Psychiatrists Aren't Crazy

August 30, 2011

Ronald Pies, MD, on why he feels psychiatry is one of the most exciting and promising medical specialties.

Psychiatrists are crazy. Or psychiatrists are brilliant. Or, psychiatrists are brilliant but crazy. Or, they are well-meaning bumblers who aren't "real doctors" - just psychologists with "MD" after their name. Or, well, you get the picture.

As a third-year medical student, I had heard all the stereotypes and canards, as well as most of the really bad psychiatrist jokes. There was a feeling in my medical school class that those of us contemplating a career in psychiatry were either the best and brightest, or the worst and craziest. In the hallways, some of our professors hinted at these extreme views, and some implied that anyone going into psychiatry would be wasting a good medical education.

Fortunately, I didn't listen to the naysayers. And, equally fortunate, I had some outstanding role models who convinced me that psychiatry was one of the most exciting and promising of the medical specialties. This belief was vindicated some 25 years later, when psychiatrist Eric Kandel won the 2000 Nobel Prize in Medicine (along with Arvid Carlsson and Paul Greengard) for his work in signal transduction in the nervous system.

During my college years at Cornell, I kept one foot in the sciences and the other in the humanities - majoring in neurobiology, with a minor in English. I also took several philosophy courses, including one on the philosophy of mind. One of my most beloved professors, M.H. Abrams, was not only one of the foremost literary scholars in the country, but also someone who had worked in the sciences. During World War II, Abrams had spent time in the Psycho-Acoustics Laboratory at Harvard. He had a healthy respect for science, and felt that it had applications even in the interpretation of literature. I remember one class in which I analyzed a poem in terms of a sequence of chemical reactions, expecting that Professor Abrams would find my analysis foolish. Instead, he liked my interpretation and encouraged me to apply my science background to the study of literature.

As a second-year student at Upstate Medical University, I had seriously contemplated going into internal medicine. I was intrigued by the mysteries of the ailing body and the subtle art of differential diagnosis. But I also yearned for something more - some field in which I could bring my interest in literature, language, and philosophy to bear on my work with patients. Again, I had good fortune in my teachers. One of our lecturers in my behavioral sciences course embodied this multi-disciplinary understanding of the human person. Gene Kaplan, a professor in the psychiatry department, seemed as comfortable with molecules as with motives. Mind and body were not separate realms, he taught us, but a single territory, susceptible to many kinds of exploration. Or, as Bob Daly, one of my mentors during residency would later put it, "With psychiatry, you can do biology in the morning and theology in the afternoon!"

During my clinical rotation in psychiatry, I was exposed to the broad spectrum of psychopathology - from panic disorder to schizophrenia. Once again, my teachers and clinical supervisors refused to Balkanize the human person into "mental" and "physical." I learned that many patients with apparent psychiatric symptoms are actually suffering from undetected neurological or endocrine disorders. I learned that major depression may respond to psychotherapy, medication, or both - and that in order to do the everyday work of psychiatry, I needed to understand the patient's inner world as much as his internal organs.

I also came to appreciate the stigma attached to mental illness - a burden of shame marking not only those who suffer with mental illness, but also those who treat it. The popular media of the day typically portrayed psychiatric patients as violent psychopaths or exotic multiple personalities. Their would-be healers were often depicted as mentally disturbed, abusive, or simply incompetent. The movie "One Flew Over the Cuckoo's Nest" had come out only a couple of years earlier, and the popular imagination was still roiling with images of Jack Nicholson's character being turned into a zombie after receiving "electroshock therapy." (To this day, many patients refuse potentially life-saving electroconvulsive therapy (ECT) because they remember "what it did to Jack Nicholson.")

Instead of discouraging me from entering psychiatry residency, these misperceptions only galvanized my determination. The compassion and humanity I saw in my teachers was nothing like the popular image of psychiatrists and psychiatry. And, in the mid-70s, there was a fresh wind blowing across the field - one that shifted the course of psychiatry in a dramatic fashion. The heyday of psychoanalysis was drawing to a close. The "biological revolution" in psychiatry was still in its infancy - Joseph Schildkraut's catecholamine hypothesis of mood disorders was only a decade old - but already, the field was abuzz with excitement. Perhaps, with the right understanding of brain chemistry, we could reverse the ravages of major depression, bipolar disorder, and schizophrenia. Perhaps, with the newly developed imaging technique known as computerized axial tomography, we would find a window into the mind, as well as the brain. Ultimately, of course, the biological revolution in psychiatry - like most revolutions - would prove to be a mixed blessing: medications we first thought miraculous have fallen short, and technology has still not pierced the mystery of the major mental illnesses. But in 1975, the new biology shone as a beacon of hope and promise.

Finally, I can't recount my choice of psychiatry as a profession without mentioning the influence of my late mother, Frances Pies Oliver. My mother was a psychiatric social worker, long before it became commonplace for women to work professionally, outside the home. As a teenager growing up in a small town in western New York, I would hear my mother's descriptions of a form of psychotherapy no less revolutionary than Freud's psychoanalysis: a technique called Rational Emotive Therapy, developed by the psychologist, Dr. Albert Ellis. Rather than probing the id for dark, oedipal currents, RET emphasized the "here and now." Ellis believed that most emotional problems arose not from unresolved, unconscious conflicts, but from irrational ideas - self-defeating nonsense that we use to beat ourselves over the head!

I think my love of philosophy was a natural "match" with RET, and I retained my interest in this technique throughout medical school and residency - indeed, even to the present day. I know that on some level, my mother's passion for understanding emotional problems was a critical factor in my decision to become a psychiatrist. Happily, she lived long enough to see me enter the profession - a decision I have never regretted, even in the tense and turbulent times we now face as physicians.

Ronald Pies, MD, is professor of psychiatry at SUNY Upstate Medical University, Syracuse, NY, and clinical professor of psychiatry at Tufts University School of Medicine. He is Editor in Chief Emeritus of Psychiatric Times, and the author, most recently, of "Becoming a Mensch" (Hamilton Books).

This article originally appeared online, September 2011, on PhysiciansPractice.com.