Tuesday, December 15, 2009

Is Psychiatry Now a “House Divided”?

Hired guns.” “Whores.” “Greedy, insensitive bastards. “ These are some of the more printable epithets used to describe psychiatric physicians who (allegedly) have “sold out to Big Pharma” ”—for example, by failing to disclose conflicts of interest, or to report large sums of money earned through their work with pharmaceutical companies. It may surprise some—but perhaps not many—that these terms of abuse were hurled not by members of some anti-psychiatry group, but by psychiatrists, writing on a well-known “watchdog” blog site. To be clear: I have no wish to excuse or rationalize the actions of some in our field who indeed have abused the public trust by engaging in any of the actions described. Anger—even outrage—is appropriate and healthy, with respect to their behavior. But must we also demonize these individuals, some of whom (notwithstanding their transgressions) have made important contributions to clinical care and scientific research?

The late Dr Albert Ellis—the psychologist who originated Rational Emotive Behavioral Therapy—always insisted that we distinguish between a person’s behavior, and the individual’s value as a human being. Writing in their classic 1961 book, A Guide to Rational Living, Ellis and his colleague, Robert Harper argued that, “…A person’s (good or bad) acts are the results of his being, but they are never that being itself.” (Ellis and Harper, 1961 p. 104, italics added).

We often tell our patients they should not condemn the totality of their being on the basis of a selfish or hurtful act they have committed—yet some of us seem all too ready to condemn a colleague in the most sweeping and dehumanizing terms, because he or she is guilty (or is believed guilty) of one or more ethical lapses. By all means, let us condemn the transgressions! But let’s also retain a scintilla of human sympathy and understanding for the flawed human beings who committed them.

The problem of “demonizing rhetoric” is obviously not confined to the field of psychiatry, where it seems to be the effluvium of a few particularly bilious individuals. The language of demonization is all too prevalent in the narratives of many political and religious groups, who attack their opponents as infidels, heretics, traitors, or even worse. Carried to an extreme, we find terms like “vermin” applied to ethnic or religious groups who are the objects of hatred or persecution—the Nazis were infamous in their use of this term. Yes, I know—there is a difference between calling someone a “drug company whore” and reducing the person to the status of vermin. But the distance between the terms is not as wide as some would persuade themselves. And when one moves from the psychiatry blog sites to the rabid anti-psychiatry websites (eg, http://outlawpsychiatry.blogspot.com/), one sees in no uncertain terms how easily an unflattering epithet can morph into a dehumanizing slur.

The divisions within psychiatry extend far beyond concerns over “conflicts of interest” and “Big Pharma”—where there are, at least, valid ethical issues to be raised. Unfortunately, the profession continues to be mired in the same fruitless arguments over “biology” versus “psychology” that anthropologist Tanya Luhrmann documented in her classic investigation, Of Two Minds: The Growing Disorder in American Psychiatry (2000). And, all too often, one hears proponents of the “biomedical” model disparaging advocates of the “psychodynamic” model—or vice verse. This sterile debate persists, despite the heroic efforts of “pluralistic unifiers”, such as my colleagues Nassir Ghaemi, Godehard Oepen, Glen Gabbard, Michael A. Schwartz, and Cynthia Geppert. These clinician-scholars have refused to buy into the Manichean world of the “splitters”; rather, they embrace a scientific-humanistic perspective that comprehends both molecules and motives. This broad-based, pluralistic model was the one I imbibed during my residency at Upstate Medical University, where a fledgling resident could —as my teachers, Robert Daly and Eugene Kaplan might put it—“do theology in the morning and biology in the afternoon.” Oh, yes—and engage in heated but respectful debate with gadfly Tom Szasz, during lunch!

Psychiatry as a profession faces many challenges, and no small number of genuine threats. From excessive involvement with “Big Pharma” to the diminished role of psychotherapy; from managed care’s fifteen minute “med checks” to controversies over DSM-V, psychiatry understandably feels besieged, these days. No doubt, we have contributed to many of these problems through our own missteps or inaction. Yet, for all its flaws, psychiatry remains the most comprehensive and humanistic of the medical specialties— and has a great deal to offer the suffering individuals who seek our help. In 1858, Abraham Lincoln—addressing the issue of slavery-- warned the nation that, “A house divided against itself cannot stand.” It would be a genuine tragedy if psychiatry becomes “a house divided” by the rancor of its own rhetoric.

Ronald Pies, MD

"Every kingdom divided against itself is brought to desolation; and every city or house divided against itself shall not stand."-- Matthew 12:25
“Judge the whole of the person charitably.”—Talmud (Pirke Avot, 1:6)

1 comment:

  1. The "division" should be not viewed so much as a divide as a continuum. Much like the traditional medical community wrestles with a "divide" between wellness and medication there is room for both strategies. As a person diagnosed with type 2 diabetes, I was started on a medication therapy, but also engaged in diet and exercise therapy. The blood sugar levels retreated to a level that were in the "normal" range and I discontinued the medication. That is not to say that choice is permenent or appropriate in all cases, but was indicated by the results of the theraputic choices.

    The problem is being committed to a single strategy that "works for everyone" and is "clearly better" is a pipe dream. The mantra of evidence based practice should be to identify effective treatments overall, not to choose one to the exclusion of another. Rather than choosing a single strategy, evidence should be used to guide choices for appropriate situations to use theraputic methods. Unfortunately, economic justification is more an incentive in some research than is advancement of knowledge.

    There are more benefits to creating a body of knowledge of effective therapies than there is a need to identify one therapy as superior. Taken in that context, there should not be a divided house and psychiatry would not represent itself as at odds with itself, rather it can represent itself as looking for better answers wherever they might be found.

    Don Moore