Joel Paris - Psychotherapy in an Age of Neuroscience

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This book is dedicated to the teachers who encouraged me to choose a career in psychiatry

Robert Biskin read an earlier version of this book and made many useful suggestions for improvement.

In 1959, a chance encounter changed my life. I was an undergraduate studying psychology at the University of Michigan. One of the graduate students in the department, who also worked for the American Friends Service Committee, invited a group of students to spend a series of weekends at a nearby mental hospital. Ypsilanti State Hospital, now demolished, had at that time 4,000 patients, who were just beginning to be treated with effective drugs. Many had been there for years. I was fascinated by what I saw, and I decided that this was the problem to which I should devote my life.

I became a psychiatrist and have never been sorry about that decision. Mental illness remains mysterious, but mystery is what makes the field exciting. One of the things I loved best about psychiatry was that it was about both the mind and mental illness, straddling the boundary between normality and pathology.

Since my student days, psychiatry has changedin some ways for the better but in some ways for the worse. One of the great mistakes of the past was to overprescribe psychotherapy and, when it did not help, to continue offering the same treatment, often for years. Now we have gone to the other extreme. Many psychiatrists spend little time listening to their patients. Our expertise is defined by the choice of drugs, which are now prescribed for almost everyone we see.

I have written this book out of a sense of loss and a feeling of hope. I was attracted to my profession by its breadth and humanism. My sense of loss comes from the fact that the field I loved has become narrow in scope, focusing almost exclusively on the biological factors in mental illness. There can be little doubt that modern psychiatry is much more scientific than it was in the past. We also know much more about neuroscience. But it is not obvious that this knowledge can be translated into practice or that our current treatments help more patients.

My feeling of hope comes from a belief that our current exclusive focus on biology is a phase that must pass. To deal with the complexity of the human mind and its disorders, psychiatry will need, in time, to return to a model of practice spanning the biological, psychological, and social aspects of mental illness.

Although this book focuses on my own profession, much of what I have to say is equally relevant to clinical psychology, to other mental health professions, and to primary care medicine. Psychologists have also been influenced by the current climate of opinion suggesting that all depressed patients should be on medications. Although physicians write most prescriptions, patients are often sent to us for consultation by psychologists asking for drugs to be added to the treatment regime. The result is, in a term famously applied to justifying a disastrous war, a slam dunk.

). However, the current volume differs in focusing on divisions within the field. I address two crucial questions. First, can neuroscience fully account for mental disorders, and to what extent can psychiatric treatment be based on this line of research? Second, in an age of neuroscience, does psychotherapy still have a role in psychiatry, and if so, how can it be integrated into practice?

I have no intention of trashing research in neuroscience, which, in the past few decades, has advanced by leaps and bounds. We knew little about the brain when I was a student. Now we are on the way to controlling the activity of individual neurons and to editing the genome itself.

The unanswered question is whether we know enough to apply this research to clinical practice. At this point, we do not. And there is another question that needs to be addressed. Even if we knew everything about the brain, would that knowledge be enough to explain how the mind works, or would we still need to study mental illness by measuring processes at a mental level? I am not a dualist, and I agree with neuroscientists that mind is what the brain does. But this book argues that thought, emotion, and behavior can never be fully explained by the activity of neurons, or their connections, and that these complex phenomena also need to be studied by considering the mind as a whole.

In the United States, the National Institute of Mental Health (NIMH), which directs research in psychiatry, has bet the farm on a project to explain all mental disorders as problems in neural connectivity (). There can be no doubt that understanding brain circuitry will be of long-term benefit to psychiatry. But attempting to reduce mental illness to these mechanisms alone may be an illusory quest.

This line of research has thus far provided no benefit for patients who need better treatment now. While neuroscience has rapidly advanced, there has been little progress in applied sciences such as psychopharmacology. Moreover, by directing all research into a model based on a connectome (a system of neural connections), NIMH will largely exclude psychosocial research from funding. This decision follows the changing zeitgeist within psychiatry, marked by an almost religious belief in the primacy of neuroscience and a downgrading of everything psychological.