She was clearly depressed, with occasional suicidal thoughts and a history of unresponsiveness to a wide variety of antidepressants. Her family history was loaded with depression: 2 maternal uncles had chronic depressive syndromes and a paternal aunt had committed suicide. She described her mother as cold, unavailable, and possibly chronically depressed. During childhood, her father, occasionally affectionate, was mostly out of the home on business trips. There was, she said, no reliable source of affection during her childhood.
She was a withdrawn, shy child who did not make friends easily. As an adolescent, she had several girlfriends (“nerdy, like me”); there was no dating and no extracurricular activities. She went to a large state university, where she was mostly withdrawn, alone. Her marriage to a fellow graduate student (the first boy she ever dated) is an emotionally distant relationship (“we never talk about feelings—only ideas”).
The question of how best to understand this patient’s depressive disorder would have been answered with different emphases during the 53 years since my residency. During those long-ago times (the 1950s), the emphasis was on psychodynamic explanations of psychopathologies. I can almost hear a supervisor (all of whom were psychoanalysts) say, “You’ve got to start with her mother. Her depression is oral. She did not get the basic psychological nurturance all infants need, and her response was to turn away from all forms of closeness.”
Patients’ stories (both content and structure) contain more therapeutically useful information than merely identifying and counting symptoms.
There would be further conjectures about her emptiness and rage. Her marriage would be understood as an unconscious repetition of the maternal relationship. Other intrapsychic factors would be emphasized because they appear to influence both her depression and her rigid personality. Much more could be said about her, for part of the attraction of psychiatry for my generation was that psychoanalysis emphasized detailed, coherent, and compelling clinical narratives.
In the years since those exciting early days (we were so certain of our explanations!), there have been successive waves of different perspectives. These have broadened our understanding: each has added some-thing of value. I think about them as infusions of new knowledge about behavior and psychopathology that do not negate the psychodynamic understandings of my residency, but rather are exciting alternative systems of understanding. The 5 major infusions were systems theory, cognitive theory, attachment theory, narrative theory, and the newer insights into the experience-dependent plastic brain.
After my training, but early in my career, the idea gained currency that studying and treating individuals separate from their relationship contexts provided an incomplete and often misleading understanding. The emerging insights of marital-family theory and research was a cutting edge of systems theory’s impact on clinical practice.
To understand a person’s behavior, one had to do more than focus solely on intrapsychic dynamics; one had to also understand the properties of the human systems in which the person’s life is embedded. How much of his or her symptomatic behaviors can be understood as responses to here-and-now circumstances?
This switch from a single theoretical perspective to a pluralistic orientation represented a conceptual dislocation resulting in the need for more clinical data and more complex formulations and frequently greater uncertainty. Such understanding led to a new group of clinical questions, including, most of all, whether the focus of treatment should be on the individual (as in traditional therapies) or on his or her marital or family system. Allegiance to a single theoretical perspective had to give way to a pluralistic orientation in which the es-sential question was “Where is the greatest treatment leverage?”
As a resident, I had no idea that I was witnessing the beginning of a cognitive revolution when Tim Beck, a young faculty member, discussed his research contrasting the dream content of hypertensive patients and controls. The true significance of this beginning became gradually apparent over the next decade or so as Beck developed cognitive theory and therapy.
In the over 50 years since those early days, cognitive therapy has become the most frequently practiced form of psychotherapy. The reasons for this remarkable growth include the observation that the previously dominant psychoanalytical psychotherapy was complex, often experienced as diffuse, and difficult to teach. Indeed, most training centers relied almost solely on supervision. In turn, cognitive therapy seemed clearer, more focused, and easier to teach. Graduate schools of psychology in particular adopted the cognitive approach to training psychotherapists. This is likely one of the factors that explain why cognitive therapies are the most intensely studied of all forms of psychotherapy.
The growth of attachment theory and research during recent decades has been remarkable. I am not certain that most clinicians appreciate the mountains of research data that developmental psychologists have produced that substantiate Bowlby’s early theoretical writings, for most of this research is published outside of clinical journals. The sheer size of the resulting empirical base is astonishing.
This research validated the premise that early infant interactions with important caregivers are taken into the infant’s developing brain and form a central template for subsequent development. Whether one uses the older psychoanalytic phrase, “internal self and object representations” or Bowlby’s “internal working model,” the security of an infant’s attachment appears to persist for most persons well through adolescence and often later. A secure infant attachment is associated with better affective, cognitive, and relational development. Further, insecure infant attachments (avoidant or ambivalent) are associated with more developmental disabilities, although they appear to be reversible through what can be thought of as correc-tive emotional relationships with spouses, therapists, lovers, close friends, teachers, and other meaningful attachments.
Why should this large body of research be so important to clinicians? The answer is because it informs us about the developmental complexity of human behavior. Understanding patients involves both understanding the human systems they are a part of in the present and their developmental pasts—including the relationship patterns that originated in the early years.
The premise that identity is constructed through the elaboration of a constantly evolving narrative of the self in which historical accuracy may be unconsciously modified in the service of present coherence has had major impact on my psychotherapeutic practice. One of the ideas that attracted some of my generation to a psychotherapeutic psychiatry was that the truth can set you free, and psychotherapy involved a search for the truth. Now, however, many students of psychotherapy believe that the process of psychotherapy can be more usefully described as helping others construct a more coherent and generative life narrative. This does not mean disregarding facts but rather understanding that a growing body of memory research indicates that the past is often unconsciously reconstructed to fit present needs—mostly in search of a coherent identity.
There is a growing body of careful research exploring the characteristics of life narratives. These include such crucial issues as overall coherence, major themes, affective quality, and turning points, all of which appear to be related to measures of ego maturity and other important indices of psychological health.
The idea that one’s basic sense of self is the autobiographical narrative one constructs for self, internalized early objects, and important here-and-now others is an important addition to an inclusive understanding of the self. Its importance to clinicians is multifaceted. Perhaps, most of all, it underscores that patients’ stories (both content and structure) contain more therapeutically useful information than merely identifying and counting symptoms.
The experience-dependent brain
The most electrifying change in our knowledge base during my 58 years has been the demonstration that the adult brain retains considerable plasticity and that synaptogenesis and, perhaps, neurogenesis, continue long after childhood. The brain affects environment through genetic influences on personality traits that evoke environmental responses. These experiences then may influence brain structure and function by turning on and off genes that produce the proteins necessary for new synapses and neurons.
Although the bulk of this emerging research involves motor functions as, for example, the restoration of upper limb mobility in stroke victims through intensive physiotherapy, some neuroscientists suggest that the qualities of important interpersonal relationships that change individual thoughts, feelings, and behaviors must also do so through a similar process. Thus, important qualities of ongoing relationships that may heal or injure the selves of the participants do so through promoting changes in brain structure and function.
The implications of these exciting neuroscientific advances for clinicians are many. Most of all, however, they direct our attention to which psychotherapeutic processes are centrally involved in the transformations of patients’ brains. We do not really know, but if changes in the behaviors of those involved in healing relationships are permanent, their brains must have changed. Who would have thought such was possible but a few years ago?
Although colleagues of my generation may have been affected by other developments during their careers, systems theory, attachment theory, narrative theory, and the idea of the experience-dependent plasticity of the adult brain have most influenced my knowledge base. They encourage attempts at integrating diverse sets of data, at times a difficult and complex task. On the other hand, they add greatly to the ongoing opportunities to help others in clinical encounters. As such, we must embrace the complexity they bring.