In November 1996, I met informally with two other members of the Group for the Advancement of Psychiatry (GAP), Vassilis Koliatsos and Robert Dorn. We drew up guidelines (Sidebar) for subsequent deliberations of the research committee that then reconstituted during the next few years and worked on the new mission.
Proposed Principles About a Needed Basic Science of Psychiatry
- Psychiatry now has no basic science in the medical pattern through which the diseases represent dysfunctional variations of normal body processes.
- Such pathophysiological mechanisms should be sought as a primary aim of our work.
- Cellular-molecular processes are variations at another conceptual level of activities of the whole organism notably and powerfully, including its social arrangements, which we agreed are largely mediated by the brain.
- There are emergent properties at the higher levels of the organism that cannot be predicted by full and complete knowledge of the “lower” level, although reductionist attempts to explain the phenomena partially in this way is a powerful conceptual and scientific endeavor.
- Top-down and bottom-up approaches to investigating such pathology refer to integrative approaches that contrast to the top-up avenue that considers only behavior and the bottom-down avenue that considers only cellular-molecular activities.
- Conceptualizing basic plans that are putatively foundation to both pathology and normality is a highly useful exercise.
- Pathology is highlighted when the behavioral state is deployed at the wrong time and wrong place, or normality if it works to enhance an individual's adaptation.
- This distinctly differs from the often inadvertant “pathologizing” of normal behavior; thus to talk of a leader as manic or hypomanic when describing his or her elated, animated, energetic, and sleepless ways is wrong in that the basic plan involved is then undercut and underemphasized. Leaders are not pathological unless there is something disadvantageous and maladaptive about the way it is expressed.
Proposed Principles About a Needed Basic Science of Psychiatry
Criteria for additional membership included breadth of research and private or academic experience, intermingled with significant educational responsibilities at various levels of the teaching hierarchy, as well as representation from various regions of the country. Members-in-training have participated vigorously, as have various guests. Vigorous interaction with GAP leaders and publications committees has resulted in broad approval of our present efforts.
The Social Brain: A Unifying Foundation for Psychiatry
The Research Committee of the Group for Advancement of Psychiatry (GAP), a specialty think-tank, has addressed psychiatry's need for a unifying scientific foundation. Such a foundation would consider the disorders commonly treated by psychiatrists in terms of the physiological baseline from which they depart, much as heart disease is understood as deviation from normal cardiac function. The relevant physiological focus for psychiatry is the social brain.
The social brain is defined by its function; namely, the brain is a body organ that mediates social interactions while also serving as the repository of those interactions. The concept focuses on the interface between brain physiology and the individual's environment. The brain is the organ most influenced on the cellular level by social factors across development; in turn, the expression of brain function determines and structures an individual's personal and social experience. The social brain framework may have greater direct impact on the understanding of some psychiatric disorders than others. However, it helps organize and explain all psychopathology. A single gene-based disorder like Huntington disease is expressed to a large extent as social dysfunction. Conversely, traumatic stress has structural impact on the brain, as does the socially interactive process of psychotherapy.
Brains, including human brains, derive from ancient adaptations to diverse environments and are themselves repositories of phylogenetic adaptations. In addition, individual experiences shape the brain through epigenesis, i.e., the expression of genes is shaped by environmental influences. Thus, the social brain is also a repository of individual development. On an ongoing basis, the brain is further refined through social interactions; plastic changes continue through life with both physiological and anatomical modifications.
In contrast to the conventional biopsychosocial model, the social brain formulation emphasizes that all psychological and social factors are biological. Non-biological and non-social psychiatry cannot exist. Molecular and cellular sciences offer fresh and exciting contributions to such a framework but provide limited explanations for the social facets of individual function.
The social brain formulation is consistent with current research and clinical data. Moreover, it ultimately must:
- Unify the biological, psychological and social factors in psychiatric illness;
- Dissect components of illness into meaningful functional subsets that deviate in definable ways from normal physiology;
- Improve diagnostic validity by generating testable clinical formulations from brain-based social processes;
- Guide psychiatric research and treatment;
- Provide an improved language for treating patients as well as educating trainees, patients, their families and the public; and
- Account for the role of interpersonal relationships for brain function and health.
In conclusion, the concept of the brain as an organ that manages social life provides significant power for psychiatry's basic science. Burgeoning developments in neural and genetic areas put added demands on the conceptual structures of psychiatry. Findings from such incoming work must be juxtaposed and correlated with the behavioral and experiential facets of psychiatry to give it a complete and rational basis. Psychiatry's full and unified entry into the realm of theory-driven and data-based medical science has been overdue. The social brain concept allows psychiatry to utilize pathogenesis in a manner parallel to practice in other specialties.
(Note: The above statement was composed by members of the GAP Research Committee during the periodic meetings of this group. The opinions expressed are those of the authors and do not represent an official opinion of GAP. Reprinted with permission from Academic Psychiatry, Copyright 2002, American Psychiatric Association.)
The Social Brain
If we propose the social brain concept as a solution, what is the problem? We begin by providing a discussion of psychiatry's quick change in conceptual base that took place during the last half of the 20th century.
Problems for Psychiatry's Quick Turnaround
“... When I began as an oral examiner in both General and Child Psychiatry [about 1970], I fretted about the narrowness of candidates' knowledge in the sciences basic to psychiatry and their reliance on impressions and poorly documented, often very limited, experience, unsubstantiated theory, or fuzzy clinical data.
“As I step aside, my concerns are quite different. Now I am distressed by the rigid, often insensitive, approach of so many candidates towards patients, their preoccupation with the details of diagnostic criteria, their focus on trivial information and seeming lack of concern for or understanding of the unique person who is their examination patient.”
Because 20th century research on drugs and definition of disorders altered professional and public opinion, psychiatry turned a sharp corner with massive changes in practice during a quarter-century period. Many reasons contributed to this, first, perhaps, discontent with unsupported theories for how its disorders had resulted and should be treated, a situation differing from the rest of medicine more secure in its heritage and approach to science. A practical second factor included publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders in 1980 (and its successors later). Operationalized definitions of disorders provided checklists for diagnosis (applicable by many besides psychiatrists though paying little attention to the niceties, to the limitations of these often arbitrarily worked out clinical approximations).
Added to this, professionals and the public were learning that new and powerful medications possessed striking efficacy. Sophisticated drug trials particularly made these findings persuasive. More gradually, powerful side effects also pervaded awareness and made clinical guidelines more cautious about drug therapy.3
Overall, however, an unsupported and undocumented treatment model — one that blamed “crooked or insufficient molecules” — allowed pharmaceuticals to take on the aura of verified but cheap, packaged therapies involving little “expensive” professional time. This resulted in the now standard “med-check.” Related to this, new general reluctance to fund any professional treatments generally began to pervade the medical scene. For therapies not using drugs, payers noted that people other than psychiatrists could do the work. With less expensive training, they could charge less (or more happily accept lesser fees from restrictive third party payers).
Thus, a goal of “relationshipless” psychiatry gained standing: one does “better business” if same or adequate results can be gained by the cheaper means of packaged treatment for molecular deficiencies, “chemical imbalances,” entailing brief physician visits combined with nonphysician therapists for nondrug treatments.
Here we depict “untoward side effects” that have accompanied the benefits from the massive business-focused transformation of psychiatric medicine. We suggest that deficiencies in the core metaphors that hold sway in the imaginations of psychiatrists, other professionals, the business ends of payers, multinational corporations, and the public have contributed to a deprofessionalization of the specialty, with lessened results for patients. We note that popular metaphors focus on a molecular level of analysis that possesses no support in research findings. Other subsequently developing data underline the importance of using an alternative, multiply layered model of the central organ of psychiatry that we label the “social brain.”
We compare the present state of affairs with those of approximately a quarter-century ago using the dimensions of the nature of knowledge (theory versus data-based) and clinical skills in application of professional knowledge (open-ended versus checklist-based interviews).
In the earlier era, knowledge gained relevancy from theory. Theory meant that professionally applicable information stemmed from a framework of detailed accumulated opinions about the workings of the human mind. Established facts did not prove or disprove speculations. Largely this stemmed from the rich tradition of psychoanalytic theory, a view of mind-functioning that resulted from Freud's and others' work with relatively few patients.
Viewed retrospectively, extrapolating to more general conclusions entailed significant risk for the durability of the conclusions. Although not all of American psychiatry's accumulated knowledge a quarter-century ago involved such theory, those components holding greatest sway did until well after mid-century, augmented by leadership in academic departments.
Complex “metapsychology” theory failed to foster or to even allow measurements by standard scientific methods. Nevertheless, we feel that it led to clinical skills that assessed reasonably well the structure and function of patients and their minds through depth-interviewing. Psychiatric clinicians gained expertise in interviewing. Core clinical skills gained in this manner helped establish trusting alliances with patients and assessed mental functioning at multiple levels of the mind. A common belief held that some people had more innate abilities for interviewing in depth; this echoes present research on psychotherapy effectiveness — now massive in quantity — that people vary considerably in such effectiveness. For example, possession of a “third ear” once positively described an able therapist or an apt student.
By contrast, research on psychotherapy previously assumed that psychotherapy could be studied using a drug-study model, a metaphor that held that a “pure preparation” of psychotherapy (parallel to a chemical compound), when identically applied, would produced the same result. Bearing on this, Bruce Wampold extensively surveyed controlled psychotherapy research and showed that the “medical model” of psychotherapy, as he calls it, emphatically does not resemble the mechanical ideal; for example, it does not resemble what happens with an antibiotic.4 Rather, as it turns out, research results confirmed treater variability plays a major role in treatment outcome.
Perhaps, even likely, the ability to understand another person in depth relates to early pain in the helping person's life, and examination of the lives of mental health professionals infers many indeed suffered psychological pain earlier in their lives. Did such developmental pain make them more sensitive to their patients during assessment? True or not, by whatever means the student came to a culmination of clinical skills, possession of the desired abilities hinged on skill in interviewing with the clinician's understanding at multiple levels. Most important, did the clinician resonate with how the patient felt? Curiously, lay people showed awareness of this kind of skill in the common fear about psychiatrist professionals; in the past, people in social situations talking to psychiatrists commonly feared the professional would “read” their mind, something less often encountered in present-day social encounters.
How Things Have Changed
Psychiatry now possesses a body of knowledge based more on a reliably ascertained database (descriptive psychiatry). Many of these data categorize commonly found symptoms found in various psychiatric disorders. Putting these on checklists means that clinicians make consistent diagnoses systematically, with lower frequency of information missed from open-ended, free-flowing interviews typical of the psychoanalytic–psychotherapeutic interviewing style.
In addition, the present clinician takes into consideration advances for understanding brain function at anatomical, chemical and molecular levels as well as on behavioral and interpersonal levels. A current trainee in psychiatry works hard to amass enormous amounts of data from disparate disciplines to understand patient problems. The field changed, therefore, from using theory-derived clinician sensitivity to those derived from empiric data on other patients. Furthermore, these new data that the clinician must consider have changed the optimal interview; instead of interviewing in-depth with understanding on multiple levels, the clinician uses a criteria-list interview. A new common fear about psychiatrists illustrates the change because the lay public knows DSM so well; thus, new social connections now voice, “I am afraid you will find me in ‘the book.’”
In addition to Enzer's quote above, other examples illustrate the change over time and illustrate the field's pendulum-swing extremes. We conjecture that pendulum swings stem from a lack of a core prevailing metaphor that might have dampened the swings, a model or image such that the “social brain” entails.
Committee member John Looney recalled his training in a psychoanalytically based child study center. Parents of children referred to a prestigious preschool day program often had professional status at the nearby university. All understood that study of the children would entail psychoanalytic techniques during day care. Study framework for a given child entailed the Metapsychological Profile, a detailed instrument for plotting of the topographical structure of the mind. Looney presented to his intimidating professors a 70-page profile of a 5-year old boy. The framework for his detailed description involved structural components of the boy's mind and his commonly used mechanisms of defense. The results were designed to guide a plan for treatment that deployed frequent analytically oriented sessions.
After rotating off the clinical service, Looney queried a colleague who had taken over what subsequently happened and learned that team members had all felt embarrassed when the child's pediatrician diagnosed attention-deficit/hyperactivity disorder and placed the child on methylphenidate, with rapid marked improvement in all areas. Even though the Looney had made good empathic contact with the child and understood him on multiple levels, the framework reduced the adequacy of his patient formulation.
If Looney's experience as a trainee illustrates one end of the pendulum swing, current trends illustrate losses of something on the other extreme. A number of board examiners besides Enzer complain that candidates can't get beyond DSM. Patients gain understanding only with respect to how they meet criteria for particular diagnoses. Candidates have little understanding of their patients as people and show little interest in how patients feel in their lives.
Looney provided an experience from his present practice. A prestigious professor from another department asked for a referral after his wife died. He felt sad and had lost function. Looney referred him to a younger, highly regarded colleague who had graduated recently from the training program with a special interest in mood disorders. Later, when queried about how it had gone, the professor expressed a troubled annoyance, noting that the young faculty member had interviewed him for 20 minutes and then wrote a prescription for a selective serotonin reuptake inhibitor. He took the medication and experienced modest relief but felt the absence of something fundamental. He said, “I went to this doctor hoping she would understand my pain. Understanding my pain did not mean giving me Prozac and seeing me a month later.”
Another example demonstrates that the shift to descriptive, databased practice has affected experienced psychiatrists as well. A distinguished psychiatrist at a top center evaluated a young man who was plaintiff in a medical malpractice lawsuit against another psychiatrist. When in a psychiatric hospital, the man had felt mistreated when placed under behavioral restrictions and wished to “get back” at the treating psychiatrist. Like patients with borderline personality disorder, he demonized the hospital clinician; in contrast, he idolized the evaluating doctor. The patient's attorney felt that the patient had developed posttraumatic stress disorder and borderline personality disorder that resulted from the hospitalization.
The evaluating psychiatrist confirmed these diagnoses by simply going over the checklist and noting criteria. Not doing an in-depth interview meant that he overlooked the patient's neediness and dependency. These plus the idealization meant that the patient wished to please the psychiatrist and answer affirmatively to questions put to him. This mistake put him in the position of testifying against other psychiatrists who had done detailed and careful interviews, aiming at as much objectivity as possible. The jury accepted not the checklist conclusions but the more extensive findings.
A distinguished psychiatry professor, Jerry M. Lewis, an earlier chairman of the GAP Research Committee, observed psychiatric practice evolve during a half-century and wrote an essay about the lay public's acceptance of the data-based body of knowledge.5 He noted that patients now identify themselves in terms of how they fit into a criteria list.
As an example, I experienced the following interaction during a teaching conference interview for psychiatric residents. The patient, a middle-aged man, clearly showed depression despite a smile on his face. After we chatted about the conference, I told him that I wished to try to understand how it felt to him, what it was like inside. He responded, “First of all, you've got to understand I'm a recovering alcoholic.”
“And how does it feel for you to be a recovering alcoholic?”
“Well, I don't know — that's just who I am. First and foremost I'm a recovering alcoholic.”
“More than anything else you feel yourself to be a recovering alcoholic.”
“Can you help me understand what else there is, what in addition it feels to be you?”
“Well, let me think. I guess next I'd say I'm depressed. I've got what they call a major depression.”
“And that feels bad ...”
“Yeah.” Here tears came to his eyes, the smile disappeared, and he sighed deeply. The silence grew, filling the conference room. After some seconds, I said, “I can feel the silence now.” We sat there quietly, and then I moved away from the sadness by saying, “Let's see if I've got it right. Inside, what it feels like to be you, is that you're a recovering alcoholic and you're depressed.”
“Yeah, doctor, you've got it.”
“Is there anything else about what it feels like to be you?”
“No, I think we covered it all.”
Clearly, the patient's prior experiences with psychiatrists molded an expectation that psychiatrists wish to understand patients as diseases, parallel to “the gall-bladder in room 307” — a designation familiar from most doctors' training in teaching hospitals.
Certainly, the example of a psychiatrist evaluating a patient for a lawsuit using only a DSM checklist demonstrates how the legal system affects psychiatry's practice. The legal system embraced the DSM style for psychiatry's body of knowledge because criteria-based presentations in court make clearer arguments.
Constrictions in financial support for psychiatric services also have obviously and greatly affected the field. Third-party payers care little about the depth to which a psychiatrist develop an understanding of the patient and about the degree to which a patient appreciates that understanding. Based on locating pathology on a molecular–biological level, quick criteria-based assessment leading to placement on medication represents the goal of much current third-party reimbursement: a documentable, minimally adequate result entailing minimum cost equals good business.
To summarize, a “perfect storm” of DSM change, drugs and the metaphors supporting their rationale, and changes in healthcare economics pervading all of medicine seem to have resulted in a changed state of psychiatric practice. Curiously, although economic factors have fostered de-emphasizing interpersonal skills and talents, such skills weigh heavily in controlled psychotherapy results. Empathy, ability to relate to people, warmth, a positive personality — all hold important roles regardless of one's mode of practice.
Psychiatry turned rapidly and unwisely away from wisdom learned earlier under the influences of theory-driven practice. Adding to this, a metaphor — one widely accepted but unsupported — facilitated acceptance of drug use. Rationales for limiting reimbursements hastened the transition.
Now we understand that the social skills of a good clinician stem from that person's educated social brain, a body organ conditioned and shaped over evolutionary time as well as within the lifetime, including the experience of professional training. As developed in this issue, all psychiatric disorders represent variations in social interactions that hinge on variations in the development and malfunction of the social brain organ. Psychiatrists need to know the organ in greater depth on all levels of analysis and then turn that knowledge to discerning the diagnoses of troubled people as well as treating them skillfully and effectively.
A ratchet-wheel has turned, of course, making old style leisurely interviews a thing of the past. Even so, brief contacts with patients reflect enormous information exchanges. How the social-focused organ works in the body of the patient, as well as in the body of the clinician, requires attention, augmented and focused by more accurate and telling metaphors.