Daniel Morehead, MD

A frequent criticism of psychiatry is that psychiatrists do not learn, practice, or value 

. Even critics within the field routinely complain that psychiatry has “lost its mind,”

 while outside critics frequently portray “toxic” biological psychiatrists in competition with with humane psychotherapists from other disciplines.

 The psychiatrist, as the story goes, is interested only in diagnosing and medicating the patient—not in understanding, supporting, or working psychotherapeutically with him or her. This story, widely reported as fact in the media,

 is an outdated and harmful myth—one that discounts the realities of psychiatric training, the complexity of the psychiatric treatment relationship, and the resurgence of interest in psychotherapy among psychiatry residents.

In the mid-20th century, psychotherapy was the treatment of choice for most mental disorders. Even after the development of the first effective 

 in the 1950s and 60s, psychotherapy remained the mainstay of psychiatric treatment, especially in the psychoanalytically dominated United States. By the late 1980s, however, the field had shifted in a biological direction. The development of selective serotonin reuptake inhibitor (SSRI) antidepressants, in particular, led to great excitement in the promise of biological investigation and treatment. Nevertheless, psychotherapy continues to be practiced by psychiatrists, with some psychiatrists devoting the entirety of their academic and clinical careers to the study and practice of psychotherapy.

The idea that psychiatry is currently divorced from psychotherapy is, in fact, divorced from reality. Here are 4 fundamental examples of the union between psychiatry and psychotherapy:

1. Psychiatry residents receive significant formal instruction in psychotherapy.

One of us (DM) is director of residency training at a psychiatry department in the northeast, and the other (MR) teaches in that program and also serves as codirector of the psychotherapy track for a psychiatry residency program in Florida. As such, we have direct knowledge of the quality and extent of training psychiatry residents receive in psychotherapy. By contrast, most critics of psychiatry do not teach in psychiatry departments and have little to no firsthand knowledge of psychiatric residency curriculum.

Training in supportive, psychodynamic, and cognitive-behavioral psychotherapy is nationally mandated for all psychiatry residents.

 Residents must also learn to integrate psychotherapy with 

 and spend a substantial amount of time practicing psychotherapy during their outpatient training. They attend several year-long didactic courses in psychotherapy and are individually assigned psychotherapy supervisors (many of whom are psychiatrists themselves). Didactic instruction typically covers a range of psychotherapy topics, such as case clinical formulation, transference, countertransference, and psychotherapeutic technique. Clinically, residents see patients for both short-term and longer-term psychotherapy treatments.

Approximately 1 quarter of psychiatry residencies also offer specific psychotherapy tracks for residents with particular interest in psychotherapy and for those who plan to pursue additional training in specific psychotherapies (eg, psychoanalytic training) postresidency.

 Many individuals, even mental health professionals, assume psychotherapy training is weaker for psychiatry than for other mental health disciples such as psychology and social work. Yet a national survey conducted in 2006 showed that psychiatry compared favorably to other disciplines for evidence-based forms of therapy training.

 Thus, the claim that psychiatrists do not learn psychotherapy is false.

2. Psychotherapy is a part of almost all clinical interactions.

While it is true that most psychiatrists nowadays do not offer traditional 45- or 60-minute psychotherapy appointments to all their patients,

 psychotherapy continues to be practiced in some form by most psychiatrists. From a psychodynamic perspective, every interaction between doctor and patient, even in the hospital setting, is an opportunity to relate to the patient psychotherapeutically. Sudak and Taormina

 have described the integration of cognitive-behavioral therapy into “medication management” visits, and Iannitelli and colleagues

 have recently discussed the application of psychodynamic principles during psychopharmacological treatment.

Undoubtedly, most psychiatrists engage in some supportive 

 during brief visits, even if they do not formally label or bill it as such. Moreover, Tadmon and Olfson

 found that 47% of psychiatrists continue to offer 45- to 60-minute psychotherapy sessions. Thus, claims that psychotherapy has simply disappeared from psychiatric practice are false.

3. In the past decade, there has been a resurgence of interest in psychotherapy and psychosocial approaches among psychiatry residents.

A 2012 survey of residents reported that 82% of them consider “psychotherapy to be integral to their identity as psychiatrists.”

 Another survey showed that residents want more psychotherapy training rather than less.

 Our experience matches the results of such research. In fact, we have observed an increasing number of psychiatry residents interested in learning and practicing psychotherapy during the past decade.

In recent years, psychiatry has become a popular and competitive specialty choice among medical students, who describe their interest in learning the art of engaging deeply with suffering patients and combining psychosocial treatments with biological interventions. Many residents are particularly eager to learn psychotherapy methods and rightfully view psychotherapy as a core, foundational skill in the practice of clinical psychiatry. Meanwhile, some professional organizations are specifically devoted to the advancement of psychotherapy training within psychiatry, such as the American Academy of Psychodynamic Psychiatry and Psychoanalysis.

4. Many leading psychotherapy scholars are psychiatrists, and this has been the case for decades.

Some of the leading figures in American and global psychotherapy are psychiatrists, including Otto Kernberg, MD; Glen Gabbard, MD; and the recently deceased 

Aaron Beck, MD, father of cognitive-behavioral therapy.

 Several psychiatrists who are leading researchers in psychopharmacology have also undertaken research validating medical psychotherapy.

 Psychiatrists comprise a significant percentage of membership of the American Psychoanalytic Association. They are also frequent presenters at national psychotherapy conferences and contributors to psychotherapy journals. 

a leading journal of psychotherapy theory and practice, is a journal of the American Psychiatric Association. Thus, the psychiatric profession remains integral to psychotherapy development and research.

Psychotherapy continues to be a core aspect of psychiatrists’ training and identity. Psychotherapy training also continues to be a substantial and mandatory component of residency training for all psychiatrists. Contrary to popular assumptions, it is not critical that all psychiatrists practice traditional psychotherapy as part of their practice. No one becomes alarmed if all cardiologists do not practice cardiac catheterization, and no one should worry that “only” half of all psychiatrists currently offer traditional 45-minute psychotherapy sessions. But all psychiatrists should continue to support psychotherapy’s place in mental health treatment, and its place in the holistic, biopsychosocial treatment that psychiatrists routinely offer.

For decades, both critics and leading psychiatrists have worried that psychotherapy among psychiatrists will one day die out and be forgotten. Yet for decades, reports of its demise have been greatly exaggerated.

is instructor of psychiatry at the University of Central Florida College of Medicine in Orlando and adjunct instructor of psychiatry at Tufts University School of Medicine in Boston. He is a psychoanalytic psychotherapist in private practice in Tampa. He can be reached at 

is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is author of 

Science Over Stigma: Education and Advocacy for Mental Health, 

published by the American Psychiatric Association. He can be reached at 

Of Two Minds: An Anthropologist Looks at American Psychiatry. 

Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill. 

5. Harris G. Talk doesn’t pay, so psychiatry turns instead to drug therapy. 

https://www.nytimes.com/2011/03/06/health/policy/06doctors.html

6. ACGME program requirements for graduate medical education in psychiatry. 2021. Accessed May 4, 2022. 

https://www.acgme.org/specialties/psychiatry/program-requirements-and-faqs-and-applications/

Psychotherapy tracks in US general psychiatry residency programs: a proxy for trends in psychotherapy education?

8. Weissman MM, Verdeli H, Gameroff MJ, et al. 

National survey of psychotherapy training in psychiatry, psychology, and social work. 

Trends in outpatient psychotherapy provision by U.S. psychiatrists: 1996-2016. 

Integrate brief CBT interventions into medication management visits.

12. Iannitelli A, Parnanzone S, Pizziconi G, et al. 

Psychodynamically oriented psychopharmacotherapy: towards a necessary synthesis. 

13. Lanouette NM, Calabrese C, Sciolla AF, et al. 

Do psychiatry residents identify as psychotherapists? A multisite survey. 

Psychotherapy training: residents’ perceptions and experiences. 

Biological v. psychosocial treatments: a myth about pharmacotherapy v. psychotherapy. 

16. Miklowitz DJ, Efthimiou O, Furukawa TA, et al. 

Adjunctive psychotherapy for bipolar disorder: a systematic review and component network meta-analysis. 

Articles

Psychotherapy: A Core Psychiatric Treatment

Psychiatry as a medical discipline is a failure. Even worse, psychiatry constitutes a series of failures over its 2-century history. The 19th-century asylums movement failed. Kraepelin’s descriptive psychiatry failed at the turn of the century. The pluralistic psychiatry of Adolf Meyer failed, leading an 

 mentality up to and including lobotomies. The Freudian revolution ended in a “slow train wreck,”

 leaving psychiatry in embarrassing disrepute. And last of all, psychiatry’s so-called biological revolution fizzled out in failure, as drug companies abandoned a profession “in crisis.”

Just Because We Do Not Know Everything Does Not Mean We Do Not Know Anything

The DSM: Diagnostic Manual or Diabolical Manipulation?

Who says so? The writer of the most highly lauded and widely read history of psychiatry today, Professor Anne Harrington, PhD. The name of that history is 

 And as histories of medical specialties go, Harrington’s work is an undisputed home run. 

 and every major periodical in the country reviewed it favorably. Former National Institutes of Health Director Steven Hyman, MD, offered a back-cover blurb, and 

™ opined that “every psychiatrist should read it.”

Is the book really as negative as I have described? Yes and no. On one hand, Dr Harrington is a skillful writer who is clearly fluent in social and intellectual history. Reading this work was like diving into an extended 

 piece, such that “enthralling” is not an unfair description. And as the back cover tells us, Dr Harrington’s work is even-handed—at least on the surface. It is neither a polemic nor an exposé. Harrington takes a mostly agnostic approach to the controversies surrounding the field, speaking with a sort of sympathetic irony about psychiatry’s misadventures. And to her credit, she regularly empathizes with the perspective of patients and families, whether it is their suffering, their sense of mistreatment, or their sense of gratitude for successful treatment.

So, what is my beef with this universally lauded work? My problem is with its metanarrative, which is neither balanced nor accurate, whose misleading take-home message perpetuates a destructive picture of the state of our field. By giving our intelligentsia the impression that psychiatry is directionless and fundamentally inept, Dr Harrington inadvertently reinforces a cynicism about mental health treatment that is sadly out of date, and a despair about progress that undermines the hopes of individuals with mental illness and their families. In short, she reinforces the notion that psychiatry is particularly prone to corruption, “troubled,” and “in crisis,”

 a notion that continues to do damage to public mental health and public support of mental health treatment.

Does Dr Harrington really describe our history as a series of failures? Consider her own summary

“The 19th-century mental hospital has failed as a therapeutic institution? All right, forget about therapy, and focus on learning what you can from the brains of your patients… The anatomical research program has been a disappointment? No problem: Focus instead on… [Adolf Meyer’s pluralistic and pragmatic psychiatry. Does this lead to] more harm than good? That’s okay: The postwar world is in crisis and needs the insights provided by psychoanalysis and social science. Things haven’t worked out with the Freudians’ expansive social agenda? Psychiatry is on the brink of losing all credibility as a profession? Not to worry: Let the biologists take over!”

And the “false dawn” of the biological revolution? It has “now run into the sand as well,” leaving psychiatry shipwrecked and (you guessed it) “in crisis.”

Given this narrative, does our author truly believe that there has been no progress in psychiatry? In a 

™ interview, Dr Aftab put the question to her, suggesting that there has been a combination of progress 

 failed revolutions in psychiatry. In response, Dr Harrington doubled down on her narrative, stating that new generations of psychiatrists simply discard the lessons of the past. Even as new approaches uncover new truths, old truths and lessons are forgotten. Psychiatry remains locked in a barren cycle of becoming “more knowledgeable about some things and more ignorant about other things” through revolution after revolution.

In truth, Dr Harrington’s meta-narrative is demonstrably false. The asylum movement did not fail. It constituted a sustained advance over previous desperate and barbaric responses to severe mental illness, with a genuine effort to provide humane and helpful care. It declined only due to scandalous underfunding and the appearance of effective pharmacological agents. The neuroanatomical psychiatry that followed did not fail. Neuroanatomical research became a permanent and increasingly important aspect of psychiatric science, and it continues to progress along with the rest of 

Kraepelinian psychiatry—a longitudinal and symptomatic perspective on nosology—continues to be fundamental for psychiatric diagnosis and will remain so until neurobiological disease categories replace it. Psychodynamic (Freudian) psychiatry continues to thrive, along with numerous other scientifically validated psychological treatments (including 

 and dialectical behavior therapy). Indeed, psychotherapeutic approaches to mental illness are now better developed and tested than at any time in the history of psychiatry. Biological psychiatry did not die or even fade during the last decade. It continues to progress, as even a casual glance at any recent issue of a major psychiatric journal will show.

None of the lessons of the major schools of psychiatry have been abandoned. All these approaches have continued to advance and become parts of a larger whole. All psychiatry residents still receive extensive training in inpatient care (asylum psychiatry), neurobiology (anatomical psychiatry), 

 and diagnosis (Kraepelinian psychiatry), biopsychosocial treatment (Meyer’s psychobiology), 

 (Freudian psychiatry), and of course biological psychiatry. All of these are alive and well, so much so that Dr Harrington’s inability to acknowledge their survival and growth begins to appear perplexing, if not bizarre.

It does not take a great deal of reflection to recognize profound progress in psychiatry. Seventy-five years ago, there were no specific psychiatric medications, and the average stay in a psychiatric hospital was 11 years.

 Fifty years ago, psychotherapy was scientifically unproven while available medications were extremely difficult to tolerate. Regardless of psychiatry’s shortcomings, today is beyond a doubt the best time in human history for patients and families who face mental illness. If public intellectuals such as Dr Harrington are unwilling to say so, then we as psychiatrists should not be shy about setting the record straight. Failure to acknowledge psychiatry’s progress might be, after all, the most destructive failure of all.

 is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is author of 

Science Over Stigma: Education and Advocacy for Mental Health

, published by the American Psychiatric Association. He can be reached at 

The author wishes to thank Ronald W. Pies, MD, and Mark L. Ruffalo, DPsa, LCSW, for their review and comments on an earlier draft of this article.

Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness

The history and future of neurological care.

Psychiatry crisis is a chance to change tack.

4. McNally R. ‘Mind Fixers’ review: there has to be a better way.

https://www.wsj.com/articles/mind-fixers-review-there-has-to-be-a-better-way-11556898375

5. Aftab A. It’s time for us to stop being so defensive about criticisms of psychiatry. 

https://www.psychiatrictimes.com/view/its-time-for-us-to-stop-being-so-defensive-about-criticisms-of-psychiatry

The many histories of biological psychiatry: Anne Harrington, DPhil.

Long-range studies of mental hospital patients: an important area for research in chronic disease.

How does a recent critique of the history of psychiatry get it wrong? 

The History of Psychiatry—A History of Failure?

It is hard to overstate the torrents of criticism that have rained down upon the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). This poor, beleaguered document has been repeatedly and energetically attacked from all sides on a routine basis. It is not only the usual critics of psychiatry who have excoriated its approach—patients and family members, journalists, members of the academy, sociologists, psychologists, psychiatrists, National Institute of Mental Health (NIMH) directors, and even DSM task force chairs themselves have come down heavily against it on both general and specific grounds.

Every major periodical in this country has featured articles critical of the DSM, from 

 The flow of critical books and articles continues to this very day.

 The DSM has been, and remains, the centerpiece of contemporary critiques of psychiatry.

The juicy narrative behind it is simply too good to resist: The DSM is not a scientific document, it seems, but a cultural creation—a “work of fiction.”

 Psychiatrists do not behave like other doctors and diagnose biological illnesses on the basis of objective tests, because psychiatrists have never been able to discover the biology of mental illnesses. Instead, they get together in committees and simply make up diagnoses for their own self-interested reasons. The 2 biggest reasons are not hard to guess: money and power. Psychiatrists define more and more normal individuals as mentally ill so that they can make money by treating them, and exercise power and influence over a society dominated by so-called mental illnesses.

Critics claim the DSM embodies an approach that is not medical, but social. Even Thomas Insel, MD, speaking as NIMH director, argued that DSM diagnosis was unlike other branches of medicine because it was “based on consensus” rather than objective laboratory measures.

 More extreme critics agree that “psychiatry’s diagnoses are agreements among self-appointed experts” and not medical entities, while it is commonplace to contrast laboratory tests and microscopic studies in the rest of medicine with psychiatry’s arbitrary creations.

 As a result, psychiatry is without a medical foundation—“built upon air.”

. They are wrong because they are mistaken about both the practice of medicine and the nature of the mental illnesses the DSM attempts to classify. I submit that you, as a practicing psychiatrist or other mental health professional, intuitively know that you are practicing legitimate and scientifically based medicine as you make use of the DSM. Allow me to put this intuition into words.

The DSM-5 includes a lengthy definition of 

, but the first 6 words will suffice for our purposes: “A mental disorder is a syndrome….”

What is a syndrome? As we know from medical school, a syndrome is simply a collection of medical signs and symptoms. Is a syndrome a disease? No—but diseases manifest as syndromes. Diseases stand behind syndromes, and many different diseases can stand behind the same syndrome (see 

Take depression, for instance. Many underlying diseases can produce depression (and the same applies for all other DSM disorders). Hypothyroidism can manifest as depression, as can obstructive sleep apnea and 

. Yet we usually do not know the specific disease behind an episode of depression. In psychiatry, we typically rule out commonly known diseases that produce depression while managing depression with general and nonspecific treatments such as psychotherapy and antidepressant medications.

Is this approach to clinical diagnosis out of step with the rest of medicine? Hardly—in primary care settings, syndromes represent the most common means of diagnosing problems and prescribing treatments.

 Think about such common syndromes as upper-respiratory infection (URI), gastroenteritis, and arthritis: All of these syndromes can be expressions of many different diseases. In the case of a URI, for instance, the primary care physician (PCP) evaluates the signs and symptoms, diagnoses the syndrome, and then prescribes empiric antibiotic treatment or other nonspecific interventions such as nonsteroidal anti-inflammatory drugs (NSAIDs)—all without knowing which specific disease is behind the URI symptoms.

PCPs do the same with a host of other conditions, including 

 and low back pain. While primary care physicians usually try to rule out common and lethal diseases associated with the syndrome, they usually treat syndromes nonspecifically—as syndromes rather than the discrete diseases behind the syndrome. Thus, hypertension is treated with antihypertensives, diet, and exercise, while low back pain is treated with NSAIDs, physical therapy, and (if necessary) cortisone injections. All of these are nonspecific treatments and represent the standard of care in medicine. So how is a psychiatrist prescribing an antidepressant any less medically legitimate than a PCP prescribing an antihypertensive?

Because DSM syndromes such as depression do not often match up with any single and well-defined disease, critics say that they are not based on anything. They regularly assert that we do not know the central etiology or pathophysiology of even a single major mental illness (with the possible exception of Alzheimer dementia). Therefore, the entities in DSM are simply guesses based on convention, as are the collections of symptoms that define them (

Yet this criticism, too, is factually wrong and based on a false dichotomy. Either we know the specific cause and pathophysiology of a mental illness (they say), or we are making up a mental illness without justification. In fact, we can know that an illness is medically and biologically real without knowing the specific cause or pathophysiology of that illness. Migraine headaches are medically real with demonstrable pathological findings, and yet neurologists know neither their specific cause nor their central pathophysiology.

The same is true for all major mental illnesses, including depression. With depression, we can demonstrate pathological findings such as hippocampal and cellular atrophy, or a dysregulated HPA system, without knowing the central pathophysiology (or pathophysiologies) of major depression. Thus, we can know that depression reflects a biological illness even when we do not know the particular pathology behind it.

Psychiatry is hardly built upon air. On the contrary, we have evidence of molecular, microscopic, endocrine, immunological, and neural network dysfunction associated with all of the major mental illnesses. All of these syndromes represent biological illnesses (

Fundamentally, psychiatrists do what other medical doctors do. They evaluate signs and symptoms, diagnose syndromes, investigate for common and lethal diseases, and prescribe scientifically supported (but mostly empiric) treatments. None of this is controlled by the DSM—it is controlled by patients and their families, in consultation with doctors who depend on scientific data for guidance. The DSM does not control psychiatric care anymore than the ICD-10 controls the rest of medical practice.

 It simply organizes sets of signs and symptoms in a way that facilitates research, diagnosis, and treatment.

Critics of the DSM are wrong. Psychiatry is not at odds with other medical specialties. Psychiatry differs from them only in the sense that more of the diseases behind psychiatric syndromes lack full explication. But this is not evidence of psychiatry’s inferiority. It is evidence that the complexity of the human brain far exceeds that of all other organs combined. Even so, psychiatry does not lack evidence that mental illnesses are biologically and medically real, and it does not lack treatments that are scientifically substantiated. The DSM is not the bible of psychiatry. It is simply the place where clinicians match diseases to treatments through the lens of medical syndromes—just like other doctors.

is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health, and is author of

 Science Over Stigma: Education and Advocacy for Mental Health

, published by the American Psychiatric Association. He can be reached at

1. Kory D. Gary Greenberg on the DSM and its woes. Psychotherapy.net. 2015. Accessed March 10, 2022. 

https://www.psychotherapy.net/interview/gary-greenberg-DSM

Debating DSM-5: diagnosis and the sociology of critique.

3. The Editorial Board. Shortcomings of a psychiatric Bible. 

. May 11, 2013. Accessed March 10, 2022. 

https://www.nytimes.com/2013/05/12/opinion/sunday/shortcomings-of-a-psychiatric-bible.html

Beyond DSM: seeking a brain-based classification of mental illness.

6. Roth MS. In search of a way to diagnose mental disorders – and to make money. 

. September 3, 2021. Accessed March 10, 2022. 

https://www.washingtonpost.com/outlook/in-search-of-a-way-to-diagnose-mental-disorders--and-to-make-money/2021/09/02/26cfb150-e66b-11eb-a41e-c8442c213fa8_story.html

7. Ault A. DSM-5 update: what’s new? Medscape. March 4, 2022. Accessed March 10, 2022. 

https://www.medscape.com/viewarticle/969662

. September 1, 2013. Accessed March 10, 2022. 

https://www.scientificamerican.com/article/mind-reviews-the-book-woe/

9. Insel TR. Transforming diagnosis. National Institute of Mental Health blog. April 29, 2013. Accessed March 10, 2022. 

http://psychrights.org/2013/130429NIMHTransformingDiagnosis.htm

10. Simons P. Medscape article reviews the fatal flaws of the DSM. 

. December 28, 2020. Accessed March 10, 2022. 

https://www.madinamerica.com/2020/12/medscape-article-reviews-fatal-flaws-dsm/

11. Nugent B. Is psychiatry dishonest? And if so, is it a noble lie? 

https://slate.com/culture/2013/05/book-of-woe-the-dsm-and-the-unmaking-of-psychiatry-by-gary-greenberg-reviewed-by-benjamin-nugent.html

Diagnostic and Statistical Manual of Mental Disorders, 5th edition.

Potential lessons for DSM from contemporary philosophy of science.

14. Finley CR, Chan DS, Garrison S, et al. 

What are the most common conditions in primary care? Systematic review.

15. Ruffalo M, Pies RW. What is meant by a psychiatric diagnosis? 

. June 7, 2020. Accessed March 10, 2022. 

https://www.psychologytoday.com/us/blog/freud-fluoxetine/202006/what-is-meant-psychiatric-diagnosis

Diagnostic ambivalence: psychiatric workarounds and the Diagnostic and Statistical Manual of Mental Disorders.

It is all too easy to be negative. It is far easier to criticize than contribute—easier to tear down than to build up. Positivity fades, but negativity seems to build on itself.

 “Friends come and go; enemies accumulate,” as Mark Twain put it.

It is easy to be negative because it is natural to be negative. As human beings—indeed as mammals—our nervous systems give more weight, more attention, and more energy to negative and threatening experiences than to positive ones.

 So at a time when many medical and scientific authorities are viewed with suspicion, negativity about psychiatry is hardly shocking. Even 

 have become a hard sell in our polarized and angry public culture.

Psychiatry has always been subject to more criticism and abuse than any other medical specialty. Dating back to the publication of Thomas Szasz’s 

 negativity about psychiatry has been a constant refrain longer than any of us have been psychiatrists, so much so that most of us hardly notice it. It is the elevator music of our professional pursuits—something that only registers when a particularly good or bad tune warbles in the background. Negativity about psychiatry has become a long-running and tacitly accepted tradition, both inside and outside psychiatry.

At least the narrative is consistent, rarely straying over the decades from Szasz’s powerful indictment: Psychiatry is unscientific. Contemporary critics assert that psychiatrists make diagnoses on the basis of a pseudoscientific and self-serving 

, and that we go about treatment through the use of dangerous and unjustified overprescribing. Because we lack a firm scientific grounding (they say), self-interest runs rampant. As psychiatrists, our arbitrary definitions of mental illness expand to include more and more “patients,” while drug companies push treatments for newer and more expansive “disorders.”

None of this affects us much as practicing psychiatrists. But, when these criticisms are left unanswered, it is deeply distorting and injurious to people outside of our field who suffer from mental illnesses. It also influences the journalists, professors, and public intellectuals who shape public opinion. All of these, in turn, affect those who make life-and-death decisions about mental health in hospital corporations, governments, and insurance companies.

Psychiatric illness is not treated the same as other medical illnesses. This tragic state of affairs persists in spite of the fact that parity has been the law of the land since 2008 (and again in 2016). Stigmatizing stories of tragedy and violence dominate news media coverage of mental illness, not positive stories of 

 The majority of individuals with mental illness do not get treatment (in any given year), and the situation is little better for those with

Negativity about psychiatry is a major impediment to the mental health of this country. What do we do? We do not oppose negativity with more negativity. Our world has grown weary of flame wars. Instead, we oppose negativity with positivity. We oppose distortion with clarity. We do not deny the problems of psychiatry; we demonstrate its strengths. We accept legitimate 

, but place them in a wider and more affirmative context. In short, we show why psychiatric illness is medically real and psychiatric treatment is medically legitimate.

As psychiatrists, the fundamentally benign nature of what we do has been too obvious for words. Few of us have wasted time debating it amongst ourselves. Instead, when we have spoken of psychiatry in the abstract, we have routinely spoken of its problems and limitations. Now, for the sake of the rest of the world, we need to habituate ourselves to explaining and affirming our field. We need to articulate a basic sense of what we are doing with each other, our patients, and the wider communities of which we are a part.

I hope that this series of articles will contribute in a small way to this project. In the coming months, I hope to offer a positive take on many of the topics that lie at the root of deep skepticism about psychiatry:

-The History of Psychiatry: A History of Failure?

-Is Psychiatry Inferior to Other Specialties?

-Psychiatric Medicines: More Harm than Good?

I believe we can answer the questions that dog psychiatry in a way that is honest, satisfying, and relatable to the public. I believe it is time for psychiatry to find its voice in a new way. We have nothing to hide and no need to patronize. We need not deal in denial, rationalization, or intellectualization. The truth will do nicely for our interests and for those we serve. We are psychiatrists, after all.

is a psychiatrist and director of training for the General Psychiatry Residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health, and is author of

Negativity bias, negativity dominance, and contagion.

The Myth of Mental Illness: Foundations of a Theory of Personal Conduct.

The Book of Woe: The DSM and the Unmaking of Psychiatry. 

Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America.

5.McGinty EE, Kennedy-Hendricks A, Choksy S, Barry CL. 

Trends in news media coverage of mental illness in the United States: 1995–2014.

6. Park-Lee E, Lipari RN, Hedden SL, et al. 

Receipt of services for substance use and mental health issues among adults: results from the 2016 National Survey on Drug Use and Health.

7. Treatment Advocacy Center. Severe mental illness and treatment prevalence. May 2017. Accessed February 8, 2022. 

https://www.treatmentadvocacycenter.org/key-issues/anosognosia/3638-serious-mental-illness-and-treatment-prevalence

In this new series, explore how to approach the criticisms of psychiatry. 

It’s Time for Us to Stop Being So Defensive about Psychiatry

,” I believe that Awais Aftab, MD, has almost entirely mistaken the overall thrust of my article. In fact, the article did not attempt to excuse psychiatrists by tone policing critics, or to deny psychiatrists’ responsibility for the problems of psychiatry. Do these sound like fighting words? I assure you they are not. The fault for such a misunderstanding is my own. By pressing in on the ambiguities of my article, “

It’s Time for Us to Stop Waffling About Psychiatry

,” Aftab has given me a precious opportunity to clarify its purpose.

Before I explain, I would like to extend more than the usual thanks to Dr Aftab for his willingness to deeply engage with my thoughts about public perceptions of psychiatry. We clearly share a passion not only for our profession, but for the patients we attempt to serve. And, in the interest of full disclosure, I should note that I am a big fan of Aftab and grateful for his many articles that have appeared in the pages of 

. I am delighted that he cared enough about my article to refute it.

According to 1 doctor, we all need to communicate the legitimacy of psychiatry as a medical specialty. 