry, pediatric psychiatry, addiction psychiatry, and social psychiatry.  And some psychiatrists are engaged more or less in biochemical molecular biological research, whereas others are doing existential psychotherapy, so it’s not one thing.  And whenever you hear people making generalizations about Psychiatry with a capital P, you should be very skeptical and ask them which of the psychiatries are they referring to. 

Dr. Wilner:
For those just tuning in, you’re listening to Book Club on ReachMD.  I’m Dr. Andrew Wilner, and I’m speaking with Dr. Ronald Pies about his new book, titled Psychiatry at the Crossroads: Can Psychiatry Find the Path to a Truly Humanistic Science? 

Dr. Pies, in the introduction to your book, you mention that psychiatry can take one of two very different paths in the future.  I want you to elaborate a little bit.  Which path are we on, or which path should we be on in your view? 

Dr. Pies:
Well, as you probably know, in the ‘80s and ‘90s there was all this frenzied excitement about the biological revolution in psychiatry, and there were all kinds of hopes—some of them well-founded, others not— that we were going to find the schizococcus, the bug that causes schizophrenia, and this was going to be a great revolution.  And indeed, I mean, we did learn a lot about the biology of psychiatric illness, but I think, unfortunately, the turn to the biological led to an excessive focus on biological factors and an excessive focus on medication sometimes to the exclusion of psychosocial risk factors, psychosocial precipitants, and causes for the patient’s disorder.  And as I said earlier, some of that has been driven by market forces.  It’s much less expensive to farm out psychotherapy to, for example, a psychiatric social worker, and restrict the psychiatrist to these 15-minute med checks, which is a terrible thing to do, and I think that the field really needs to find its way at these crossroads. 

What is it going to be?  Is it going to be, as you were alluding to earlier, dispensing pills, or is it going to be a biopsychosocial discipline that looks at motives as well as molecules?  So to speak.  And that is the central question that my book tries to answer.  And of course, I want the answer to be that we’re going to move on the right road toward a holistic biopsychosocial discipline. 

Dr. Wilner:
Dr. Pies, that’s great to hear.  Now before we close, are there any other thoughts you’d like to leave with the audience today? 

Dr. Pies:
I would just say that there’s a lot of misunderstanding about psychiatry in the general public.  Some people bandy about this notion of the chemical imbalance and think that that’s what psychiatrists believe in and that was mostly a slogan generated by pharmaceutical companies in their direct-to-consumer advertising.  Psychiatrists really want to approach the person’s problems from a holistic standpoint, and if you find the right psychiatrist, he or she will address the psychological issues, the social issues, and the environmental issues that you’re dealing with, as well as the medical and pharmacological issues.  So I’m hoping that people will give psychiatric treatment a fair hearing and a fair chance.  It can be very helpful. 

Dr. Wilner:
Wonderful.  This has been an insightful look into the field of psychiatry and a great discussion on your new book.  I’d like to thank my guest, Dr. Ronald Pies, for sharing his thoughts. 

Dr. Pies, it was a pleasure speaking with you today. 

Dr. Pies:
Thank you very much, Dr. Wilner.  It’s been a pleasure. 

Dr. Wilner:
For ReachMD, I’m Dr. Andrew Wilner.  To access this and other episodes in our series, visit ReachMD.com/BookClub where you can Be Part of the Knowledge.  Thanks for listening.