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Resolving Psychotherapy’s Identity Crisis
A revolution in the understanding of brain biology has produced potent new drugs to combat mental illness. But there is still a need for psychiatrists who can do more than write prescriptions. Combining medication and the “talking cure,” therapists are now making progress against ailments once thought untreatable.
May 1996
by Bruce Fellman
When they work according to plan, the 100 billion cells in the human brain make it capable of both the mundane and the sublime—from the brushing of teeth to the composing of symphonies. Sometimes things go awry, however, and when that happens, the results can range from a temporary case of the blues to outright insanity.
For much of this century, the care of the mentally ill has fallen to psychiatrists, who since the days of Sigmund Freud have traditionally worked with “talking cures,” the process of gradually peeling back the layers of a patient’s personal history through hours of conversation. More recently, therapists and patients alike have been turning to briefer forms of intervention, some of which have drawn the fire of skeptics as “McTherapies.”
But changes in the understanding of brain biology are now contributing to a fundamental shift in the way many psychiatrists envision mental illness. Such devastating conditions as schizophrenia and manic-depression, along with a range of lesser psychoses, are now seen as products of failures in the neural circuitry, rather than as the result of unresolved emotional conflicts. These advances in neuroscience have made possible an array of drugs that are effective against conditions that analysis and other types of traditional therapy couldn’t touch, and this development, along with changes in the way medical care is delivered (and paid for), has brought dramatic and, sometimes, divisive changes to psychiatry. “It’s no longer possible to conceive of mental illness as simply a battle, in Freudian terms, between the super-ego and the id, with the ego getting caught in the middle,” says Benjamin S. Bunney, the Charles B. G. Murphy Professor of Psychiatry and chairman of the department. “It’s hard to ignore the brain as an organ anymore.”
As a result of these developments, the therapeutic world has been rocked by what some have called a “holy war” between psychoanalytically oriented psychiatrists and their more biologically oriented colleagues—between the “talkers” and the “pill-poppers.” Lawrence H. Price, a Yale associate professor of psychiatry, says that at some institutions the “psychotherapy-or-drugs” conflict has resulted in “academic ethnic cleansing,” the wholesale dismissal of one group or another. One of the few places that seem to have arrived at consensus rather than conflict over this “identity crisis” is Price’s own department.
The reason, says Bunney, has to do with the long-term use of what remains a fundamental tool of the trade. “There’s real communication between the basic biologists and the clinicians,” he says. “Discoveries made in the laboratory lead to hypotheses about how the brain is functioning, or, in the case of disease, malfunctioning, and the clinicians can then test those hypotheses on patients. There’s tremendous cross-fertilization.”
Bunney is quick to acknowledge that disagreements exist, but he argues that the ability to “crosstalk” has facilitated collaborations within the department as well as with other parts of the University, such as the Law School and the Whitney Humanities Center, and that these collaborations have helped Yale’s psychiatrists come to grips with their differences. He also points out that the process has been aided by a tradition of conversation between biologists and therapists at Yale that began when Fritz Redlich, a Viennese-trained psychoanalyst with an interest in the biology of the brain, brought the parties together as chairman of the psychiatry department in the 1950s.
The increasing acceptance of psychopharmacology is indicative of a “sea change” in psychiatry, says Price. “The thinking was that drugs would prevent psychotherapy from progressing, but now even senior analysts who thought of themselves as purists are using medications.”
The main reason is this: The drugs work in situations where traditional forms of therapy—analysis in particular—simply fail to help. This is not to say, however, that psychiatrists are abandoning the couch. William H. Sledge, the department’s associate chairman for education, says he still believes that Freud’s ideas about the unconscious and the influence of childhood experiences on adult behavior are useful in treating inner turmoil. But Sledge, who works with patients suffering from schizophrenia, admits that analysis, while a “unique form of education,” is powerless against many kinds of psychosis.
Lawrence Price is an expert in the treatment of one of these resistant conditions, the obsessive-compulsive disorder. Somewhere between 1 and 3 percent of this country’s population (the number is similar in other countries and cultures) are in the grip of what Price calls “unwanted, intrusive, irrational, and repetitive thoughts that are accompanied by repetitive behaviors.” A classic example of OCD is an obsession with germs and dirt. “We’ve seen people who’ve had analysis develop lots of insight into their OCD condition, and they clearly have come to recognize that what they’re thinking and doing is ludicrous,” says Price. “But they’re still washing their hands 40 times a day.”
Within the past five years, improved technology—particularly PET scanners and magnetic resonance imagery—has allowed researchers to watch the brain at work, and when they looked inside the heads of OCD patients, they saw a peculiar pattern of activity. The front part of the brain, says Price, “was in overdrive.” This hyperactivity, however, is a symptom of the condition; the cause, he believes, lies at a deeper, and so far invisible, level of the brain. “I suspect that the governing mechanism isn’t working,” the psychiatrist explains, “so the brain never says, 'OK, I’m done.' It’s like a record that keeps skipping.”
Price and his colleagues are working with a group of drugs that block the action of an important chemical messenger in the brain. About 50 percent of the time, the OCD brain calms when the medications are given, and the patients improve, sometimes dramatically. “This used to be a chronic and untreatable condition, but that’s absolutely not the case now,” says Price, who has worked with more than 600 patients at the Connecticut Mental Health Center, a collaborative effort between the psychiatry department and the Connecticut Department of Mental Health. The ability to treat OCD is, Price notes, “one of the real success stories in psychiatry.”
So is the department’s approach to the treatment of panic attacks. Some five million people periodically experience these unprovoked and overwhelming bouts of intense anxiety. “Most of them don’t get adequate treatment,” says Andrew Goddard, an assistant professor of psychiatry who heads the department’s Anxiety Disorders Research Clinic.
Research has shown that about 70 percent of panic attack sufferers can be helped by medications. “In psychiatry, this percentage is excellent,” notes Goddard. For the past 30 years, antidepressants have been the drug of choice, but recently scientists and clinicians at Yale have shown that the same type of chemicals used to treat OCD (the best-known of which is Prozac) are highly effective.
In the case of panic attacks, as in other disorders, it is now possible to watch the malfunction in progress. Using an anxiety-provoking substance called yohimbine, researchers can induce an attack and then observe the cerebral reaction. “We see a reduction in blood flow in the frontal regions of the brain,” says Goddard, noting that this deficit in an area associated with the ability to reason correlates with a clinical observation. “Patients tell us that during a panic attack, they can’t think, they can’t will themselves out of it.”
Drug treatment helps return the brain to a semblance of normality, but researchers have discovered that the effect can be amplified by a behavior modification technique known as cognitive therapy, which by itself is effective in about 70 percent of panic attack sufferers. Cognitive therapy helps people unlearn bad habits and develop good ones, such as the ability to consciously restrain the panic response. Why a talking technique would work in this particular situation is a matter of conjecture, but Goddard suspects that the disorder involves two problems: an in-born overresponsiveness of the brain’s primitive “fright-or-flight” system, and the inability—probably learned—of the brain’s thinking centers to take charge.
“Both therapies have biological effects,” says Goddard, noting that the department’s work in panic attacks is an example of how biological research has validated the effectiveness of some forms of psychotherapy. In fact, the work is a validation of Fritz Redlich’s bringing both camps together, for researchers are finding that while either treatment alone can help 70 percent of sufferers, using both therapies together can enable 90 to 95 percent of panic attack victims to overcome the problem.
An equally dramatic example of the effectiveness of the combined approach is the department’s pioneering work with a drug called naltrexone. Yale psychiatrists have long used the medication to help heroin addicts overcome addiction, but on December 31, 1994, the Food and Drug Administration, as a result of research done at Yale and at the University of Pennsylvania, approved naltrexone for fighting alcoholism. “Its use represents a substantial shift in the way we’ve treated this disorder,” says Stephanie O'Malley, a leading naltrexone researcher and the associate director of Yale’s substance abuse treatment clinics.
Psychoanalysis has long been deemed ineffective in this area, and these days, many people find help in the 12-step program of Alcoholics Anonymous and a short-term cognitive approach that teaches new coping skills.
“The most important thing is to get a person to stop drinking in the first place,” says O'Malley, adding that the longer alcoholics can stay sober, the better the chance that what therapists term psychosocial intervention can help patients turn their lives around. “Naltrexone blunts the urge to drink,” she explains. And since a “substantial period of abstinence is predictive of how well patients will do later, the medication gives them a running start, a foundation to build on to be successful.”
No one knows precisely why naltrexone reduces the craving for alcohol, and O'Malley is quick to point out that scientists suspect the drug is not by itself particularly effective in the long term. But when combined with the proper form of psychotherapy, its use has created a breakthrough for the treatment of alcoholism. A recent study that O'Malley and her colleagues published in the research journal Archives of General Psychiatry compared a group of patients who were given naltrexone and counseling to a group whose therapy involved taking a placebo and receiving counseling alone. After six months, two-thirds of the naltrexone group were predominantly free of alcohol problems, while only one-third of the placebo group was problem free. “This is a very significant improvement,” she says.
These three examples highlight the direction in which the profession is heading. But will there be someone willing to pay for the journey? The failure of the Clinton administration’s health-care legislation in 1994 left a vacuum that was quickly filled by a proliferation of managed-care options, all of which imposed a strict “bottom-line” ethic on the practice of medicine. Psychiatry, says Benjamin Bunney, has been especially hard hit. “The mentally ill have never been valued by society and, because until recently we haven’t done the studies to determine which therapies are efficacious, mental health care is often seen as a bottomless pit of chronic illnesses that don’t have cures,” he says.
Small wonder that many insurance companies have cut back on mental health benefits. Small wonder, too, that fewer and fewer students are entering the profession. “This is a dark period,” says William Sledge, who notes that, in keeping with a national trend, the department recently cut back the number of psychiatric residencies from 22 to 15.
Changes in federal law have eliminated funding sources, and the managed care revolution, along with the advent of psychopharmacology, has changed the kind of care that can be made available. Thomas H. McGlashan, executive director of the Yale Psychiatric Institute (a private facility that treats both adolescents and adults), notes that in 1986, the average patient stayed at YPI for more than a year. “The old psychoanalytic model was that you provided the mentally ill with an alternative life experience, a protected place away from stresses and strains where they could get back on the track of normal development they'd derailed from,” says McGlashan, who has worked as an analyst and is currently doing research in the basic biology of personality disorders.
By 1990, patients were in residence at YPI for 60 days, and six years later, the average stay is less than two weeks. This shift to a predominantly short-term stay has meant, McGlashan admits, that the institute’s 66 beds, which used to be fully booked, are now on average only two-thirds full. “We’re struggling financially,” he says. “It’s simple economics. There are plenty of patients out there, but there are fewer of them who can pay.”
The irony is that the health-care revolution threatens to deny people access to a system that, because of the revolution in psychiatric research, can finally help them get well. “This is a tremendously exciting time for biological psychiatry,” says Eric Nestler, the Elizabeth Mears and House Jameson Professor of Psychiatry and Pharmacology, and an expert on addiction, “because for severely ill patients, we now have the tools to deal with the illnesses we’re charged with treating.”
In these uncertain times, the Yale “crosstalk” model seems to offer some hope for both patients and professionals. “The psychiatrist of the future is going to have to be a good psychotherapist and a good psychopharmacologist—it shouldn’t be an either-or situation,” says George Heninger, a professor of psychiatry whose research has involved looking into the biology of many of the major forms of mental illness. “The disorders we are dealing with—the mental 'car wrecks'—are not attitudes. They’re major abnormalities in brain function, and they require major repair jobs. So while we need people and techniques to bend back fenders, there will always be a need for people who can do tuneups, for people who can do psychotherapy.”  |
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