Psychiatry As a Psychobiological Discipline NADIA TOMY, MD

Review Article

YAKOV SHAPIRO, MD Psychotherapy and its Role in Psychiatric Practice: A NICHOLAS JOHN, MD ROWAN SCOTT, MD Position Paper. I. Psychiatry as a Psychobiological Discipline NADIA TOMY, MD

Economic, political, and ideological land- KEY WORDS: integrated treatment, process scapes have impacted the practice of psy- research, psychiatry, psychobiology, psychotherapy, chiatry throughout its evolution as a medi- subjectivity, therapeutic alliance cal discipline. Despite enormous scientific advances over the course of the past century, many psychiatrists continue to operate with a From Canada come 2 guest articles that split Cartesian picture of mind versus brain present the model of an integrated psychobio- and entrenched ideological positions ranging logical, intersubjective approach to the treat- “ ” from biological chemical imbalance to rig- ment of psychiatric disorders. The authors’ idly followed manualized psychotherapy argument is in the tradition of wise physicians approaches, both of which frequently result in over the centuries who have emphasized consid- fractured clinical care. With the impact of eration of the whole patient as a person. But systemic economic and political pressures in now there is abundant scientific evidence that Canada and the United States, the attention to “mind” and “brain” are inseparable aspects of a the doctor-patient relationship has taken a unitary entity, and that psychotherapy and back seat to high-volume practices, compu- biological treatments inevitably affect both terized assessment tools, and the focus on aspects. This paper elaborates that concept evidence-based treatments for behaviorally and surveys the evidence for it; the second fi de ned syndromes in the Diagnostic and paper, to appear in the July 2016 issue of this Statistical Manual of Mental Disorders that journal, will present the evidence in greater ’ often come at the expense of the patient s depth. In recent decades, our understanding of experience of his or her illness. We spend the traditional doctor-patient or therapist- much time teaching the next generation of patient relationship has deepened to account psychiatrists what to prescribe versus how for the unconscious elements of a continuous to prescribe; what manualized treatments to interplay between 2 whole human beings administer versus questioning why our who both have a complex subjective life. This patients engage in dysfunctional patterns of view, called “intersubjectivity,” replaces a thinking, feeling, and relating to others, and view of the psychiatrist or therapist as the what impact these patterns may have on their objective, detached expert who administers interaction with us in the here-and-now of the a standardized treatment for a diagnosis. treatment setting. In this paper, we propose Psychobiological therapy is now recognized as an integrative psychobiological model, in which biological interventions carry personal meanings, and relational transactions in the SHAPIRO, JOHN, SCOTT, and TOMY: Department of Psychiatry and Psychotherapy Supervisors’ Group, Univer- treatment setting are a form of learning that sity of Alberta, Edmonton, AB, Canada results in lasting physiological changes in the Copyright © 2016 Wolters Kluwer Health, Inc. All rights brain. Psychiatry needs to reconnect with its reserved. roots as a science of attachment and meaning, Please send correspondence to: Yakov Shapiro, MD, Depart- in which attention to the objective, subjective, ment of Psychiatry, University of Alberta, 2931-66 St., and relational domains of the patient-pro- Edmonton, AB, Canada T6K 4C1 (e-mail: [email protected]). vider experience is equally foundational for ACKNOWLEDGMENTS: The authors acknowledge the help- any successful treatment outcome. ful input of Ron Oswald, MD and Tania Oommen, MD. (Journal of Psychiatric Practice 2016;22;221– The authors declare no conflict of interest. 231) DOI: 10.1097/PRA.0000000000000159

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a multi-layered engagement between 2 human or her illness too often take a back seat to the beings, in which their subjective lives affect each symptom-driven diagnostic categories of the Diag- other within a therapeutic framework designed nostic and Statistical Manual of Mental Disorders to be conducive to beneficial change. (DSM) classification.3 Since the 1980s, biological Notable is the report that, even in a national psychiatry, with its reductionist “mindless brain” health system such as Canada’s that provides metaphor of patient care, has also become the pre- care for all of its people, current administrative dominant model in academic psychiatry training, and clinical practices interfere with the inte- further deepening the divide between biological and grated, person-oriented approaches that are psychotherapeutic schools of thought. most effective for complex, persistent psycho- Economic stresses in public health funding in biological disturbances. Canada and the advent of “Managed Care” in the United States have put the therapeutic aspects of Norman A. Clemens, MD the doctor-patient relationship under mounting Psychotherapy Section Editor pressure, with psychiatrists increasingly being forced into the role of psychopharmacology con- The relationship of psychotherapy and psychiatry sultants, providing brief (10 to 20 min) “expert” has been a tumultuous one. The pendulum of bio- interviews (med-checks) in the name of cost-effi- logical versus psychosocial treatments has swung ciency. A Canadian article advocating this approach widely over the last 120 years since the discovery of was recently published in the Globe and Mail,4 the “talking cure.” The early hope for a scientifically where the authors proposed redefining the role of based “neurology of the mind”1 gave way to an psychiatrists and suggested that, “Psychiatrists emphasis on the classical psychoanalytic frame- provide diagnostic assessments and treatment rec- work, sometimes to the exclusion of emerging find- ommendations; other mental health professionals ings from evolutionary biology, infant development, such as psychologists and social workers provide and the newly developing disciplines of affective, psychotherapy and other front-line treatment.” cognitive, and social neuroscience. With the advent They reference the American, British, and Aus- of humanistic, gestalt, cognitive-behavioral, and tralian systems in which “psychiatrists are limited relational schools, the spectrum of psychotherapy to rapid, high-volume psychiatric drug con- approaches today has ballooned to over 500,2 sultation.” This brings up the specter of a conveyor- sometimes practiced without clear data for their belt approach to patient care, in which spending efficacy or specific indications for their use. Many of more time with our patients to understand and these therapy schools similarly eschewed develop- address their experience of mental illness becomes ments in neuroscience, perpetuating a “brainless a dispensable luxury. mind” approach to patient care and deepening the Psychiatry today is at a crossroads. Increasingly, schism between biological and psychosocial aspects we have to defend the very foundation of our field as of psychiatric treatment. a biopsychosocial discipline—the treatment pro- On the other hand, the advent of psychopharma- vider’s relationship with his or her patient and cological modalities since the 1950s has served to attention to the patient’s subjective experience of his shift the emphasis of psychiatry toward biological or her illness.5 We are witnessing an unprecedented interventions, with a proliferation of pooled stat- proliferation of generic manualized treatments, both istical data to inform individual patient care. Mental in psychotherapeutic and psychopharmacological illness is increasingly seen as an aberration or domains, which are validated to target shifting DSM “chemical imbalance” in the brain that could be syndromes rather than the human beings who suffer corrected by psychopharmacological agents, electro- from them. Psychiatrists increasingly operate high- convulsive therapy, and, more recently, deep brain volume practices and rely on computerized tools or and repetitive transcranial magnetic stimulation. allied health professionals to gather information Although these therapeutic modalities are impor- about their patients in response to pressures to tant and some of them have demonstrated ther- reduce waiting lists or satisfy the demands of third- apeutic efficacy in specific conditions, the patient’s party agencies. Increasingly, our patients are unique developmental history and experience of his treated as a “commodity” that has to be efficiently

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“processed” to minimize health care costs or increase brain/mind as a unified system that possesses a the profit margin. Despite the emphasis the Cana- fundamental first/third person complementarity.8 dian Royal College of Physicians places on biopsy- The “biological” neuroscience perspective operating chosocial orientation in psychiatric treatment and psychopharmacological and brain-based modalities training, and the statement by the United States often gets equated with “scientific psychiatry,” Accreditation Council on Graduate Medical Educa- while attention to the patient’s subjective experi- tion that integrated psychotherapy/psychopharma- ence and relational dynamics in the treatment set- cology is a core competency area,6 the languages of ting is relegated to little more than dispensable biological and psychotherapeutic psychiatry remain pseudoscience. From the psychobiological per- as far apart as ever. spective, a functioning human brain has both sub- The purpose of this 2-part series of articles is to jective and objective aspects to it, which operate as review the evidence showing that psychotherapy is an interconnected whole; by way of a comparison a form of biological intervention that induces last- from physics, elementary particles behave simul- ing structural changes in the brain, its efficacy taneously as a particle and a wave and show the equal to and often exceeding that of psycho- property of entanglement so that one cannot be pharmacological modalities. Conversely, there is studied in isolation from the other. The aspects of increasing evidence that patient expectations and brain/mind reality are distinct but inseparable and experience of treatment and the quality of the doc- irreducible to each other; therefore, the question of tor-patient relationship are crucial factors that whether mental illness is “really” a neurochemical contribute to medication response in all treatment imbalance in the brain or a subjective experience in settings.7 Paying attention to how, not just what, to the mind is meaningless, and is akin to asking prescribe, and combining psychotherapeutic and whether a photon is “really” a particle or a wave. psychopharmacological modalities can improve Physical science has taught us that neither position treatment outcome and adherence, and tends to be can stand alone; both are valid depending on the more effective than either treatment alone. observer’s vantage point and stand in fundamental Above all, we would like to open up a debate on complementarity in elucidating the nature of the very definition of psychiatry as a scientific dis- physical reality. In psychiatry, a functional system cipline that focuses on the patient’s unique psycho- that achieves the level of complexity we describe as biology, where his or her experience of mental ill- “a living person” is inseparably psychobiological:we ness and treatment is given equal priority to can only address psychopathology in a meaningful “objective” physical symptoms and evidence-based way by attending to both the objective behavioral/ statistical data. We hope to see the next generation neuroscience presentation and the patient’s sub- of psychiatrists trained to relate to a suffering jective experience of his or her biology. human being in the patient’s chair rather than be The second-person “I to You” intersubjective per- caught between the Scylla of manualized psycho- spective has been the subject of increasing attention therapy treatments and the Charybdis of dispensing in psychiatric treatment and training in the past statistical diagnostic labels and drugs to treat their 30 years, fueled by the formulation of attachment patients’“brain-based” pathology without paying theory, the impact of mother-infant research, and attention to the meaning of their experiences. the advent of interpersonal and relational psychotherapy models. The relational stance, also descri- “ ” PSYCHIATRY AS A PSYCHOBIOLOGICAL bed as two-person psychology (as opposed to DISCIPLINE one-person psychology of treating the psychiatrist as an impartial observer or limiting the therapeutic The schism between the third person “Itoit” interaction to the treatment provider’s “good self”) objective perspective and first-person “Itome” has largely replaced the traditional “blank screen” subjective experience continues to plague psychi- approach informed by the classical “objective atric treatment and training. Reductionistic science observer” model in physical and psychological sci- and the vestiges of Cartesian dualism (a deeply- ences. According to the classical view, physical entrenched separation between “biological brain” reality was seen as objective and independent of the and “immaterial mind”) impacts our ability to treat conscious observer, a paradigm instrumental in the

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development of both psychoanalysis and the medi- or negate their efficacy.13 The interface between cal model of psychiatric treatment. Mental illness, neuroscience, relational models of treatment, and in this view, is an intrapsychic aberration that the dynamic systems perspective has been partic- exists within the patient and has to be analyzed by ularly fruitful in providing a new informational an impartial expert-observer (whether psycho- language capable of unifying the “objective” domain analyst or psychopharmacologist) who provides a of synaptic mechanisms of psychopathology proper diagnosis and prescribes effective inter- with subjective and intersubjective systems of vention for it. Divergent as they were, classical meaning.14 psychoanalysis and biological psychiatry both fell The perspective of psychobiology forcibly argues into a common trap of focusing on the isolated for a systemic approach to brain/mind functioning patient-system and ignoring the complex inter- that integrates objective neuroscience and behav- subjective dynamics between the patient and the ioral presentation with the patient’s subjective caregiver that are now known to be a cornerstone of experiential perspective (Fig. 1). Steven Stahl, any successful treatment outcome.9 a renowned psychopharmacologist, recently We know now that an observer is inseparable commented that “psychotherapy can now be con- from the act of observation, a paradigm defined as ceptualized … as a neurobiological probe capable of the “participant observer” in quantum mechanics, inducing epigenetic changes in brain circuits, not where the very presence of an observer funda- unlike the ultimate actions of psychotropic drugs” mentally alters the wave function of the system (p. 251).15 Psychiatry is in a unique position among under observation.10 In the psychological domain, the medical sciences precisely because it aims to the complex attachment matrix with significant systematically study and address the interplay others continually shapes both our subjective sense of physical, psychological, and social/relational of “self” and synaptic networks underlying our aspects of mental illness; we do not identify our- subjective experience; in relating to others, we selves as neurologists because we treat “person participate in an ongoing process of mutual psy- diseases” rather than “brain diseases.” Whether or chobiological change. The participant observer not neurophysiological findings are present in position is nowhere more evident than in psychiatric treatment, where biological interventions FIGURE 1. Psychobiological model of inte- carry critical psychological meanings, and ther- grated psychiatric treatment: both psycho- apeutic interactions become a psychobiological tool therapeutic and psychopharmacological that induces lasting changes in the patient’s brain 11 interventions have biological impact on the physiology. The emergent patient-caregiver sys- brain, and both carry personal and rela- tem is seen to catalyze the development of more tional meaning, which contribute to thera- fi ’ adaptive con gurations in the patient s brain/mind peutic effects. system in a self-organizing, nonlinear process of therapeutic change.12 Psychiatric practitioners can bridge the persis- PSYCHOTHERAPY PSYCHOPHARMACOLOGY tent brain-mind divide by working within an integrated psychobiological model, in which we treat the person of our patient as a complex adaptive system that has both objective and subjective MODIFIED SYNAPTIC NETWORKS aspects to it. In addition, the intricate inter- PERSONAL & RELATIONAL PERSONAL &MEANING RELATIONAL subjective matrix between the complex adaptive MEANING system of the patient and that of the caregiver underlies every psychiatric intervention. Within this model, psychotherapy becomes a form of tar- geted biological process with the power to rewire ’ the patient s synaptic networks; conversely, bio- THERAPEUTIC EFFECTS logical treatments carry a wealth of subjective meanings and relational contexts that can facilitate

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psychopathology, the critical focus of psychiatric psychological implications as a transference inter- attention is on the patient’s verbal and nonverbal pretation. From a psychobiologic perspective, then, experience, such as the content of hallucinations/ a clinician’s task is not to decide between ‘biological’ delusions in a psychotic patient, or affective tone and ‘psychological’ therapies, because all therapies and relational dynamics in a patient with a mood or are always both” (p. 232). anxiety disorder. It is important to point out that attention to subjective and interpersonal domains does not PSYCHOTHERAPY HAS A LASTING IMPACT ON make psychiatry any less of a scientific discipline. THE PATIENT’S BRAIN STRUCTURE: THE In 2009, Velmans provided a useful classification of OBJECTIVE NEUROSCIENCE PERSPECTIVE objective, subjective, and intersubjective science, The idea that psychotherapy as a form of learning pointing out that all science is necessarily inter- can permanently affect brain physiology goes back subjective and depends on shared private experi- to Nobel laureate Eric Kandel’s19 seminal work ences; without knowing subjects, there is no published in 1979, “Psychotherapy and the single knowledge of any kind.16 Subjective and inter- synapse,” in which he stated: “I would argue that it subjective data can be examined using the same is only insofar as our words produce changes in each rigorous empirical criteria of identifying pathologic other’s brains that patient-therapist intervention patterns, forming hypotheses about their etiology, produces changes in patients’ minds. From this and subjecting them to relational validation in the perspective the biologic and psychologic approaches treatment setting, the paradigm defined as process are joined” (p. 1037). In a follow-up paper published research in individual and group treatment. The in 1998,20 Kandel proposed 5 principles of psycho- psychobiological approach brings to the forefront biological integration as part of a “new intellectual our patients’ agency in actively constructing their framework of psychiatry,” stating: “Insofar as psy- reality rather than being passive victims of their chotherapy or counseling is effective and produces brain pathology, and it helps us to avoid the pitfall long-term changes in behavior, it presumably does of treating our patients as “aberrant brains” whose so through learning, by producing changes in gene subjective experience we can ignore—a mirror fal- expression that alter the strength of synaptic con- lacy to the uninformed psychotherapist’s “disem- nections” (p. 460). In a recent interview, Kandel bodied mind” approach. The integrated science of psychiatry, therefore, arises at the intersection of objective, subjective, FIGURE 2. Psychiatry as an intersection of and intersubjective informational domains (Fig. 2). objective, subjective, and intersubjective Several integrative models such as interpersonal science. neurobiology17 and psychodynamic psychopharma- cology7 argue for incorporating psychotherapeutic and biological treatment modalities within the intricate web of intersubjective interactions in the treatment setting that contribute to treatment OBJECTIVE SUBJECTIVE response and compliance. This position was suc- SCIENCE SCIENCE cinctly summed up by Amini et al18: “In a psychobiologic model, the long-held distinction between PSYCHIATRY ‘psychological’ treatments and ‘biological’ treatments largely disappears … psychotherapy is not merely a conversation, or an intellectual exchange of words and ideas. Instead, it is an attachment relationship, which is a physiologic process capable INTERSUBJECTIVE of altering underlying neural structure. From this SCIENCE perspective, psychotherapy is just as ‘biological’ as any other treatment modality. Conversely … psy- chopharmacologic treatment has as many

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succinctly summed up the current state of psycho- principal brain areas: higher-order executive areas biological research: “Psychotherapy is a biological including the dorsolateral prefrontal cortex; cortical treatment, a brain therapy. It produces lasting, midline structures responsible for self-other repre- detectable physical changes in our brain, much as sentations (ventral and dorsal anterior cingulate, learning does” (quoted in McWilliams21). ventromedial and dorsomedial prefrontal cortex, There is now an overwhelming amount of evi- posterior cingulate, and precuneus); and limbic dence that a wide range of psychotherapy inter- areas responsible for emotional processing (insula, ventions have a direct and lasting effect on brain amygdala, ventrolateral prefrontal areas). They physiology. Early studies focused on cognitively demonstrated that clinical improvement in post- based treatment modalities, but there is also now traumatic stress disorder (PTSD) following imagery increasing evidence for the biological impact of exposure and cognitive restructuring is positively psychodynamic and integrated treatments. Baxter correlated with right ventral ACC activation, and et al22 showed normalization of right caudate inversely correlated with right amygdala activation, metabolism following successful behavioral therapy once again suggesting that psychotherapy recruits for obsessive-compulsive disorder. Later studies by cortical inhibitory regions to compensate for the same team using positron emission tomo- trauma-based limbic overactivity. graphy23 demonstrated normalization of a larger In the psychodynamic domain, Beutel et al29 cortico-striato-thalamic system in responders to showed that short-term dynamic psychotherapy in behavioral therapy. Paquette et al24 showed nor- panic disorder leads to increased prefrontal activa- malization of regional cerebral blood flow in the tion to panic-specific stimuli with a corresponding dorsolateral prefrontal cortex, which is implicated decrease in limbic (amygdala-hippocampal) metab- in working memory and conscious behavior plan- olism in treatment responders, findings which ning, as well as normalization of parahippocampal are again consistent with the prefrontal down- overactivity after successful cognitive-behavioral regulation of limbic overactivity. In the first study therapy (CBT) treatment. The authors concluded that investigated molecular markers of psycho- that, “Changes made at the mind level, within a therapy, Karlsson et al30 provided evidence psychotherapeutic context, are able to functionally that short-term dynamic psychotherapy increases rewire the brain” (p. 401). These results have been 5-HT1A receptor density (a known trait marker for corroborated by Straube et al,25 who showed major depression) in a wide range of networks increased bilateral activity in the insula and ante- including prefrontal, parietal, and temporal cortex. rior cingulate cortex (ACC), the regions that down- Indeed, there is evidence that patients undergoing regulate limbic overarousal responsible for intense psychodynamic treatment continue to improve fol- fear reactions, following successful CBT. lowing therapy discontinuation, which is not always Treatment-specific regional brain changes fol- the case for psychopharmacological or shorter term lowing CBT for major depression have been dem- interventions alone.31 A recent comprehensive onstrated by Mayberg’s group.26 These changes review of nearly 20 studies on brain changes fol- involve metabolic increases in the hippocampus and lowing psychotherapy32 documented the physio- the dorsal cingulate, and decreases in the dorsal, logical effects of CBT, interpersonal psychotherapy, ventral, and medial frontal cortex. The authors dialectical behavior therapy, and psychodynamic hypothesized that psychotherapy downregulates therapy in diverse patient populations, including the prefrontal-limbic system implicated in mood/ those with major depressive disorder, obsessive- anxiety disorders in a top-down manner. This and compulsive disorder, panic and social anxiety dis- other studies (see review by Linden27) suggest that orders, specific phobias, PTSD, and borderline per- psychotherapy may be recruiting inhibitory cortical sonality disorder. circuitry to compensate for higher limbic/amygdala Several other studies also deserve mention. activation that is responsible for hypervigilant Dichter et al33 showed that, in behavioral activation states in patients with depression, anxiety, or per- therapy, remission of avoidance symptoms in sonality disorders compared with controls. Frewen patients with major depressive disorder was corre- et al28 proposed a useful psychobiological paradigm lated with fMRI prefrontal changes in the reward for the impact of cognitively based therapies on 3 system, including paracingulate (reward selection),

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right caudate (reward anticipation), and orbito- treatment interventions than similar symptoms in frontal areas (reward feedback). Sharpley34 an otherwise well-adjusted business executive with reviewed the neurobiological effects of both CBT caffeine dependence. We need psychiatric nosology and psychoanalytic therapy, which have been to navigate the enormous complexity of psychopa- shown to reverse depression-associated hyper- thology and care provision, but we always have to cortisolemia, with serotonin transporter (SERT) remember that we treat sick people and not dis- levels being significantly increased following embodied DSM constellations of symptoms. As 12 months of psychodynamic psychotherapy. clinicians, we have to constantly question: How do Patients with borderline personality disorder fol- we apply our statistical knowledge in this unique lowing successful dialectical behavior therapy show case? Why is this person reacting the way he or she changes in the right ACC, right temporal and pos- does? What is the meaning of his or her symptoms? terior cingulate, and right insula areas that What combination of psychotherapeutic and correlate with decreased emotional overarousal.35 psychopharmacological interventions would be re- Studies of the analgesic effects of hypnosis show quired in this particular case? selective suppression of ACC/somatosensory activ- In addition, no treatment is a cure for all. Brief ity in pain processing.36 The findings of Lindauer CBT interventions advocated by HMOs and third- et al37 utilizing brief eclectic psychotherapy showed party insurers in the United States and Canada a positive correlation between remission of PTSD may be an excellent strategy to treat a patient with symptoms and changes in the activity of the left uncomplicated adjustment disorder, but prescribing medial prefrontal cortex, a region known to inhibit a course of 6 telephone-based sessions for a victim of amygdala response. Most intriguingly, narrative extensive developmental trauma or a patient with a exposure therapy in PTSD patients has recently personality disorder may do more harm than good been shown to reverse trauma-associated increases because deeper and more consistent therapeutic in basal DNA breakage in treatment responders exploration would be required. Strong evidence compared with controls.38 exists that complex psychiatric presentations benefit from longer term treatment, which is highly 39 THE ROLE OF PSYCHOTHERAPY IN cost-effective. Just as we may select an activat - PSYCHIATRY ing antidepressant or appetite-promoting anti- psychotic for a patient with anorexia and retarded The challenge in medicine is to select effective depression, we need to select an appropriate treatments that would benefit our patients and psychotherapeutic intervention out of a full range of allow reasonable access to them. Quantitative evidence-based treatments that fits our patient. research demonstrating safety, specificity, effec- Does the patient present with an acute or chronic/ tiveness, and cost-benefit analysis of psychiatric recurrent syndrome? Is there evidence of devel- interventions is essential for this purpose. However, opmental trauma or personality pathology? What is we are in danger of losing sight of our patient by the quality of the patient’s interpersonal related- focusing exclusively on “objective” nosology and ness? If we do not prescribe a hypnotic without syndrome-validated interventions. Clinical syn- exploring the pattern and nature of the patient’s dromes do not exist independently of the patient’s sleep disruption, we cannot automatically prescribe experience of his or her illness. Psychiatric classi- a course of standard manualized treatment to fication can be likened to charting star con- everyone who presents with psychological distress. stellations: they do not exist “out there in the sky” The challenge of integrated treatment is to devise but represent accepted conventions that can be an individualized treatment plan that would useful in navigating our way around the globe. Just address the question: “What works for whom?”40 as the stars that we see forming the constellations Pressures toward manualization and statistical can belong to completely different systems, pre- diagnostic and treatment guidelines, useful as they senting symptom clusters may arise from different may be in research settings, can contribute to the etiologies in different patients. A recent onset of dehumanization of psychiatry. In the words of panic symptoms in a young mother who had been a Duncan and Miller,41 “Manuals equate the client victim of childhood abuse requires a different set of with a DSM-IV diagnosis and the therapist with a

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treatment technology, both interchangeable and presentation as the problem to be fixed, to con- insignificant to the procedure at hand” (p. 148). As ceptualizing presenting pathologic patterns as the it stands, “empirically supported therapies” and patient’s imperfect adaptations to his or her life evidence-based practice guidelines rely on averaged experiences. By providing a healthier relational statistical data across many subjects and treatment environment and psychopharmacological stabiliza- providers, an approach that tends to ignore the tion in the here-and-now treatment setting, we subjective and intersubjective dimensions of psy- create a “secure base” for change that allows more chiatric treatment.42 By focusing on the “syndrome” functional adaptations to take shape in the course and ignoring the unique aspects of the patient of the treatment. This perspective is consistent with presentation and patient-provider interaction, memory reconsolidation and epigenetic plasticity manualized treatment can lead to the “conveyor- research,45,46 and integrates objective, subjective, belt” model of care, where we end up treating and intersubjective perspectives that can truly generic diagnostic labels with generic interventions unify psychiatry with medical science. Symptoms over a predetermined generic period of time. become clues to the underlying psychopathology To use a musical analogy, we could be asked to rather than problems in themselves. In effect, every listen to “the best” averaged performance of a Bach successful treatment provider helps the patient to fugue compiled from multiple recordings by differ- make sense of his or her emotionally laden experi- ent artists and use it as a template to teach future ences (working through “feeling bad”) and uses generations of musicians. Technically flawless as some theory-based structure (whether psychother- such a “manual” might be, it would be entirely apeutic, psychopharmacological, or both) to form a meaningless and even harmful because the con- meaningful relational bond that influences the sistency and richness of the individual inter- success or failure of the treatment. The dynamics of pretations have been lost. It is the patient who forming a therapeutic alliance parallel findings provides the “musical score” for the treatment from mother-infant research concerning what process; the majority of our patients do not present facilitates the development of secure attachments,47 with categorical DSM diagnoses, and it is the rule and they transcend brand-name treatment rather than an exception that patients in clinical (as approaches, being equally applicable in both opposed to research) settings have multiple comor- psychotherapeutic and psychopharmacological do- bid conditions and transcend the diagnostic cate- mains. gories, which themselves shift from one DSM edi- 43 ’ tion to the next. In addition, patients symptoms CONCLUSIONS do not remain static, changing in the course of the treatment. In his recent book, Allen Frances,44 A great deal of progress has been made in eluci- chair of the DSM-IV Task Force, stated: “DSM has dating the biological effects of various psychother- to stay simple but psychiatry doesn’t. DSM diag- apy interventions, substantiating their efficacy, and nosis should be seen as just one small part of an applying them in various patient populations, both overall evaluation that would also comprehensively as monotherapy and in combination with psycho- account for the more complicated and individual pharmacological modalities.48 Process research aspects of each patient” (p. 25). demonstrates that the quality of the doctor-patient Clinicians may need to move from conceptualiz- relationship, the patient’s expectations of treating psychiatric diagnosis as “fixed and objective ment, and the patient-provider fit comprise some of categories” to looking at diagnosis as a process of the “common factors” that contribute to treatment getting to know our patients that grows out of the outcome in all schools of psychotherapy, as well as deepening therapeutic relationship. In this view, to psychotropic medication response.49 There is presenting symptoms become evolving constructs, clear evidence that psychotherapy is a cost-effective the tips of psychopathologic icebergs floating within intervention for a variety of psychiatric conditions, the currents of the patient’s subjective experience; reducing both the direct and indirect economic they gradually “melt” and change their config- burden of mental illness.50 These data strongly urations during the treatment process. We have to suggest that both psychopharmacological and move from looking at the patient’s symptomatic relational/psychotherapeutic aspects of treatment

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are equally foundational in psychiatric practice, patient’s pathologic patterns of adaptation to their comprising an integrated, psychobiological developmental environment are brought into the approach to patient care that transcends the Car- treatment setting and remolded in the course of tesian brain-mind dichotomy. It is just as detri- patient-provider interactions. Psychopharmaco- mental to ignore the patient’s experience of the logical and psychotherapeutic modalities partner illness and the relational patterns that he or she together in building new synaptic pathways that brings into the treatment setting, as to treat a allow patients to restructure the meaning of their severely depressed or psychotic patient without subjective and interpersonal reality in a nonlinear, appropriate medications. The process of diagnosing self-organizing process of change. From the psy- and prescribing, and the relational transactions chobiological perspective, the real problem may not during the doctor-patient interchange are both reside in the illusory separation of biological versus endowed with a plethora of meaning that can either psychotherapeutic interventions but in focusing on facilitate or adversely affect the treatment outcome. the patient’s “objective” symptomatic presentation In their stunning reanalysis of data from the National at the expense of his or her subjective meaning and Institute of Mental Health 1985 Treatment of Depres- relational interactions. Recent trends toward psy- sion Collaborative Research Program, McKay et al49 chotherapy integration and combined psychotherapy/ identified a “prescriber effect,” with prescribers who were psychopharmacology treatment within a single-pro- rated as being in the top third of the sample in terms of vider model are instrumental for this purpose. treatment outcomes, having better outcomes with pla- Above all, we need to teach future generation of cebo treatment than were achieved by the third of psy- psychiatrists to understand the person in the chiatristswhowereratedastheleasteffectiveandwere patient’s chair rather than to turn into glorified prescribing active antidepressant medications. In dem- pharmaceutical or manual-driven technicians, who onstrating that the treatment effects of psychiatrist predominantly dispense generic diagnostic labels and prescribers were greater than those of active medication, statistically validated treatments for them. William McKay and colleagues49 cite earlier warnings from Osler’s timeless statement that, “It is much more Sadock and Sadock51 that “physicians’ failure to estab- importanttoknowwhatsortofapatienthasadis- lish good rapport with patients accounts for much of the ease than what sort of a disease a patient has” holds ineffectiveness of care” (p. 6). Similar findings in the particularly true in psychiatry. To achieve this goal, psychotherapy domain reported by Duncan and Miller41 we have to shift our focus from teaching what to have shown that therapeutic efficacy is not dependent prescribe to how to prescribe; from teaching evidence- on the therapist’s theoretical adherence or technical based treatments to empirically supported principles proficiency but rather on his or her biological versus of change,52 and from teaching brand-name man- psychological orientation and attitude toward longer ualized technical skills to understanding why our term individualized treatment. In their words: “Psycho- patientsreactthewaytheydo.Embracinganinte- therapy is not … the sterile, stepwise process of surgery, grated psychobiological model of psychiatric care that nor the predictable path of diagnosis, prescription, and addresses the whole person of our patient and makes cure. It cannot be described without client and therapist, ourselves full coparticipants in the process of adaptive coadventurers in a journey across largely uncharted change is a major step toward this goal. territory” (pp. 148–149). Attention to individual and relational meanings can serve as an invaluable diagnostic and treatment tool that can only be downloaded to RECOMMENDATIONS FOR THE ROLE OF computer software or allied clinical staff at the patient’s PSYCHOTHERAPY IN PSYCHIATRY peril. The need to attend to the patient’s subjective (1) Psychiatry should be seen as a fundamentally experience and here-and-now relational process psychobiological discipline that aims to address both underscores the fact that a patient and treatment the patient’s objective pathology and his or her provider together not only bring their unique sub- subjective and relational experiences, including jectivities into the treatment process, but also form relational dynamics in the treatment setting. a joint complex adaptive system that catalyzes its (2) The study of subjective experience and inter- own trajectory toward therapeutic change.14 The subjective interactions inherent in the doctor-

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patient relationship should be put on an equal understanding the patient’suniquesubjective footing with the study of the brain, in keeping dimension and the intersubjective interplay inher- with the delineation of objective, subjective, and ent in the doctor-patient relationship should be intersubjective science. incorporated in all psychiatric residency curricula. (3) The separation of biological and nonbiological In addition, psychopharmacological and psychother- treatments in psychiatry is obsolete. Both apeutic supervision should not be divorced from psychotherapy and psychopharmacology occur each other, which only serves to perpetuate the in the context of the therapeutic relationship; brain-mind dichotomy. Instead, integrative both induce structural changes in the brain; and approaches, such as psychodynamic psychopharma- both carry a wealth of subjective meaning that cology and combined medication/therapy treatment, influences treatment outcome. should be utilized whenever possible. (4) Attention to the therapeutic alliance and integrated psychotherapy/psychopharmacology should be considered fundamental to any psychiatric treatment. In most clinical situations, REFERENCES the question is not whether a patient needs 1. Freud S. Project for a scientific psychology. In: Gay P, medication or therapy, but what kind of medi- editor. The Freud Reader. New York and London: W.W. cation and what kind of therapy are most Norton & Co; 1989/1895. 2. Lilienfeld SO, Arkowitz H. Are all psychotherapies appropriate. As professionals trained in both created equal? Sci Am Mind. 2012;24:68–69. 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