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 

 (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on

Ronald W. Pies, MD

So, you think you have a pretty good handle on DSM-5—what the lay press loves to call, quite misleadingly, “Psychiatry’s Bible”? OK, maybe you know most of the criteria for the major categories of serious mental illness. No doubt, you are aware of serious problems with some aspects of DSM-5 (the 

, including the limited reliability and validity of many of its disorder categories.

 But how well do you understand the “deep structure” of DSM-5 as a diagnostic tool?

Just to get your adrenaline flowing, try taking this 2-minute quiz:

A. DSM-5 permits the clinician to make a mental disorder diagnosis simply by checking off the symptoms listed in a disorder’s diagnostic criteria.

B. To make a DSM-5 mental disorder diagnosis, the clinician need not assess the social, psychological and biological factors that may have contributed to the patient’s condition.

C. DSM-5 is an embodiment and expression of the “biomedical” model in psychiatry.

D. DSM-5 posits that mental disorders are discrete entities sharply distinguished both from “normality” and from each other.

 you can stop here. Pat yourself on the back and grab a coffee. Otherwise, you might want to read on.

Critics of psychiatric diagnosis often caricaturize the DSM process as the “Chinese Menu” approach. Thus, a professor of history and philosophy—in an article titled, “Forget talking, just fill a script: how modern psychiatry lost its mind”—

In clinical practice, DSM-III led to a “Chinese menu” approach to psychiatric diagnosis: a specific mental illness can be diagnosed if a sufficient number of boxes can be ticked. This is only of limited value in clinical practice.

Indeed, merely checking off boxes of symptoms (and signs) 

but that is not at all what DSM-5 calls for.

 As my colleague, Dr Mark Ruffalo, and I 

, the DSM-5 makes it crystal clear: Simply checking off symptoms 

cannot and does not constitute a psychiatric diagnosis—

The case formulation for any given patient must involve a careful clinical history and concise summary of the social, psychological and biological factors that may have contributed to developing a given mental disorder. 

Hence, it is not sufficient to simply check off the symptoms of the diagnostic criteria to make a mental disorder diagnosis 

"You cannot snag a DSM diagnosis merely by collecting a group of signs and symptoms."

, the case formulation “. . . is a core clinical skill that links assessment information and treatment planning. It is a hypothesis about the mechanisms that cause and maintain the problem. It answers the question, ‘Why is this person, having this type of problem, now?’”

In principle, the case formulation—and by extension, the final DSM diagnosis—requires medical knowledge, or at least access to medical consultation, in order to assess the “biological factors” that may have contributed to the patient’s problem. Finally, we should note that, in addition to meeting sign/symptom criteria for a mental disorder, virtually all the major 

 require evidence of “clinically significant distress or impairment in social, occupational or other important areas of functioning.” You cannot snag a DSM diagnosis merely by collecting a group of signs and symptoms. There must also be adverse consequences in the person’s life.

The DSM-5 Is “Biomedical”? Not So Much

It is clear from the aforementioned description of the case formulation that the DSM-5 explicitly uses a “biopsychosocial” approach to diagnosis. In addition, DSM-5 has extensive coverage of cultural issues, as they impinge on differential diagnosis. Excellent examples of the “case conceptualization” using a bio-psychosocial-cultural approach may be found in the text by Sperry and Sperry.

Nonetheless, some commentators—mainly critics of psychiatric nosology—have asserted that DSM-5 represents the “biomedical” model. For example, 1 paper 

Diagnostic and Statistical Manual of Mental Disorders

 . . . offers a biomedical framing of people’s experiences of distress and impairment, and despite decades of criticism, it remains the dominant approach.

These authors go on to argue that, “. . . a biomedical construction of ‘mental illness’ all too frequently fails to protect individuals from delegitimation and stigma.” That is a provocative claim worth examining but is beyond the scope of this essay. What is striking about the paper by these 2 psychologists is that the term “biomedical” is never fully defined. The authors do 

 the biomedical model is oriented “around the problems of the body . . . such as genetics or neurochemistry.”

If we take that rough formulation as a guide, it can be readily seen that—with a few exceptions—there is very little in DSM-5 that invokes “genetics” or “neurochemistry.” True, DSM-5’s discussion of 

 does reference abnormalities on chromosome 4; and other neurocognitive disorders, such as Lewy body disease, are linked to genetic abnormalities. But such references to specific genetic abnormalities are by far the exception, particularly for the more classically “psychiatric” disorders, such as schizophrenia and bipolar disorders. (We do find, under the rubric of “Risk and Prognostic Factors,” the statement that “Schizophrenia and bipolar disorder likely share a genetic origin . . .”

Table 1. What DSM-5 Is and What It Is Not

As far as I know, discussion of “neurochemistry” as a 

 in any of the common psychiatric disorders is entirely lacking in DSM-5. (So much for “chemical imbalances”). With only a few exceptions, DSM-5 avoids commitments regarding etiology. Indeed, the 

, “a diagnosis does not carry any necessary implications regarding the etiology or causes of the individual’s mental disorder. . .”

 One can see this as a serious deficiency in the DSM-5—but one cannot claim the 

endorses anything resembling neurochemical etiologies or “chemical imbalances” for the major mental disorders.

 that the DSM-5 “offers a biomedical framing of people’s experiences of distress and impairment.”

 Deacon, in a detailed review and critique, argues that “The biomedical model posits that mental disorders are brain diseases and emphasizes pharmacological treatment to target presumed biological abnormalities.”

 I do not contest that description, but nothing in Deacon’s analysis shows that DSM-5 is essentially “biomedical” in the sense he explicates.

Fuzzy Boundaries, Overlapping Symptoms, and Dimensions of Pathology

Another common claim is that DSM-5 is a strictly “categorical” framework that conceptualizes mental illness as a collection of discrete, diagnostically separable entities. As one paper puts it, “. . . the DSM-5 is a categorical system. Thus, individual disorders are regarded as discrete units—“you either have it, or you don't.”

 A related claim is that DSM-5 posits a clear and distinct separation between mental abnormality and “normal” mental or psychological states. 

In truth, neither claim is supported in the DSM-5 (

). On the contrary, the Introduction to the 

The results of numerous studies of comorbidity and disease transmission . . . make strong arguments for what many astute clinicians have long observed: the boundaries between many disorder “categories” are more fluid over the life course than DSM-IV recognized, and many symptoms assigned to a single disorder may occur, at varying levels of severity, in many other disorders. These findings mean that DSM . . . should accommodate ways to introduce dimensional approaches to mental disorders, including dimensions that cut across categories . . . Although some mental disorders may have well-defined boundaries around symptom clusters, scientific evidence now places many, if not most, disorders on a spectrum with closely related disorders that have shared symptoms, shared genetic and environmental risk factors, and possibly shared neural substates . . . 

In short, we have come to recognize that the boundaries between disorders are more porous than originally believed.

Furthermore, the DSM-5 does not argue for a hard and fast boundary between “normal” and “abnormal” states and conditions. On the contrary, it states:

The boundaries between normality and pathology vary across cultures for specific types of behaviors…Hence, the level at which an experience becomes problematic or pathological will differ. The judgment that a given behavior is abnormal and requires clinical attention depends on cultural norms that are internalized by the individual and applied by others around them, including family members and clinicians.

Table 2. A Possible Prototype for Schizophrenia

All this is not to say that psychiatric illnesses are merely “

” labels that have no corresponding physical or pathological referents in “the real world”—a thorny topic for another time.

 DSM-5 merely affirms what all good clinicians know: There are many 

 in the realm of psychopathology, often influenced by culture; and it is very doubtful that we can “carve Nature at its joints.”

 that democracy is the very worst form of government, except for all the others that have been tried.

 It is tempting to suggest, tongue slightly in cheek, that DSM-5 is by far the worst diagnostic framework psychiatry could have chosen—except for all the rest. To be sure, many different approaches to psychiatric diagnosis have been 

Personally, I favor a prototype-based diagnostic approach for every-day clinical work; and a parallel set of “research diagnostic criteria” for investigative purposes (

). “Prototype” diagnosis refers to the use of idealized models or archetypes of disease, rather than either “categorical” or “dimensional” methods of classification. 

 discuss and debate various diagnostic models in a wide-ranging colloquium.

It seems very clear that diagnosis is, and will always remain, a necessary part of clinical care, both in general medicine and psychiatry. When a patient presents with the complaint, “I hear threatening voices in my head,” we simply must

—a word whose etymology means, “knowing the difference between.” For example, we must know the difference between “threatening voices” stemming from combat-related trauma, on the one hand, versus schizophrenia or anti-NMDA receptor encephalitis

 on the other. Otherwise, our treatment is likely to be misguided.

No, whatever the lay press claims, DSM-5 is not “The Bible of psychiatry.’ It is not a sacred, eternal, and inviolable text, or even a very sophisticated diagnostic tool. John Talbott, MD, professor emeritus of psychiatry and former president of the 

, “If you let the specifics of the DSM tie you down, it prevents you from practicing the art of medicine. So, I would hope people would not be bound by it, but be flexible and use their clinical judgment instead.”

I agree. But before we use the DSM-5’s text to line our bird cages—as a renowned British psychiatrist I once met described the utility of the DSM-III—we should at least understand what DSM-5 does, and does not, represent.

 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 

 Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

1. jmm1000. Dr Pepper "So Misunderstood" feat Carol Kane - 1973-1974. YouTube. June 30, 2017. Accessed March 17, 2021. 

https://www.youtube.com/watch?v=WA_NnXyDDLk

2. Regier DA, Narrow WE, Clarke DE, et al. DSM-5 field trials in the United States and Canada, Part II: test-retest reliability of selected categorical diagnoses. 

3. Pols H: Forget talking, just fill a script: how modern psychiatry lost its mind. 

 October 21, 2012. Accessed March 17, 2021. 

https://theconversation.com/forget-talking-just-fill-a-script-how-modern-psychiatry-lost-its-mind-9569

4. Ruffalo ML. Pies RW. Psychiatric Diagnosis 2.0: The Myth of the Symptom Checklist. 

 June 14, 2020. Accessed March 17, 2021. 

https://www.psychologytoday.com/us/blog/freud-fluoxetine/202006/psychiatric-diagnosis-20-the-myth-the-symptom-checklist

. Washington, DC; American Psychiatric Publishing, Inc: 2013.

6. Gintner GG. Using DSM-5 in Case Formulation. Louisiana Counseling Association presentation. Accessed March 17, 2021. 

http://www.lacounseling.org/images/lca/Conference/DSM-5%20LCA%20Case%20Formulation%20Rev.pdf

Mastering this Competency with Ease and Confidence.

9. Deacon BJ. The biomedical model of mental disorder: a critical analysis of its validity, utility, and effects on psychotherapy research. 

10. van Heugten-van der Kloet D, van Heugten T. The classification of psychiatric disorders according to DSM-5 deserves an internationally standardized psychological test battery on symptom level. 

What kinds of things are psychiatric disorders?

12. Gabor, GT. ‘Carving nature at its joint’: The Platonic method of division in Plato, Aristotle, and their Neoplatonic commentators. 

. AAI3466699. 2011. Accessed March 17, 2021. https://research.library.fordham.edu/dissertations/AAI3466699

13. Churchill W. The Worst Form of Government. International Churchill Society. November 11, 1947. Accessed March 17, 2021. 

https://winstonchurchill.org/resources/quotes/the-worst-form-of-government/

14. Phillips J, Frances A, Cerullo MA, et al. The six most essential questions in psychiatric diagnosis: a pluralogue part 3: issues of utility and alternative approaches in psychiatric diagnosis. 

. 2012;7:9. Accessed March 17, 2021. https://peh-med.biomedcentral.com/articles/10.1186/1747-5341-7-9

15. Kayser MS, Dalmau J. Anti-NMDA receptor encephalitis, autoimmunity, and psychosis. 

16. Vlessides M. The Past, Present, and Future of the DSM. 

. December 15, 2020. Accessed March 17, 2021. 

https://www.medscape.com/viewarticle/942694#vp_1

Articles

A DSM-5 diagnosis requires a biopsychosocial case formulation—not just a symptom checklist.

Poor DSM-5—So Misunderstood!

It is hard to believe that 17 years have gone by since I published a piece in 

, titled, “The Poet and the Psychiatrist.” At that time, I alluded to “an unusual therapy group” I co-led as a resident, nearly 40 years ago, in which psychiatric inpatients “… were encouraged to bring in poetry—whether their own or that of others—and read it to the group. A psychiatric nurse and I encouraged discussion of the feelings, images, and memories the poems would almost invariably evoke.”

We often found that patients who rarely expressed their feelings in the course of a formal therapy session would do so in the context of the poetry reading. Sadly, the very idea of conducting such a group in today’s climate of truncated psychiatric care seems quaint or naïve, at best. This point was brought home to me in a 

Editor-in-Chief, John J. Miller, MD, in which he detailed the economic pressures on psychiatrists over the past 30 years, leading to the now infamous “15-minute medication check.”

Dr Miller pushed back on this procrustean limit by suggesting—or at least, imagining—that psychiatrists extend the session to 16 minutes. The extra minute, he suggested, could be used to gain some important personal information about the patient. Questions might include, for example, “Who do you feel had the greatest influence on you growing up?” or “When do you feel most at peace with yourself?” or “What do you do for relaxation?”

Riffing off Dr Miller’s suggestion, I would like to propose another question that we might put to certain suitable patients—a question I raise as both a clinician and a poet.

 But first, I would like to examine the whole notion of the medication check, with the aim of reimagining it as something more than a superficial exercise in refilling a script.

For starters, I would urge psychiatrists to resist the 15-minute med check model, wherever and whenever possible. I realize that will not be greeted with enthusiasm in most managed care settings, but I think there are good reasons—and compelling ethical imperatives—why we should push back hard. As child psychiatrist David Rettew, MD, succinctly put it, “In 15 minutes…there is barely enough time to go over side effects, dose and medication changes, and informed consent, let alone engage in discussions about what may really be going on in a patient’s life and how a multitude of other possible interventions (improving sleep, exercise, nutrition, relationships) might be useful.”

There is good reason to believe that resistance is not always futile. For example, in 2011, Lorraine Roth, MD, commented as follows:

“I retired from the VA last year and have worked a number of Locum Tenens positions since then. One was at a mental health clinic that needed a psychiatrist to cover for a few months. They stated that evaluations were one hour, med checks 15 minutes. I said I need 30 minutes. I explained that 15-minute checks are adequate for those patients who are “doing well, just need a refill,” but 30 minutes allows for the adequate evaluation and decision-making necessary for patients who are not doing well. In addition, it is essential to write a good progress note, and trying to include that in a 15-minute slot is not workable. They granted my request for 30-minute med checks.”

The situation has probably worsened since Dr Roth posted her comments, and not all psychiatrists will have the leverage she apparently had. Still, I believe that serious pushback is worth a try.

 see patients for only 15 minutes, try to find a way to humanize what might otherwise be a perfunctory, robotic encounter. For example, H. Steven Moffic, MD, has explored the usefulness of asking med check patients, “What gives you meaning in your life?” Or, more colloquially, 

 Dr Moffic asked patients to write out their answers prior to the 15-minute med check, and found that this 1 question often elicited important information. For example, one patient answered like this: “DS, who had posttraumatic stress disorder (PTSD), answered, ‘Nothing.’ After I felt a chill, I asked if she felt suicidal, and she did. We changed her medication and increased the frequency of appointments.”

It is also important not to underestimate the need for psychodynamic understanding of the patient, even—or perhaps especially—in the brief space of a med check. Glen Gabbard, MD, has observed,

“Psychiatry has probably made far too much of a distinction between psychotherapy and pharmacotherapy in training and in practice. Psychotherapeutic skills are needed in every context in psychiatry because the same phenomena that emerge in psychotherapy-transference, resistance, countertransference, schema, automatic thoughts-appear in other contexts. All clinical work in psychotherapy depends on attending to the therapeutic relationship.”

Dr Miller made essentially the same point in his video, 

Making Psychotherapy Part of Every Psychiatric Visit

 noting that from the time you greet your patient in the waiting room to the time you escort them to the door as they leave, “…everything you do is psychotherapy” and “every microsecond is a personal interaction.” Indeed, sometimes a med check cannot move to completion until the patient’s hopes, fears, fantasies, and resistances are understood and explored.

The 1-Minute Poetic Encounter: Reimagining the Med Check

Please join me now in a brief thought experiment. Imagine you are able to negotiate with the powers that be, such that you can extend that nefarious 15-minute med check to 25-30 minutes. Let us further imagine you have a patient—Mr A, a 70-year-old divorced, retired teacher with major depressive disorder, now in remission—whom you see twice a month for med checks. He has clearly benefitted from his antidepressant (bupropion 250 mg qd), but he finds it very difficult to share any deep feelings during your meetings with him. When you ask him “How are you feeling?” he shrugs and says, “Not depressed like before, Doc. Just kind of 

.” He sees a psychiatric social worker twice monthly for supportive therapy and she reports a similar experience with Mr A. “He’s not clinically depressed anymore,” she reports, “but he just seems very closed off and shut down, emotionally flat.” You consider the possibility that his antidepressant may be causing this feeling, but—unlike the SSRIs

—bupropion almost never causes this kind of emotional flattening. In your current session, you tell Mr A that you have often found it helpful to use poetry in your work with patients. Then you ask him one simple question: “Mr A, would you be interested in using poetry to help change that blah feeling?” He seems dubious at first but says he will give it a try.

Playing out this thought experiment: might you be able to use your expanded, 25-minute med check appointment to bring poetry into the clinical context? For example, could you ask Mr A to select a poem that is meaningful to him and then allow for 5 to 10 minutes to read and discuss the poem?

This might be an occasion, as Theodor Reik, PhD, would put it, to 

 whereby one “…attends to vague impressions, intuitions, images, associations, and even melodies.”

Indeed, in my experience, the patient’s very selection of the poem can represent a kind of projective test, whereby the patient’s fears, feelings, and fantasies become attached to the poem. A few patients may even wish to bring in poems they themselves have written, which, in my experience, is often a royal road into the patient’s psychology.

Problems and Concerns: The Ideal and the Real

Alas, not all thought experiments yield good results in real life. Unfortunately, the med check context is probably not suitable for extended encounters with poetry. Having spent over 20 years in the Massachusetts Department of Mental Health, providing medication for some of the sickest patients in the state, I know from experience that time is just too tight—even with a 25-minute med check session. In one DMH facility, the psychiatric staff had to push the administration hard to be granted this generous slice of time. Some of my near-catatonic patients would take 10 minutes just to get their coats off, and another 10 minutes before they would feel ready to speak!

As my colleague and fellow poet, Richard M. Berlin, MD, put it in a personal communication (email 2/17/21),

“Even 25 minutes is a challenge, since there’s a note to write and another patient waiting. [There are] too many issues to talk about before poetry can enter. I think the group setting is probably the best context: lots of time, many interpretations, and easier to talk about the feelings/ideas that are ‘out there’ in the poem, with the understanding that poetry will be center stage.”

Then, too, there is the risk—albeit rare—of an untoward reaction to reading certain poems. In general, it is important to avoid poems that, in the words of psychiatrist Jack Leedy, MD, “…offer no hope, or that might increase the depth of the [patient’s] depression…”

Indeed, the reading of some types of poetry may be a distressing experience for extremely fragile patients, who may regress in the face of overwhelming or primitive emotions. I once discovered this the hard way, treating a patient with borderline personality disorder and PTSD who underwent 

 in response to poetic material, during a therapy session.

Accordingly, careful selection of patients—and poems—is important. In general, I would suggest the use of poetry therapy for relatively stable patients who are not prone to regression, or use of primitive defense mechanisms like projection or projective identification. You should also be prepared for some spilling over of the session, in the event the poem evokes a strong emotional reaction—another reason that the med check is not an ideal context for poetic explorations. It is, however, an appropriate venue for broaching the issue.

So, what to do for Mr A? Since he is already seeing a psychiatric social worker for supportive therapy, that might provide a suitable context for the therapeutic use of poetry—provided, of course, that the therapist is amenable to the idea, and has had substantial experience with poetry therapy (PT). More information regarding PT credentialing may be found on the website of the 

 (JPT), edited by Nicholas Mazza, PhD, and sponsored by NAPT.

 Another option would be for the psychiatrist to see Mr A in individual or group psychotherapy, in which poetry could be integrated.

Finally, patients are not the only ones who can benefit from poetry. As Dr Berlin has written, “Doctors need poetry to bring them closer to their patients… Poetry can help doctors become better healers because poems teach us to see the world from the emotional viewpoint of another person.”

I believe that psychiatrists who engage with poetry in their clinical work will come to understand what William Carlos Williams, MD, meant when he wrote:

: My deep appreciation to Dr Berlin, Dr Moffic, and Dr Miller, for their comments and suggestions on an earlier draft of this paper.

1. Pies RW. The poet and the psychiatrist. 

https://www.psychiatrictimes.com/view/16-minute-med-check

4. Rettew D. Psychiatry’s med check: is 15 minutes enough? 

https://www.psychologytoday.com/us/blog/abcs-child-psychiatry/201511/psychiatry-s-med-check-is-15-minutes-enough

5. Roth L. Re: Psychiatry and the 15-minute med check. 

https://machimon.wordpress.com/2011/07/15/psychiatry-and-the15-minute-med-check/

6. Moffic HS. The meaning of life in a 15-minute med check. 

https://www.psychiatrictimes.com/view/meaning-life-15-minute-med-check

7. Gabbard GO. Deconstructing the “med check.” 

https://www.psychiatrictimes.com/view/deconstructing-med-check

8. Miller JJ. Making psychotherapy part of every psychiatric visit. 

https://www.psychiatrictimes.com/view/making-psychotherapy-part-of-every-psychiatric-visit

9. Sansone RA, Sansone LA. SSRI-induced indifference. 

10. Safran J. Theodor Reik’s listening with the third ear and the role of self-analysis in contemporary psychoanalytic thinking. 

https://www.researchgate.net/publication/51095312

Poetry As Healer: Mending the Troubled Mind.

12. Pies R. Adverse reaction to poetry therapy: A case report. 

13. National Association for Poetry Therapy. Home. Accessed February 23, 2021. 

14. Berlin RM. Why Doctors Need Poetry. In: 

15. Williams WC. Asphodel, That Greeny Flower [excerpt]. Accessed February 23, 2021. 

https://poets.org/poem/asphodel-greeny-flower-excerpt

Coulehan J, Clary P. Healing the healer: poetry in palliative care. 

Leedy JJ. Principles of poetry therapy. In Leedy JJ, ed. 

https://www.psychiatrictimes.com/cultural-corner/poetry

Deluty RH. Connecting, unburdening, and enlightening: reflections on poetry and psychotherapy. 

Pies R. Poetry therapy in the treatment of borderline personality disorder. 

When, where, and how to use poetry in a clinical setting.

Reimagining the 15-Minute Med Check Through A Poet’s Eyes 

“Let me be very clear: The scenes of chaos at the Capitol do not reflect the true America. This is not who we are.” —

Psychiatrists need no lecture on the concept of “denial.” After all, it was Anna Freud who first identified and explained this well-known defense mechanism, over 70 years ago.

 In brief, as Dr Rui Miguel Costa put it in a recent paper,

“By denial, individuals cope with stressors by not acknowledging their reality and/or their consequences. This can range from common resistance to accept consequences of certain events to psychotic denial, in which even denial of physical aspects of immediate surroundings can happen. In a broader sense, denial may include negation, constructing fantasies to replace the stressor, minimizing the stressor, and maximizing what could make one dismiss the stressor . . .”

The days and weeks leading up to the egregious mob takeover of the U.S. Capitol building suggest that denial was very much in evidence, among multiple persons and agencies. In retrospect, it seems clear that authorities at several levels of government either ignored or denied the reality of the nightmare that was about to unfold. Thus, Alex Newhouse—an expert on far-right extremism—

“The attack on the U.S. Capitol building on January 6 was shocking, but no one following right-wing activity on social media should have been surprised. The attempt by President Donald Trump’s far-right supporters to violently stop Congress from certifying the Electoral College vote and formalizing Joe Biden’s election victory was consistent with their openly expressed hopes and plans . . . By surveying social media data from mid-December to Jan. 5, I discovered thousands of posts referring to the planned protests as if they were a coming revolution. In some circles, the event became synonymous with a final battle . . . when ordinary Americans would take back the government.”

The days and weeks leading up to the egregious mob takeover of the U.S. Capitol building suggest that denial was in play-- and the culminating event was perhaps only a prelude to what may lie ahead. Can Americans work together to restore domestic tranquility?

In the aftermath of the Capitol riot, it was left to novelist Francine Prose to express 

“Perhaps the most powerful shocks, the most painful surprises, are the ones that we saw coming yet refused to believe would happen. Our ability to fear something and, at the same time, assume it will never occur is one aspect of human nature that seems particularly ill-suited to our continued wellbeing and survival . . .”

Denying the American Legacy of Seditious Violence

President-elect Biden’s speech to the nation on January 6 was, in my view, heartfelt and moving. I am among those who would dearly like to believe that the unspeakable actions of the Capitol building mob “. . . 

do not reflect the true America. This is not who we are.”

 And yet,with all due respect to Mr. Biden, I believe our history as a nation suggests that the violent takeover of the Capitol building does indeedreflect 

 of “who we are” as a nation. To claim otherwise, even with noble intentions, is to engage in some degree of denial.

As Professor of History Shannon M. Smith recently wrote, the violent takeover of the Capitol is part of “. . . a long history in the U.S. of local, state and national political leaders encouraging white supremacist groups to challenge or overthrow democratic governments . . . [and] today, white supremacists appear to interpret politicians’ remarks as support for their cause of a 

 to create a white-dominated government.”

To cite but 1 example of the “long history,” there was the coup and riot staged in Wilmington, NC, in 1898. As Brent Staples explains:

“The uprising was engineered by white supremacists who unseated a government that had been elected by an alliance that included black citizens and white progressives. Scores of black citizens were killed during the uprising . . . and prominent blacks and whites were banished from the city under threat of death. White supremacists eventually hijacked the state government, stripped black citizens of the right to vote and brought black political participation to a close.”

In short, scenes of men with Confederate flags parading through the defiled Capitol building last week—though unprecedented—should not be seen as merely an aberration in our history. But is this sort of event really representative of “who we are,” to use Mr. Biden’s phrase? The answer is complex. In my view, the tensions and animosities that led to the American Civil War have never been fully resolved and continue to surface to this day. Journalist Edward Ball, author of 

“We cannot come to terms with the Civil War because it presents us with an unacceptable kind of self-knowledge. We think, as Americans, that we possess a heroic past, and we like to think of our history as one of progress and the spread of freedom, even transcendence. But the Civil War tells us that we possess a tragic history instead, over which we must continually paste a mask of hope.”

Indeed, we might redefine “denial” in the terms Ball uses: the defense mechanism whereby we bury “an unacceptable kind of self-knowledge.” In this broader sense, denial grades into its kindred defense mechanism, 

And yet, “who we are”—as a country and a people—is not fixed in the stars or written in stone. If the American experience has taught us anything, it is that we can address and correct our past mistakes; otherwise, there would be no 13th Amendment or Civil Rights Act. The process of change is often slow and painful--and, as the unconscionable attack on the Capitol has demonstrated, sometimes violent. Yet in the end, I count myself a believer in Martin Luther King’s teaching: “The arc of the moral universe is long, but it bends toward justice.”

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style. 

The views expressed in this article are those of the author and do not necessarily reflect the opinions of

1. WATCH: President-elect Joe Biden delivers remarks on situation in DC. WSLS 10. Accessed January 12, 2020. 

https://www.wsls.com/news/politics/2021/01/06/watch-live-president-elect-joe-biden-speaks-on-economy/

. New York: International Universities Press; 1946.

3. Costa RM. Denial (Defense Mechanism). In: Zeigler-Hill V, Shackelford T, eds. 

Encyclopedia of Personality and Individual Differences.

 Cham, Switzerland: Springer; 2017. https://doi.org/10.1007/978-3-319-28099-8_1373-1

4. Newhouse A. Far-right activists on social media telegraphed violence weeks in advance of the attack on the US Capitol. 

 January 8, 2021. Accessed January 12, 2020. 

What role does denial play in the collective American psyche?

Ronald W. Pies, MD

Articles

Poor DSM-5—So Misunderstood!

Reimagining the 15-Minute Med Check Through A Poet’s Eyes

Denial, The Capitol Takeover, and a Tragic American Legacy

What We Tell Patients about Depression, and What They Say They Have Been Told

Psychiatry and the Dark Night of the Soul

Is Depression a Disease?

What Kind of Science Is Psychiatry?

Screening Instruments Do Work for Bipolar Disorder, But Not by Themselves

Is the Country Experiencing a Mental Health Pandemic?

How Avicenna Recognized Melancholia and Mixed States—1000 Years Before Modern Psychiatry