Month: September 2007

The New York Times has an article on the changing fortunes of the New York Psychoanalytic Institute and why psychoanalysis is being increasingly marginalised in mental health.

Psychoanalysis, the name for both the theory practice of psychological treatment developed by Freud, was once the driving force behind American psychiatry and the only game in town as far as psychological treatment was concerned.

It is now becoming increasingly marginalised, thought of as a bit eccentric, and overtaken by newer cognitive therapies. Some of the reasons for this are undoubtedly to do with the culture of psychoanalysis itself.

A major historical factor has been the long and contentious history of the movement, which has been subject to constant splits, disagreements and factional in-fighting.

Part of the reason for this, perhaps more than for other therapies, is that psychoanalysis involves a much closer relationship between theory and practice.

In this framework, mental illnesses arise from unresolved emotional conflicts that the mind tries to handle by various psychological defences. These defences may fail, or they may be counter-productive in the long-term, supposedly leading to the symptoms of mental disorder.

The goal of psychoanalysis is not necessarily to reduce the symptoms but to resolve the inner conflicts (Freud famously said he wanted to transform “neurotic misery into ordinary unhappiness”).

So, what tells you when the patient is improved? Why psychoanalytic theory of course.

And if you come up with a new theory of a disorder, you are, by definition, suggesting a new form of treatment, and often, new criteria for therapeutic success.

You also might be suggesting that your colleagues’ practice is wrong – hence the infighting and divisions.

In contrast, most other forms of treatment (including drugs and other psychological therapies) rely on descriptive measures of symptom improvement that form of the benchmark of psychiatric outcome studies, so theory and practice are much less intertwined.

Analysts will argue that these other treatments only deal with the surface symptoms and don’t deal with the ‘deeper concerns’, but the same issue arises – what constitutes ‘deep’ in this context is psychoanalytic theory.

In contrast, the development of cognitive behaviour therapy (CBT) has seen an opposite pattern. If new innovations work, they are typically re-included under the same CBT banner – giving the impression of a single unified therapy, when in fact, the boundaries are quite loose and determined by what has been shown to be effective in studies.

One of the other quirks of psychoanalysis, is that it’s selective for people who are quite wealthy.

Training as a psychoanalyst takes up to seven years, and requires you are in therapy yourself, usually for five times a week, at a cost of up to £100 ($200) a session. This comes on top of the cost of the training course itself.

For patients, therapy can also take years, and while most analysts will have discounts for the less well off, the costs can be significant. So despite some notable exceptions, it’s mostly the wealthy treating the wealthy – a curious enclave of the upper middle classes.

These factors also mean it’s very difficult to subject psychoanalysis to randomised controlled trials, because it’s so unlike anything else. This has made a new generation of clinicians, brought up with the mantra of ‘evidence based medicine’, suspicious of it.

With great reluctance in some quarters, the principles of psychoanalysis have been shoehorned into a number of briefer versions: psychoanalytic psychotherapy, transference-focused psychotherapy and so on.

Interestingly, symptom outcome studies have found that these can be quite effective, particularly it seems for ‘personality disorders‘ – a group of fairly ill defined diagnoses, but which typically involves destructive mood and relationship problems.

Despite the eccentricities and circular reasoning involved in some aspects of psychoanalysis, 100 years of practice has led to some important insights.

However, only recently has research started to pull out the wheat from the chaff in terms of how it can be applied to the demands of 21st century mental health care.

Link to NYT article ‘Patching Up the Frayed Couch’.
Link to AJP editorial on treatment of borderline personality disorder.

Renowned psychologist Dr Mary Pipher has handed back her American Psychological Association presidential award in protest at the organisation’s refusal to ban participation in US military interrogations which some deem to be torture under the Geneva Convention.

However, the whole issue of psychologists participation in government interrogations shadows a significant, but little mentioned, change in the status of psychologists in the medical establishment.

Fifty years ago, clinical psychologists were little more than test technicians who provided information for psychiatrists to interpret.

During the last decade, clinical psychology training has become equally, if not more, arduous than medical training, and psychological interventions have been shown to be highly effective.

Consequently, psychologists are now being considered on a par with physicians in many organisations. For example, psychologist-led mental health and brain-injury teams are increasingly common.

This change in status is being increasingly reflected in the law. In the UK’s 2005 Capacity Act, psychologists are now able to sign assessments concerning someone’s mental competence to make a contested decision, something that was previously reserved for medical doctors.

The recently approved UK Mental Health Bill is likely to allow psychologists, rather than just psychiatrists, to take a lead in ‘sectioning’ people – i.e. detaining them if they’re deemed a risk to themselves or others owing to mental illness.

In the the US military, and in some US states, psychologists are now able to prescribe medication, previously the sole domain of physicians, and the APA is pushing for the extension of these rights.

Not all psychologists are of a same mind on these issues, and many see these changes as much as a ‘poison chalice’ as as benefit.

In many ways, psychologists and psychiatrists are a ‘good cop, bad cop’ double act in mental health. Psychiatrists can forcibly drug and detain people, while psychologists can tut and scowl with the patient and continue to work collaboratively to improve their mental state.

Of course, patients may be a lot less willing to work with psychologists if they’ve played a role in their detention or forcible medication.

Internal debates aside, the fact that the US Government is quite happy to rely on psychologists, rather than physicians, for their interrogation practices is testament to a general change in status.

Contentious issues concerning a potent mix of economics, ethics and power balance shifts are common for physicians, who are used to governments wanting to give or take responsibilities away from them to suit their political agenda or latest reform plan.

In contrast, these sorts of ethical dilemmas are relatively new for psychologists.

What makes this an interesting time, is that psychology is in a transition period where lots of legal changes are being made to solidify their responsibilities.

This makes the profession much more susceptible to influence by government, and it will be interesting to see how these issues play out, of which the debate over military interrogations is perhaps only an early skirmish.

Link to interview with Dr Mary Pipher.

The Carlat Psychiatry Blog contacted psychiatrist Prof C. Lindsay DeVane about an article on antidepressant drug interactions he apparently co-authored for the medical journal CNS Spectrums. In reply, DeVane noted that the article was ghost-written on behalf of a drug company and denounced it as “piece of commercial crap” and ‘ridiculous’, ‘inaccurate’ and ‘simplistic’.

DeVane was apparently persuaded to take part in a round-table discussion on the interactions between antidepressant drugs, for which attendees could gain ‘CME’ or ‘Continuing Medical Education’ points, needed for doctors to demonstrate that they are keeping their skills and knowledge updated.

After the discussion, the a commercial medical education company i3CME, produced an article based on a video tape of the session with the participants names listed as authors.

Ghostwriting, the practice where drug companies or medical writing agencies create scientific articles to which established researchers add their names, still occurs, despite recent attempts to clamp down on it.

It relies on an academic system where researchers’ careers depend on the number of publications, and on drug companies’ need to boost the profile of their products by adding the names of high-profile scientists to the relevant research.

It’s a big business, and there are a number of agencies that just specialise in writing scientific articles for commercial companies that later get handed to ‘star’ researchers for, at best, checking, and at worst, just signing.

In this case, it seems the article was written without DeVane’s agreement, so it’s refreshing to see someone disown it, rather than simply add it as another gold star to their CV.

Importantly, DeVane notes that his views on the topic had already been accurately and fairly represented in an earlier article [pdf] which he had personally authored.

The Carlat post has more details on the affair, including DeVane’s own description of what occurred.

Link to further details (via Furious Seasons).

A just published study that looked at the religious beliefs of different types of medical doctors in the US has found that psychiatrists are the least religious among the medical specialities.

The study also found that non-psychiatrist physicians who were religious, were least likely to refer a patient with symptoms of mental illness to a psychologist or psychiatrist, and were more likely to refer them to a member of the clergy or religious counsellors.

There’s also a few interesting facts about the demographics of US psychiatrists:

Compared with other physicians, psychiatrists were more likely to be Jewish (29% versus 13%) or without a religious affiliation (17% versus 10%), less likely to be Protestant (27% versus 39%) or Catholic (10% versus 22%), less likely to be religious in general, and more likely to consider themselves spiritual but not religious (33% versus 19%).

Perhaps the fact that psychiatrists are least likely to be religious is not surprising since they deal with lots of people who have experiences that they explain as neurological disturbance but which often appear as no different from what would otherwise be considered spiritual experiences.

For example, Joan of Arc had experiences which could be easily classified as auditory hallucinations, as did many saints, visionaries and prophets throughout history.

This is still a pertinent issue. In a classic 1997 paper psychiatrist Bill Fulford and psychologist Mike Jackson examined some written records of (admittedly intense and atypical) contemporary spiritual experiences and noted that they would fulfil the diagnostic criteria for schizophrenia – except for the fact that they were of immense benefit to the people concerned.

More recently, psychologist Ryan McKay noted that current neuropsychiatric models of delusions would also include religious beliefs if they were considered under the same criteria [pdf] – although it could be said that this is just as likely to be a criticism of our scientific understanding of delusion as it is a consideration of spiritual belief.

However, it’s probably true to say that spending a great deal of time explaining seemingly mystical experiences as the result of biomedical disturbance probably makes you a little more sceptical of some of the mystical experiences on which many mainstream religions are based.

Link to abstract of scientific study.
Link to write-up from Yahoo! News.