Psychiatry is Alive and… Well, It’s Complicated

Is psychiatry as we know it “dead”? [1] Not on your life! But if you believe some of the doleful pronouncements in the blogosphere, you might as well be hanging crepe for our profession.

Yes, we need to address some significant problems within and outside our discipline, as is true of most medical specialties. But to paraphrase Mark Twain, reports of psychiatry’s death have been greatly exaggerated.

That’s not to deny that psychiatry has faced some serious challenges and setbacks in the past few years. Nor is it to paper over the problems that beset our field, including but not limited to improving our still evolving diagnostic system [2]. But I believe psychiatry has the will and the ability not just to survive, but to thrive, amidst the current crises. And one encouraging sign is the recent uptick in senior medical students choosing to enter psychiatry [3]—more on this anon.

Before pursuing the underlying issues further, we need to consider a bit of punctilious punctuation. There is a myth circulating in the blogosphere—usually among the most extreme critics of our profession—that there exists some monolithic entity called “Psychiatry” (with a capital “P”).

This critical narrative usually depicts “Psychiatry” as an undifferentiated conglomerate of moneyed interests and murky science, corrupted by Big Pharma and interested only in the authoritarian exercise of power.

I’m not referring to responsible critics who want to reform psychiatry [4]. I’m talking about polemical rhetoric aimed at marginalizing and delegitimizing more than 45,000 psychiatrists in the U.S.–the overwhelming majority of whom are decent, compassionate healers who must cope every day with the immense suffering of patients afflicted with psychiatric illnesses.

There’s nothing wrong with writing books or blogs about prominent psychiatrists who, in fact, have been unduly influenced by Big Pharma. After all, we need to be alert to financial and ethical conflicts of interest [ 5 ].

But I suspect it would be much harder to write a best-seller about the thousands of work-a-day psychiatrists who get up every morning and listen to the Iraq war veteran who suffers from post-traumatic flashbacks; the grieving mother whose drug-addicted son died from a heroin overdose; the patient with Alzheimer’s who no longer recognizes his wife; or the college student with schizophrenia who says that “the Devil’s voice” is telling him to jump out a window.
Unfortunately, books about kindness, dedication and patience are a hard-sell to publishers these days. Yet these are the qualities that I have witnessed in my teachers, students and colleagues, over the past 33 years.

And, yes—often it was my patients who were most inspiring, and from whom I learned the deep lessons of courage. They did not consider themselves “psychiatric survivors” in the perverse sense anti-psychiatry groups like to promote; rather, my patients understood that they had survived devastating illnesses–no less real or debilitating than heart disease or cancer.

And, like oncology patients, they reluctantly accepted some significant side effects of their medication, knowing that the benefits of treatment outweighed the risks.

Diversified Profession

There is another sense in which capital “P” Psychiatry is misleading. Our profession is incredibly diversified. You might be a geriatric psychiatrist consulting to a nursing home—or an existential psychiatrist examining mortality and meaninglessness.

You might specialize in psychopharmacology or provide classical psychoanalysis. (Yes, yes–we always hear that psychiatrists have “stopped doing psychotherapy”—yet a 2008 study showed that almost 60% of psychiatrists were providing psychotherapy to at least some of their patients [ 6 ]). As psychiatrist Leigh Jennings recently noted:

“Psychiatrists work in many diverse settings that include residential treatment centers for teens, jails and prisons, eating disorder treatment centers, and nursing homes. Forensic psychiatrists evaluate accused persons and function as expert witnesses in court. Community psychiatrists work with teams of case managers to provide mental health care for the homeless and underprivileged. Sleep doctors treat sleep disorders and run sleep labs. Psychosomatic (aka Consult/Liaison) psychiatrists see medical/surgical inpatients. Geriatric psychiatrists evaluate and treat late-life psychiatric syndromes. And researchers work for academic or private organizations creating and disseminating knowledge.” [7]

In short, “Psychiatry” as a single-minded, corporate entity is a caricature of our profession, and a creature of those who wish to disparage or abolish it.

Chemical Imbalance Theory

So, for example, the claim that “Psychiatry” as an institution deliberately foisted a simplistic “chemical imbalance theory” upon an unknowing public is mostly a lot of hooey [8; and see accompanying note], and those who foster this myth of victimization still don’t understand the difference between a hypothesis and a theory.

(The former might be likened to a single strand; the latter, to a tapestry).** It is nearer the truth to suggest that if you ask 45,000 American psychiatrists about “chemical imbalances” as a cause of mental illness, you will get 46,000 answers!

To be sure, neurobiological models and pharmacologic therapies have dominated our field in the past two decades–often for the good, but sometimes to the detriment of our deeper understanding of the patient [9].

Nevertheless, the “biopsychosocial” model pioneered by Drs. George Engel and John Romano [10] remains the predominant approach to psychiatric illness in major psychiatric training centers, such as the University of Rochester [ 11] and SUNY Upstate Medical University (my alma mater) [12].

Psychiatry is Alive and… Well, It’s Complicated

Ronald Pies, MD

Dr. Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor-in-Chief Emeritus of Psychiatric Times (2007-2010).


APA Reference
Pies, R. (2015). Psychiatry is Alive and… Well, It’s Complicated. Psych Central. Retrieved on February 17, 2020, from


Scientifically Reviewed
Last updated: 7 Jun 2015
Last reviewed: By John M. Grohol, Psy.D. on 7 Jun 2015
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