Psychotherapy in the Age of the Brain

"The age of the brain" has focused considerable intellectual and financial resources on achieving better understanding of the neurobiologic functioning of the brain in health and disease, in the hope of enhancing treatment for mental disorders. As part of this effort, psychiatry residencies de-emphasized psychotherapy education. Leaders of academic departments came to prefer faculty with credentials and experience that aligned the department of psychiatry with the focus on the age of the brain.

Psychotherapy training dwindled in many but not all residency training programs and the shift toward biologic preeminence meant psychotherapy nearly became lost as part of the skill set of many practicing psychiatrists.¹ Some questioned whether psychotherapy, where it was indicated, ought to be provided in split treatments, with psychologists or social workers providing therapy at presumably lower costs than psychiatrists, while psychiatrists principally provided psychopharmacologic treatment.

Concurrent with the age of the brain came the impact of a transformation in funding for behavioral health treatments in the form of managed care. Managed care is part of an overall zeitgeist of resource limitation that affects today's world in such geopolitical arenas as global warming, depletion of fossil fuels, and loss of biodiversity. As such, managed care operates with the same moral imperative as the environmental movement, but it has often been associated with draconian limitations of care and with a clear preference for psychopharmacology over psychotherapy.²

The importance of psychotherapy was initially de-emphasized in the age of the brain and the era of managed care. Over time, however, several developments contributed to a significant resurgence of interest in psychotherapy. These include research findings suggesting that psychotherapy causes changes in the brain and is a highly effective treatment for a range of disorders. Furthermore, the leadership of the American Psychiatric Association (APA) and of the Residency Review Committee (RRC) became concerned about the potential loss of psychotherapy as part of the identity, skill set, and training of psychiatrists and took appropriate actions to reverse this trend.

Important contributions from a new generation of researchers suggest that psychotherapy is an effective treatment for a range of psychiatric disorders. Following the lead of Aaron Beck, cognitive-behavioral therapy (CBT) researchers elaborated on a psychotherapeutic approach that has roots in psychodynamic theory but is more behavior and symptom focused and psychoeducational in its approach to patients. CBT therapists have led the way in developing psychotherapies that could be outlined in a manual and that are amenable to randomized controlled trials. In addition, they have demonstrated that CBT is superior to placebo and/or equivalent to the use of medications for a range of disorders,³ including mood, anxiety, and personality disorders. Through imaging studies, CBT researchers have also demonstrated that effective CBT treatment leads to brain change. For example, CBT responders can be distinguished from CBT nonresponders in the treatment of obsessive-compulsive disorder on the basis of brain change.⁴

More recently, psychodynamic psychotherapy researchers have also been able to demonstrate evidence of change using empirical research designs. Milrod and colleagues⁵ showed that psychodynamic therapy is effective in treating panic disorder, while Chiesa and Fonagy⁶ demonstrated that psychodynamic therapy is effective in personality disorders. Similarly, Clarkin and colleagues⁷ provided promising evidence that their manualized psychodynamic therapy called "transference focused psychotherapy" is beneficial in the treatment of suicidal patients with borderline personality disorder.

A number of studies have suggested that the combination of medication and psychotherapy is superior to either alone, and several suggest that the provision of both treatment modalities by a psychiatrist is actually less expensive than split treatment.^8,9

As the effectiveness of biologic treatments has been scrutinized, there has been increasing recognition of problems posed by treatment-resistant disorders. Studies suggest that 15% to 50% of patients with major depressive episodes have treatment-refractory illness,^10,11 and that only a minority recover fully with psychopharmacology.¹² The addition of psychotherapy to psychopharmacology may be effective for some patients with treatmentrefractory mood disorders comorbid with personality disorders.^11,13

In their study of 681 patients with chronic major depressive disorder, many of whom had histories of early adverse life experiences, Nemeroff and colleagues14 found that a form of CBT called the "cognitive behavioral analysis system of psychotherapy" was superior to nefazodone(Drug information on nefazodone) for the subset of chronically depressed and treatment-resistant patients who also had histories of early abuse or other adverse early life experiences. They note, "Our findings suggest that psychotherapy may be an essential element in the treatment of patients with chronic forms of major depression and a history of childhood trauma."

This is a significant statement from researchers who have made important contributions to understanding neurobiology during the age of the brain. Their findings may shed light on why the intensive psychotherapy treatment program of the Austen Riggs Center (4-times-weekly individual psychodynamic therapy plus immersion in a sophisticated milieu program and state-of-the-art psychopharmacology) has been associated with significant improvement in patients with previously treatment-refractory mood disorders, nearly two thirds of whom have histories of early adverse life experiences.¹³