“Explanation” vs. “Exploration” in Mental Illness

A quickie post here today:  I invite you all to go check out my most recent contribution to the “Couch in Crisis” blog at Psychiatric Times online, entitled “Symptoms and What They Mean.”


Free registration at Psychiatric Times is required.  Cheers!

25 Responses to “Explanation” vs. “Exploration” in Mental Illness

  1. stevebMD says:

    And if you’ve signed up for an account, be sure to check out Ron Pies’ more scholarly assessment of the same dialectic.

  2. AA says:

    Hi Steve,

    “Would that have been incorrect? Not according to conventional psychiatry. But with a response like that, I would have completely invalidated her own subjective interpretation—her own reality.”

    Hmm, since when is psychiatric research objective?


  3. giannakali says:

    I suggest you visit some of the withdrawal boards online Steve. I know you’ve been invited to at least one. There you can find stories of thousands that are not what psychiatrists “expect.” They don’t expect it because they’re not trained to expect it. It’s a tragedy, pure and simple and many of us are harmed and suffering as a result.

    It’s much more convenient to believe the medicine you use is always helpful rather than devastatingly destructive for some, I’m sure.

    I wrote a post a while back, a plea to MDs to help us heal.

    It would actually be a good economic choice if nothing else as we have nowhere to go where we are believed, in general. What’s more few MDs feel comfortable with the extreme unknown involved in treating those of us with the worst forms of iatrogenesis…it’s not nice to sit with our agony…and so they blame us…make it our fault.

    I have a doctor who is not like that. I’ve given you his name. I wish you’d contact him since you said you knew and liked him.

  4. Iatrogenia says:

    Dr. Steve —

    I’m puzzled by your use of “subjective reality.” Is this a term of art in psychiatry?

    Is there a qualitative difference between “subjective reality” as voiced by the patient, and a realer, more valid reality in the psychiatrist’s interpretation of the patient?

    Two situations:

    A) A patient visits a psychiatrist saying she thinks she has “social anxiety disorder.” She saw it in a TV ad, where a sad bubble turned into a happy bubble after taking Paxil. She asks for Paxil.

    The psychiatrist diagnoses her with Social Anxiety Disorder, diagnosis code 300.23, helpfully provided by DSM-IV to assist GSK in efforts to sell Paxil.

    In this case, the patient has channeled the word of God — real reality — directly to the psychiatrist.

    B) Two years later, the patient quits Paxil, tapering off over 3 weeks as recommended by the psychiatrist. She comes down with severe withdrawal symptoms that last for many months, describing them in consistent detail at every follow-up visit.

    In this case, the patient is expressing “subjective reality.” The doctor pretends to listen but dismisses this as the patient’s fixation or delusion.


    Dr. Pies says there are two schemas in use by psychiatrists to understand patients, the first being:

    “This individual’s brain function—-her serotonergic system, neurocircuits, nerve growth factors, etc—-may be aberrant in some way that is causally contributing to her depression (erklaren)…”

    So this is what psychiatrists think about. A bunch of “brain function” theories that have been pie-in-the-sky for decades.

    As a novel approach, Dr. Pies urges clinicians to add the second schema, “phenomenological”: “understanding the contents and structure of the patient’s felt experience.” This requires listening to the patient for 5 minutes and accepting at least some things she says as “true.”

    Does psychiatry have no shame?

    • stevebMD says:


      Maybe I’m missing something here, but I don’t think I used the phrase “subjective reality” in my post. (I even did a text search… I can be a bit obsessive about these things!)

      But since you brought up the issue, I will say that the patient’s subjective experience is what matters. Period.

      “Reality” is evasive. Illusory, even. We’ve never really proven, for instance, that mania is caused by dysfunctional hippocampal signaling, but doggone it, our most “effective” mood stabilizers enhance hippocampal CA1 excitatory postsynaptic potentials, so that hypothesis must be right. Right?

      To use Dr Pies’ phrase, “understanding the contents and structure of the patient’s felt experience” (verstehen) should be our goal. Hopefully, this agrees with our biochemical model (erklaren), as difficult as it might be to see this side of the coin. His article encourages psychiatrists to embrace this dialectic.

      What I’m emphasizing, however, is that our explanatory power often comes up short. In such cases, the only “reality” we have to work with is the patient’s subjective experience, which is the only factor that should guide our treatment. Is there a biological explanation for this “reality”? Absolutely. But our current explanatory models don’t provide it. This should behoove us to search for it, rather than dismiss it outright.

      • Iatrogenia says:

        We agree that the patient’s subjective experience is the only “reality” we have to work with. Whew!

        What a lot doctors would learn if they only listened to their patients.

        With current biochemical models, I see no hope whatsoever in agreement between verstehen and erklaren. Dr. Pies is always trying to salvage some dignity from the train wreck that is contemporary psychiatry.

  5. AA says:


    With all due respect, I feel you missing the point of various replies. Using the term “subjective” is a discounting word that comes across as invalidating a person’s experience even if that wasn’t your intention.

    Furthermore, patient experiences that initially were labeled in that manner or even in worse derogatory terms many times turn out to be quite accurate. A perfect example is the issue of SSRIs and weight gain which psychiatrists initially denied was an issue. Fortunately, that is less of a problem although still, too many patients deal with clueless clinicians.

    For various reasons unrelated too psychiatry, I have been been on the website of Steven Park, who is an ENT. One of his favorite sayings is that his patients are his best teachers. They guide him as to what he should learn next.

    Imagine how much more favorable psychiatry would be viewed if it adapted that attitude. So when several patients keep complaining about med withdrawal reactions that last past that “two week period” (which by the way seems to be the answer for everything), they would be motivated to learn more as Gianna pleaded in her post.

    Then again, there is reality.

  6. A tip from a crafty psych patient says:

    Just a side note, you can read the posts on psychiatric times without registering. When the article pops up and before it automatically directs you to register if you hit the x at the top it will stop on the article and keep it from going on to the registration page. I do this all the time as I don’t particularly want to register with psychiatric times.

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