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Integrating Psychotherapy and PharmacotherapyReview - Integrating Psychotherapy and Pharmacotherapy
Dissolving the Mind-Brain Barrier
by Bernard D. Beitman, Barton J. Blinder, Michael E. Thase, and Debra L. Safer
WW Norton, 2003
Review by Robert Tarzwell, M.D.
Oct 22nd 2004 (Volume 8, Issue 43)

The authors of Integrating Psychotherapy and Pharmacotherapy chose the rather seductive subtitle of Dissolving the Mind-Brain Barrier.  While I admire the audacity, almost as cheeky as Dennett's Consciousness Explained, the book itself, of course, does no such thing.  That gap in epistemic space is nearly as wide as the gap in conceptual space between psychiatry's two prevailing solitudes – biological and social psychiatry, with their preferential biases toward medications or else psychotherapies, respectively.  Are we beginning to see encouraging signs that the Great Schism is in early stages of repair?  Professor Beitman, in the Preface, boldly asserts that "Psychiatry is the mind-brain profession.  Mental health professionals can no longer afford the dichotomy.  The authors of this book are firmly committed to healing this conceptual schism" (p. xi).  For my part, amen to that.

However, the reader gets no call to action within the psychiatric politic.  Instead, the book is aimed at a clinical audience.  Specifically, it is aimed at psychiatry residents, and Beitman indicates it was test-driven by a resident group at Missouri-Columbia.  Part I of the book is primarily a collection of clinical vignettes where combined treatment issues are prominent.  Organized around six topics, each chapter presents a brief introduction, a clinical case, a series of questions for discussion, followed by a set of suggested answers to spur further discussion.  The sections end with the anecdotal reactions of the psychiatry residents who test-drove the cases.  Part II of the book, far more salient to a wider audience, discusses the current state of the literature on combining psychotherapy with medication, devotes a chapter to "psychodynamic neurobiology,"  and includes a chapter, more of interest to specialists, on "split treatment," that situation where an individual receives psychiatric medications from one practitioner and psychotherapy from another.

The first section of "Part I:  Issues, Vignettes, and Commentary," is "Research in Combined Treatments," and the authors convey a critically important message:  "Combined treatments do not uniformly produce additive benefits" (p. 3).  Clinical lore suggests that patients do better with both psychotherapy and medications, but research doesn't bear that out in an unqualified way.  Throughout the book, however, it is never qualitatively clear what is meant by psychotherapy.  Quantitatively, the authors are definitely talking about CBT (cognitive-behavioral therapy), interpersonal therapy, family therapy, and psychodynamic therapies.  But so what?  Psychotherapy cannot be doled out, in measured fashion, like a drug, with a guaranteed amount of active compound, free of impurities.  Psychotherapy depends directly on the practitioner and on that person's ability to form a therapeutic alliance with the sufferer.  This is both good common sense and well borne out by psychotherapy research.  It is, furthermore, the single biggest predictor of a good therapeutic outcome, far outstripping the theoretical orientation or training of the therapist.[1]

Despite this, combined treatment research, thus far, has made little effort to address the quality of the therapy being delivered in terms of therapeutic alliance.  Instead, it resigns itself to addressing much easier questions, such as tape review to ensure the psychotherapy model under study is being adhered to.  The question of model-adherence may be important, but it must necessarily take a back seat to the overriding issue of whether the therapists in the study are actually any good at psychotherapy, over and above being good at a particular variety of therapy.  Beitman (and then Thase in Part II of the book) neither acknowledges nor addresses this serious conceptual shortcoming in combined research, a shortcoming which, I suggest, jeopardizes the validity of the entire combined treatments research enterprise.

Section 2 on "Pharmacotherapy During Psychotherapy" discusses the fascinating question of prescribing a pill as a psychotherapeutic act in itself, all questions of receptor biochemistry aside.  Beitman discusses the various ways in which the prescription might be psychologically viewed by the patient, from negative abandonment, through positive gift, and the vignettes are very compelling.  However, the question just dying to be asked goes unaddressed:  if the act of prescribing is so psychologically powerful, why should we suppose that the active compound does anything to the mind and brain that cannot be accounted for by psychological explanations alone?  This is not an idle question.  A Cochrane Review of antidepressants versus active placebos (compounds which generate side effects similar to antidepressants but are not thought to have psychopharmacological activity) found that "differences between antidepressants and active placebos were small. This suggests that unblinding effects may inflate the efficacy of antidepressants in trials using inert placebos."[2]  By "unblinding," the authors refer to the common problem of patients in the active treatment arm realizing they are on active treatment by virtue of experiencing unusual side-effects which would be unlikely on inert placebos.  Essentially, when patients can't tell if they're on the active drug or the placebo, their outcomes are eerily similar.

Beitman seems to inadvertently make this point himself in Section 3, "Psychotherapy During Pharmacotherapy," where he discusses the doctor/patient relationship, pointing to research which reveals that "the better the relationship the higher likelihood of a positive response to medication" (p. 35).  Even more interesting are some of the statistics he quotes about psychiatry residents who inform their patients that they are graduating and therefore leaving the patients in the care of others: "about 20% of their patients worsened, 32% required medication changes, and about 10% decided to quit their medications" (p. 36).  Sadly, Section III misses the opportunity to wonder skeptically about psychiatric medications and makes the automatic assumption that the medications are good.  Since they are good, it is therefore advantageous to encourage compliance, and much of the section discusses CBT techniques to help patients explore their non-compliance, challenge it, and overcome it.  But if the benefits of medication are not clearly separate from the caring relationship itself, and if the compounds have known toxicities, why jeopardize the known healing potential of the caring relationship by encouraging patients to stay on medications if they have no clear wish to?  This is paternalistic, coercive psychiatry, even though well intentioned.  Careful skepticism towards medications and their putative mechanisms of action would obviate many a power struggle within psychiatric clinics.

Section 5, "The Sequencing Problem (Using Panic Disorder as an Example)," grapples with the issue of whether to start with psychotherapy, medications, or both at once.  The research that would be required to have definitive answers is complicated, making it hard to know what is influencing what, and it is also expensive, making the generation of sufficient statistical power less likely.  Therefore, much of the time, there will be no clear guidance from literature.  Again, it will be an issue to be decided between the treater and the sufferer, on the strength of their relationship, patient preferences, and the treater's skills.  Beitman suggests situations where medications are "required" first (schizophrenia, bipolar disorder, but again, refer to the Bola and Mosher reference for a sharply differing opinion), where psychotherapies are "required" first (simple phobias, uresolved grief), and where it simply isn't clear (post traumatic stress disorder, borderline personality disorder).  In a wonderful vignette, Beitman describes the treatment of a young woman with panic disorder who developed acute paranoia while on clonazepam, just after discovering her daughter being bullied at school.  The case richly illustrates how a medication side-effect (disinhibition) can have deep psychological roots from the story of the patient's own bullied life.

Part II of the book, "Research Perspectives, Split Treatment, and Psychodynamic Neurobiology," offers three papers which provider deeper background reading on the topics raised in Part I.  The review by Thase on integrating medications with psychotherapy finds that carefully scrutinizing the research reveals "a systematic underestimation of the additive effects of combined treatment, especially among subgroups with more severe mental disorders" (p. 112).  The review is thoughtful and sophisticated.  One notable surprise finding Thase mentions is that, although the data are limited, prescribing psychiatrists seem to have better outcomes than prescribing primary care physicians.  He does not speculate as to why this might be so. 

Thase also, unfortunately, not only espouses the well-worn psychiatric mantra that "schizophrenia or mania should not be treated with psychotherapy alone," but goes much further and blares that "to knowingly withhold pharmacotherapy from patients with these disorders is tantamount to malpractice. . .when pharmacotherapy is indicated as a life-saving treatment" (p. 132).  Notably absent from this rather dramatic assertion are the perspectives of psychotics and manics who find themselves medicated against their will and suffer very serious side-effects.  Unfortunately, there is no way of knowing in advance who will benefit from neuroleptic treatment, and a very sizable minority of psychotics gain no appreciable benefit from neuroleptic treatment.[3]  Furthermore, peer-reviewed research has demonstrated that acute psychosis can be managed effectively without neuroleptics through the use of caring relationships in structured settings.[4]  I find it meddlesome to have a renowned psychiatric researcher dictate to his profession what constitutes malpractice, especially when the issue is not at all clear-cut, and so much scientifically well-founded difference of opinion exists in the literature.  This is psychiatric culture, not good science.

The final chapter in the book, "Psychodynamic Neurobiology," by Professor Blinder, is an intelligent and artful synthesis, using psychopathology as an example of how top-down and bottom-up approaches to bridging the mind-brain gap are yielding rich results.  His analysis is far more sophisticated than the usual "this structure mediates that phenomenon" approach and signals a new sophistication within psychiatry, one which moves beyond simplistic, epiphenomenal or identity monism (i.e. "Mental event x is brain event y or is caused by brain event y.").  This is the best stuff in the book and comes closest to "dissolving the mind-brain barrier."

It is hard to make a final assessment of this book.  It brings to light the critical issue of the therapeutic alliance and its overriding importance in helping suffering people to do better, whether by way of medications, psychotherapies, or both.  It has crisp clinical vignettes which highlight underlying conceptual and clinical dilemmas.  It also has a wonderful essay on the neurobiology of psychodynamics, almost worth the price of the book on its own.  However, it isn't nearly critical enough of the research literature in combined therapies, which it nevertheless claims to review.  There is no effort to robustly define psychotherapy, no effort made to wonder about just how much room is left for medication efficacy when psychological factors are fully accounted for, and the bald assertion about what constitutes malpractice is stunning.  What the book does accomplish is to encourage deeper thinking by mental health clinicians of all stripes about just how subtle and pervasive their relationships are with the suffering, and it most certainly abolishes the notion that physicians can hide behind prescription pads.  The doctor is the pill.

 

© 2004 Robert Tarzwell

 

Robert Tarzwell is a fourth year psychiatry resident at Dalhousie University in Halifax, Nova Scotia, Canada.  His psychiatric interests include emotion-focused psychotherapy, evolutionary accounts of psychopathology, and the causes of madness.  His philosophical interests include the mind-body problem, the problem of psychiatric nosology, and the philosophy of science, particularly as it relates to the scientific investigation of psychiatric disorders.

 



[1] Frank, J.D. and Frank J.B.  Persuasion and Healing:  A Comparative Study of Psychotherapy.  3rd Edition.  Johns Hopkins University Press:  1993.

[2] Moncrieff J, Wessely S, Hardy R. Active placebos versus antidepressants for depression (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley & Sons, Ltd.

[3] Bentall R.P.  Madness Explained:  Psychosis and Human Nature.  Penguin Books: 2003, pps. 499-504.

[4] Bola J.R. and Mosher L.R.  Treatment of Acute Psychosis Without Neuroleptics:  Two-Year Outcomes from the Soteria Project.  Journal of Nervous and Mental Diseases 191:219-229, 2003.


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