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Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

, FRCPC, PhD, DPhil, is Professor and Chair of the Department of Psychiatry at the University of Cape Town (UCT), Cape Town, South Africa. Dr Stein did his undergraduate and medical training at UCT. To avoid compulsory service in the all-white South African army he left for the United States, where he completed his residency in psychiatry and a postdoctoral fellowship in psychopharmacology at Columbia University. After Mandela was democratically elected President, Dr Stein returned to South Africa where he has remained since. His training also includes a PhD in clinical neuroscience, and a DPhil in philosophy, both from Stellenbosch University. His research work has focused on anxiety and related disorders, including obsessive compulsive and related disorders, and trauma and stressor-related disorders. He chaired the DSM-5 and the ICD-11 workgroups on obsessive-compulsive and related disorders. His own research has been continuously funded since his residency, and has had significant impact, as evidenced by a Google scholar h-index>140, by the broad range of work led by his mentees, and by research awards including the Ethics in Psychopharmacology award by the International College of Neuropsychopharmacology. He has received the Lifetime Achievement Award from the World Federation of Societies of Biological Psychiatry.

Dr Stein has been interested in both psychiatry research and in philosophical writing since his residency. As a resident, he won the Karl Jaspers Award from the Association for the Advancement of Psychiatry and Philosophy in 1991 (I had the privilege of winning the same award in 2018). As part of the DSM-5 revision process he wrote an article, collaborating with a number of leading figures in philosophy and psychiatry, titled “

What is a mental/psychiatric disorder? From DSM-IV to DSM-V

” that has been cited nearly 500 times.

 In 2008, he brought together his interests in psychopharmacology and philosophy in 

 (Cambridge University Press, 2008) and this year he has further extended his work in philosophy with the publication of 

Problems of Living: Perspectives from Philosophy, Psychiatry, and Cognitive-Affective Science

 (Academic Press, 2021). This is an ambitious book, tackling questions not only about the nature of mental disorders, but also about the mind-body problem, the relationship between reason and emotion, happiness and suffering, morality and truth, and the meaning of life.

: You are the first African author I have interviewed for this series. Does being South African influence your work on philosophy and psychiatry?

: Well, it is notable that South Africans have made some really important contributions to psychiatry. The work of Joseph Wolpe, MD, developing behavior therapy comes to mind, as does Isaac Marks, MD’s contribution to anxiety disorders (others are detailed in a 

 On the other hand, critiques of psychiatry have had particular resonance here, emphasizing how social determinants and health systems are closely bound up with the history of apartheid and continue to influence mental health. From early on in my studies I was aware of both the positive contributions of psychiatry, as well as of important critiques of the field, and wondering what to make of this.

: Your specific interest in the philosophy of psychopharmacology distinguishes you from many other authors and commentators in this area. Psychopharmacology too is a field where there have been advances, but also important limitations.

: Yes, I fully agree. The introduction of antipsychotics, antidepressants, anxiolytics, and mood stabilizers in the 20th century was a complete game-changer for psychiatry. At the same time, the receptors targeted by early agents continue to by and large remain the focus of current clinical psychopharmacology. Neuroscience has become increasingly sophisticated, and yet our understanding of how psychotropics affect symptom relief remains somewhat rudimentary. We should celebrate the fact that appropriate diagnosis and pharmacotherapy of changes many individuals’ lives for the better. But we must remain aware that there is massive underdiagnosis, particularly in low- and middle-income countries, that not all patients respond to pharmacotherapy or other interventions, and that over-diagnosis and over-treatment is also an issue.

: Selective serotonin reuptake inhibitors (SSRIs) and other antidepressant medications have been the subject of a lot of controversy in recent years. There is the perpetual question: why have they performed so poorly when compared to placebos in randomized controlled trials (RCTs) and what does that say about their real-world clinical efficacy? There is increasing awareness of the prevalence and severity of antidepressant withdrawal, and other adverse effects. There is the implosion of the popular idea that antidepressants exert their effect by correcting some biochemical abnormality in individuals with depression. And there is the escalating search for more potent psychopharmacological interventions for treatment resistance. As someone who approaches psychopharmacology through a philosophical lens, how do you view these developments? Are they reflective of a deeper malaise in the field of psychopharmacology? Have we been asking the right sorts of questions about efficacy, safety, and mechanism of action? Has there been something lacking in our mainstream conceptual understanding of psychopharmacology that is being reflected in these on-going discussions?

: In my thinking about these sorts of issues in psychopharmacology, and related questions in philosophy of psychiatry, I find myself always trying to walk the line between overly hagiographic accounts and overly critical views of psychiatry. When I think of how psychotropics can impact thinking and feeling, and be so therapeutic, I am filled with awe (about the complexity of the relevant mechanisms), and with gratitude (that we are able to help individuals suffering from mental disorders). But I am also very aware of the robust criticisms of psychopharmacology’s evidence-base, of iatrogenic illness, and of how far we still have to travel in psychopharmacology. I don’t think there’s a deep and readily addressed conceptual solution in psychopharmacology research. We have long been aware, for example, that neurotransmitters cut across dimensions of behavior (the pioneering work of Herman van Praag, MD, PhD comes to mind), and that while psychopharmacological dissection may be a useful tool (one of my mentors was Donald Klein, MD!) the idea that there is going to be a specific psychotropic that is particularly effective for each disorder is way too simplistic.

I do think, though, that in clinical practice it may be helpful to think about psychopharmacology not only from a molecular perspective, but also from an evolutionary medicine perspective (Randolph Nesse, MD, is another of my mentors!). This helps explain why anxiety is so common, why there are endogenous anxiogenic and anxiolytic mechanisms (which we can then target or mimic), why medications that target adaptive defenses can be clinically useful (an antitussive can reduce symptoms even though cough is highly adaptive), and why the motto “a pill for every ill” is far from the solution. From a research perspective, while I love the current idea that clinical trials can be based on translational neuroscience approaches (eg, testing if a drug alters an important biomarker or endophenotype), successful bench-to-bedside advances remain fairly unusual in psychiatry, and I worry that we do not put commensurate attention and funding into pragmatic clinical trials. The United Kingdom’s Recovery Trial to quickly test drugs for efficacy against COVID-19 in day-to-day practice is inspiring. Should we not be doing the same sort of thing for mental disorders? (I hope Josh Gordon, MD, PhD, and Miranda Wolpert, PhD, are readers of your column!)

: I hope they are too! You have often differentiated between the 

 positions. Tell us a bit more about these, particularly as you envisage them with regards to psychiatry.

: I have used these terms in part to find a middle path that I mentioned earlier, avoiding both overly hagiographic and overly critical views of psychiatry and psychopharmacology. I have also used them to help find a way of integrating key philosophical views on science, language, and medicine. Thus, I use the term 

 to refer to positions that emphasize essential natural kinds and scientific laws, holding up, say, the periodic table as an example of how science should work, and arguing that diseases too have essential features, which we need to explain. And I use the term 

 to refer to positions that emphasize social construction and hermeneutic methods, pointing out that our concepts vary from time to time and place to place, arguing that mental disorders are socially constructed and that the experience of being ill needs to be understood. I try to put forward an 

 approach which avoids the scientism of the classical view and the skepticism of the critical view, and which sees science (including psychiatric science) as both a social activity, and as providing powerful accounts of the structures, processes, and mechanisms underlying phenomena, including disorders.

: Among the philosophers who have had a formative influence on your intellectual development, you mention the British philosopher Roy Bhaskar, PhD, and his critical realism. What are some of the fundamental ideas of critical realism and what do you think they have to offer to our philosophical understanding of science and psychiatry?

: Bhaskar taught me that science is both a social activity and provides powerful accounts of real phenomena, and I continue to find his naturalistic account particularly persuasive. In arguing that this account can be extended to the social sciences, I see critical realism as integrating philosophical positions that focus on 

), mechanisms, and facts in the social sciences, together with positions that focus on the importance of 

), narratives, and values in these fields. In my mind, this kind of integrative approach is redolent of work of the psychiatrist-philosopher Karl Jaspers, who I also see as emphasizing the importance of both explanation and understanding.

: You have also been heavily influenced by pragmatic philosophers such as John Dewey, PhD, and by the work of George Lakoff, PhD, and Mark L. Johnson, PhD. Can you say more about why you see the work of these authors as important, and what you think they have to offer to our philosophical understanding of science and psychiatry?

: Bhaskar is interested in the success of science, and he provides a 

 account of this success. Lakoff and Johnson are particularly interested in the findings of cognitive science, which views mind as embodied (in the brain) and embedded (in society). For me, their 

 helps account for many additional phenomena, including for example our metaphors of disease. Dewey’s 

 is older than the work of these modern authors, but in my mind, it prefigures it. He emphasized, for example, how knowledge is not so much based on a representation of the world, but rather is more based on engagement with the world. The classical position is a naturalist one, but by seeing physics and chemistry as the exemplars of science par excellence, it runs the risk of scientism and reductionism. I see pragmatic, critical, and embodied realism as allowing a 

 that emphasizes the complexity of the world, the usefulness of multiple explanations of such multilayered concepts as disease, and the intertwining of facts and values in medicine and psychiatry.

: Jaspers’ methodological pluralism sees 

 as distinct methods with distinct advantages and limitations such that are both essential in the realm of psychology and psychopathology. However, in such a methodological pluralism, 

 remain incommensurable, coexisting, but without a meaningful connection or bridge. When you talk about the bridging the 

 divide, do you mean the same thing as Jasperian pluralism, or do you mean something different, perhaps a sort of naturalistic account which can explain how 

: That is a great question, that I suppose I am still struggling with. I see 

 as commensurable, and I am hopeful that scientific explanations, although multiple, can be integrated. Ken Kendler, MD, who like you and me is a fan of explanatory pluralism, has put forward the notion of 

 and perhaps this sort of idea is able to form the basis of a bridge. We sometimes forget how deeply metaphoric our concepts are, and I wonder if some of the gap between 

 is based on how they use different metaphors for science and for psychiatry. My intuition is that a more comprehensive metaphor of science and psychiatry would allow a better bridge, and more successful integration. I find the schema construct or metaphor particularly useful in bridging psychodynamic and cognitive-behavioral theory and practice, and I would suggest that work on schemas may also be useful in accounting for how humans including clinicians bring together 

. Would you like to introduce the book to the readers in your own words? What are some of the major themes and conclusions of the book?

: It has been more than a decade since I wrote 

, and I have been wanting to get back to thinking about philosophy and psychiatry. I have been fortunate that a postdoctoral fellowship in philosophy and psychiatry was established in our department, and this has encouraged me to do so. I see the volume as expanding on my earlier work in a few key ways. First, whereas my earlier volume was on psychopharmacology, here I draw on a whole range of different scientific findings about the brain-mind. Second, my earlier volume spoke mainly about scientific naturalism and explanatory pluralism, but here I expand more on moral naturalism and value pluralism. Third, my earlier volume spoke mainly to the philosophy and ethics of psychopharmacology, whereas here I expand to cover the philosophy and ethics of a range of aspects of human life, including the question of the meaning of life.

There are also key continuities between the volumes. First, I continue to use the framework of classical, critical, and integrative positions to help frame philosophical and psychiatric debates. Second, I continue to be committed to scientific and moral naturalism, hoping that humans can achieve progress in both arenas through rigorous thinking-imagining, and paying attention to facts and values, and to principles and particulars. Third, I think I remain keenly aware of both the value and harms of science and psychiatry, and indeed the pros and cons of life more generally. The possibility of a middle way, of a balanced approach, is a central issue for me, and I hope the volume is useful for readers also interested in that kind of path.

Given my interest in embodied cognition, I am very aware that expressions such as “a middle way forwards” and “a balanced approach” employ metaphors. My last chapter in 

 is a brief reflection on the metaphors we use for thinking through life, the big questions and hard problems that it raises, and ultimately its meaning. I suggest that the metaphor of 

 may be a particularly useful one, and I spend some time in fleshing it out, and in advocating engagement with the world (rather than the sort of navel-gazing that some seem to advocate), and encouraging a course that avoids both unbridled optimism and relentless pessimism (of the sort that is seen in some self-help and philosophical literature). It is a bit whimsical in spirit, but I hope it appeals to at least some readers.

 to talk about brain-minds. Can you tell us more about it and what you see as the advantage of employing this metaphor?

: The mind-body problem includes the hard problem of consciousness, and key philosophical positions include physicalism, dualism, and functionalism, which relies in part on the hardware-software distinction in cognitive science. We increasingly use the hardware-software metaphor in everyday life, as well as in psychiatry. It is easy for us to talk about medications as changing our hardware, and psychotherapy as changing our software. But while brain-as-thinking-machine metaphors can be useful, they also lead to important errors: psychiatry needs to remain vigilant and avoid brainless and mindless approaches. For me, the term 

 helps emphasize how the brain-mind (a term I think we should use more often) is biological through and through, with cognitive-affective phenomena embodied in brain processes and embedded in social activity.

: Something I found really fascinating and insightful was your discussion of wetware and placebo response. You write, “the placebo response can be characterized as embodied in our particular wetware (and underpinned by a range of specific psychobiological mechanisms), and as embedded in our interactions with healers (which are powerfully meaningful for us). We might therefore propose a placebo Turing test: a computer may be considered to think and feel if it demonstrates a placebo response. Put differently, a key difference between wetware and hardware-software is that wetware entails the sort of structures, processes, and mechanisms that can produce a placebo response.”

Placebo response in this context is not a bug, not some pesky feature of our psychology that merely makes it difficult for researchers to conduct successful RCTs. Rather, it becomes an essential characteristic of our embedded, embodied, and enactive selves! I never thought of it that way.

: The Turing test, which asks that we interact with a computer, and decide whether it is a person or machine, is well-known. Stevan Harnad, PhD, has rigorously put forward variations of the Turing test, which help think through distinctions between humans and computers. For example, once robots can move around a room, and say dance with us, it becomes harder to distinguish persons from machines. Thinking about these issues as a psychopharmacologist, I was struck by the idea that even if machines can move and dance, there is yet another a level of human interaction that is captured by the placebo response, and that then helps us with distinguishing humans from machines. I am not sure that non-psychopharmacologists will find this the best way of arguing that human cognitive-affective processes are embodied and embedded, and so I particularly appreciate your being enthusiastic about this idea!

: At one point you write, “What about the fact that much psychotherapy is aimed not at specific mental disorders, but rather at ‘problems of living’? Can we really make progress in providing help for this sort of issue?”

 I think you are right that a lot of psychotherapy is aimed at problems of living, but it seems to me that a lot of contemporary pharmacotherapy is also aimed at problems of living, especially the use of SSRIs in primary care settings for the treatment of depression, anxiety, stress, etc. According to the Centers for Disease Control, between 2015 and 2018, 

 were prescribed an antidepressant medication!

 It just does not seem that way because we are able to hide the distress and impairment behind all sorts of diagnostic labels. I am not taking the extreme Szaszian view here that all psychiatric disorders are problems of living, but more of a gentle skeptical view that there is no natural distinction to be found. Would you agree with that?

: Your point that both psychotherapy and pharmacotherapy address problems of living is a trenchant one. And I am with you with regards to a gentle skeptical view that there is a spectrum from psychiatric disorders through to problems of living, and my sense is that this is increasingly recognized both in neuroscience (eg, in the Research Domain Criteria framework) and in global mental health (which often speaks of the spectrum from illness to health). In 

, I often turn to Aristotle. I trust we are better at treating bipolar disorder than the ancient Greeks, but I suspect that the ancient Greeks were as good as helping individuals with problems in human relationships as we are, demonstrating the sort of practical wisdom (

) that is required in medicine and psychiatry. Although advances in obsessive compulsive disorder inspired me to go into that field, and although I am proud of the ongoing progress the field has made, I suspect that Aristotle and his physician father would have some good techniques up their sleeves to manage some quite serious mental illnesses. Certainly, Aristotle’s thinking about mental disorders is sometimes very prescient.

: As I was reading your discussion of metaphors, I thought of 2 things. The first is a quote by Derek Bolton, PhD, and Grant Gillett, MSc, DPhil, from their book on the biopsychosocial model, a work you cite as well. They write at 

: “What is missing from and obscured by these two-dimensional picture metaphors of levels and nested domains is the temporal, evolutionary and developmental, parameter… no static metaphor, whether in terms of levels or nested systems, capable of being drawn on a page, does justice to the new systems sciences, which essentially invoke dynamical interaction in present time, on the basis of co-evolution through deep time.”

 De Haan has a wonderful ability to illustrate her arguments using metaphors. She has talked about vulnerability to mental illness using the metaphor of laying down 

: “once there is this path it is so much easier to walk that road again rather than go through all the trouble and hard work of making a new path. We slip into old patterns because they have become so engrained and come so naturally. Vulnerability is like having deeply engrained paths, making relapse probable, yet we are not destined to walk them.”

 One of her most delightful metaphors is that when we think of minds, we should “think cakes, not clockworks.” At the same time, like yourself, she argues that metaphors are never innocent and require eternal vigilance.

I think these 2 instances show us the power of metaphors to constrain us as well as liberate us. Our historical understanding of biopsychosocial complexity has been constrained by static metaphors, while new metaphors (such as baking a cake as a metaphor for organizational causality) free us from old mechanical ways of thinking. What is your view on the use of metaphors in philosophy and psychiatry?

: Dr Bolton co-supervised my dissertation in philosophy, and I am a fan of his work as well as of enactive approaches to psychiatry. I fully agree with your view that metaphors can constrain as well as liberate us. I have been interested in how metaphors work in our distinctions between typical and atypical disorders. In a typical disorder, metaphors such as being 

 work well: someone with pneumonia is attacked by a bug, we fight back with a drug, and they are not blamed but rather deserve the sick role. However, in an atypical disorder, these metaphors work less well: someone with alcoholism is not simply attacked by an external agent, rather they have to take some responsibility for their illness, and there is debate about the extent to which they deserve the sick role. It is as if we shift from medical to moral metaphors for conditions such as alcoholism. So, I like the idea of metaphors of addiction that bridge the medical and moral in order to avoid blame, but also to emphasize responsibility. It is also interesting to me that we use the metaphor of 

 for thinking through healthiness and goodness, and indeed Aristotle and other writers of the Axial Age appropriately emphasized the importance of the golden mean, of moderation, and of balance.

: Your experiences with professors of psychoanalytic orientation vs those of neurobiological and nosological orientation during your psychiatric residency seem to have left a deep mark on you. I have observed that the biological psychiatry vs psychoanalysis divide was often thought of as the central schism of the field by several of my psychiatric professors as well. Fortunately, this schism has played less of a role in my own education. One of the features of the biological psychiatry vs psychoanalysis divide was that it was very much an internal schism, a divide within the psychiatric community. The notable schisms that I think our field is confronting now are between quite different players. Schisms between so-called 

 technological approaches (pharmacotherapy, CBT, etc) vs existential-humanistic-psychodynamic approaches; biomedical models vs interpersonal-relational models; and the epistemic authority of medical professionals vs epistemic authority of users of psychiatric services (exemplified by movements such as neurodiversity, mad pride, service user/survivors/ex-patients, etc). 

My approach to these schisms is in alignment with the same pluralistic and integrative approaches that you adopt. However, a concern increasingly comes up when I discuss these things: within a pluralistic-integrative framework integrating these polarities, it is no longer obvious that psychiatry as a medical profession—that has increasingly specialized in psychopharmacology and clinical neuroscience over the last 3 decades—serves as the suitable umbrella profession for the integrated domain, instead of, say, clinical psychology, or social work, or even efforts led by service users. If neuroscience and psychopharmacology will no longer be of central importance in the new pluralism (at least it’s not obvious), then why should psychiatry continue to claim its existing power? This is also a point that 

 with me: “I am a deep believer in pluralism, too, but I believe that a road to true pluralism will require the courage to share power. In other words, alongside becoming less reductionist, the field also could consider becoming less hegemonic… I have suggested that the field would be stronger and serve patients better if it functioned as one part—the medical part—of a cooperative ecosystem of mental health experts.”

: I agree with you about the importance of the schisms that you mention (my sense is that these partly reflect aspects of the biological-psychoanalytic schism), and I am glad that you are in alignment with pluralistic and integrative approaches to addressing them. In 

, I emphasize the importance of epistemic humility and of owning our fallibility; so absolutely we need to be open to entirely new ways of explaining, understanding, and improving mental health. Certainly, mental health is too important to be left to psychiatrists. My work on trichotillomania has clearly taught me how much service users know, and how valuable they are in creating solutions. At the same time, I would want to appropriately acknowledge the breadth and depth of psychiatry. So, with regard to sharing hegemony, I may be a bit more conservative than you would like. In my book, I refer a few times to the work of Jonathan Haidt, PhD, who as you know has argued for diversity of political positions; I do wonder if greater balance between conservativism and progressivism in general may not be useful, as we move forwards.

: What do you see as some of the challenges we face in the pursuit of an integrative and pluralistic approach to psychiatry, and how can psychiatrists, especially trainees, better prepare for these challenges ahead?

: Another great question, from your columns I know you have a knack for making thinkers think harder! In line with my view that despite its important limitations, psychiatry does have extraordinary breadth and depth, I would argue that our field does already exemplify explanatory pluralism, and that a good clinician is necessarily taking an integrative approach. I do think that explicitly providing residents conceptual frameworks, as you have advocated for, is a good idea; this might be useful in seeing the explanatory pluralism we use as something to be proud of rather than concerned by. I do think that explicitly providing residents with exposure to good clinicians and researchers, who are able to explain how they integrate different ideas and approaches, is useful. Finally, although I appreciate that it is important to be hopeful about the future, I also think that more explicit humility might be helpful at times; in our understandable zeal to address suffering, we may run the risk of overselling what we can do with any particular treatment approach, or any particular research program. In sum, I go back to a favorite metaphor: a balanced approach is key!

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of 

is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of Psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the 

Dr Aftab has no relevant financial disclosures or conflicts of interest. Dr Stein discloses that he has received research grants and/or consultancy honoraria from Johnson & Johnson, Lundbeck, Servier, and Takeda.

1. Stein DJ, Phillips KA, Bolton D, et al. What is a mental/psychiatric disorder? From DSM-IV to DSM-V. 

2. Stein DJ. Psychiatric contributions from South Africa: ex Africa semper aliquid novi. 

3. Kendler KS, Campbell J. Expanding the domain of the understandable in psychiatric illness: an updating of the Jasperian framework of explanation and understanding. 

5. Brody DJ, Gu Q. Antidepressant use among adults: United States, 2015-2018. The Centers for Disease Control and Prevention. September 2020. Accessed June 28, 2021.

6. Bolton D, Gillett G. The biopsychosocial model 40 years on. In: 

The Biopsychosocial Model of Health and Disease: New Philosophical and Scientific Developments

8. Aftab A. Sense-making and the enactive turn in psychiatry: Sanneke de Haan, PhD. 

. October 22, 2020. Accessed June 28, 2021.

9. Aftab A. The many histories of biological psychiatry: Anne Harrington, DPhil. 

Travelling the middle road between skepticism and scientism in psychiatric research and treatment.  

From Classic and Critical to Integrative Psychiatry: Dan J. Stein, MD, PhD, DPhil

With Sigmund Freud’s development of modern psychotherapy in the 1890s, a new method for treating psychopathology was born. A neurologist by training, Freud was first and foremost a medical doctor who, in 1895, wrote that with psychoanalysis he wished to create “a psychology that would be a natural science.”

 Throughout his career, Freud maintained his belief that future advances in neuroscience would validate his ideas on the unconscious, and that later modifications to psychoanalytic technique could render it effective for more severe mental diseases like schizophrenia.

Yet, in the past 50 years, and especially the past 30, we have witnessed the concept of 

 applied to a host of endeavors unrelated to the treatment of psychopathology. These fields include marital, family, and relationship therapy; career and corporate counseling; positive psychology and general self-improvement; new age energy healing; and, most recently, life coaching. It is conceivable that the current number of therapists in the United States working in areas such as those listed previously exceeds the number of therapists interested primarily in the treatment of psychiatric disorders.

The American Psychological Association’s 

“…any psychological service provided by a trained professional that primarily uses forms of communication and interaction to 

 dysfunctional [disordered] emotional reactions, ways of thinking, and behavior patterns.”

Yet, among some modern psychoanalysts and existential therapists, there is a tendency to see psychotherapy as a process wholly unrelated to the concept of mental illness (ie, not as a form of treatment for illness, but rather as an endeavor undertaken for other reasons), a position that deviates significantly from the psychiatric and psychoanalytic conceptualization of psychotherapy for the vast majority of the 20th century.

While this demedicalization of psychotherapy coincides chronologically with the growth in lay analysis (ie, the practice of psychotherapy by nonphysicians), I contend that it is not solely due to this factor. Psychiatric social workers were the first nonphysicians to practice psychotherapy beginning in the early 20th century, engaging in this practice well before it was adopted by the fields of psychology and counseling, but psychotherapy remained chiefly focused on the treatment of the mentally ill during this period.

 Rebranding psychotherapy as a nonmedical endeavor unrelated to 

 has come with numerous negative consequences.

The Consequences of Demedicalization for Patients

I contend that there are 3 main consequences to demedicalizing psychotherapy:

1. Psychotherapy becomes devalued relative to other forms of psychiatric treatment, despite its proven effectiveness for a range of mental disorders.

2. Access to psychotherapy as a treatment for mental disorders becomes more difficult, as fewer therapists choose to specialize in treating psychiatric patients and instead become focused on other forms of therapy or counseling.

3. Training requirements for psychotherapists continue to loosen, so that many graduating therapists have had little to no exposure to patients across the psychiatric diagnostic spectrum.

While all 3 points are vital, I wish to comment briefly on number 3, which I see as particularly worrisome. Training standards for psychotherapists in this country have been falling for decades. For instance, some clinicians finish graduate school without ever having assessed a patient with schizophrenia or 

. Internship sites may be located in a variety of nonclinical settings. Without adequate training in the assessment and treatment of mental disorders, nonmedical therapists are less likely to choose to work with these patients—and may put them at risk of harm if they do.

These factors have led to a shortage of properly trained psychotherapists nationwide. In my own metropolitan area of over 3 million individuals, there are only a handful of therapists in private settings who work with patients with severe mental disorders, such as 

. Yet, the online therapy directories are filled with listings of therapists who specialize in relationship problems and life coaching. The sad reality is that the patients who need the most help are the ones least likely to find it. The 

 of psychotherapy becomes a barrier to access of competent mental health care.

In saying that psychotherapy is primarily a form of medical treatment, I am not suggesting that its practice once again be limited to physicians. In a broad sense, a whole host of medical interventions are provided by nonphysicians, such as nurses and physician assistants, and I contend that psychotherapy is one of those interventions. As noted above, psychiatric social workers practiced psychotherapy within departments of psychiatry starting in the 1910s. During this time, psychotherapy remained a medical treatment for psychiatric disorders.

Likewise, I do not contend that these nonmedical extensions of psychotherapy, such as helping businesspeople climb the corporate ladder, are not legitimate activities that serve a useful purpose. It is simply to say that these other enterprises, as worthy (and lucrative) as they may be, distract us from psychotherapy’s main goal: the alleviation of the human suffering caused by mental illness. What we are left with is a psychotherapy that works for the rich and healthy, not the sick and disabled.

The Consequences of Demedicalization for the Field of Psychotherapy

Not only is demedicalizing psychotherapy bad for psychiatric patients, it is also bad for psychotherapy itself. When psychotherapy is seen by the general public—and by some mental health professionals—as something other than treatment (eg, as mere conversation to deal with day-to-day life struggles), it becomes an intervention of secondary or tertiary importance in the psychiatric armamentarium. If psychotherapy is seen as not really treating mental disorders (“Medications treat the illness, psychotherapy just helps people cope”), then its use will gradually fall out of fashion in favor of other, usually biological, treatments. Yet we know that psychotherapy is the treatment of choice for a range of mental disorders, including personality disorders, posttraumatic stress disorder, mild depressive disorder, and others.

Even in instances where psychotherapy is not indicated as monotherapy, such as in the treatment of bipolar disorder or schizophrenia, its use is not merely supportive in nature and it still reflects a form of treatment. When conceptualized through a biopsychosocial lens, even complex diseases like schizophrenia possess a psychosocial component, and psychotherapy can legitimately be seen as 

While much of the demedicalization of psychotherapy has been the result of harmless motives, there is also an antipsychiatry push to conceive of psychotherapy as something other than treatment. This line of argument goes something like: “Mental illness does not exist and thus psychotherapy does not treat illness.” Szasz made such an assertion in his 1978 book 

 but his conclusions were based on a faulty interpretation of the concept of disease.

 One need not be a psychotherapist, or even place much stock in psychotherapy, to see the problems inherent in this line of reasoning.

Lastly, conceptualizing psychotherapy as a medical treatment does not necessitate or imply a theory of biological causation of psychiatric disorders. The psychoanalysts of mid-century American psychiatry certainly viewed psychotherapy as treatment in the literal sense, but few saw psychiatric disorders as biological diseases. While a thorough discussion of the meaning of “disorder” in psychiatry is well beyond the scope of this paper, it suffices to say that one can conceptualize mental disorders as bona fide medical diseases due to their associated suffering and incapacity

 regardless of any known or imputed biological abnormality.

Freud’s original aim for psychoanalysis was as a method for treating mental illness. Psychotherapy remained, for many decades, primarily a form of medical treatment, even when practiced by nonphysicians. Attempts to define analysis—and, by extension, psychotherapy—in other ways deviate historically from its original and primary intention. The more recent application of psychotherapy to problems unrelated to psychopathology dilutes the value of psychotherapy, loosens training requirements, and leads unnecessarily to barriers to care.

is Instructor of Psychiatry at the University of Central Florida College of Medicine in Orlando, FL, and Adjunct Instructor of Psychiatry at Tufts University School of Medicine in Boston, MA. He is a psychoanalytic psychotherapist in private practice.

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Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness.

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Understanding schizophrenia: Toward a unified biological and psychodynamic approach.

7. Pies R. On myths and countermyths: more on Szaszian fallacies. 

Why did medicine and psychotherapy part ways? How can they be brought back together? 

Psychotherapy as a Medical Treatment

Posttraumatic stress disorder (PTSD) can be exceptionally 

. But recent studies have suggested the efficacy of a surprising option: 

For PTSD, 3,4-methyl​enedioxy​methamphetamine (MDMA) appears to be especially 

. In this Mental Health Minute, Devon Christie, MD, CCFP, IFMCP, RTC discusses her latest study results on this topic and what might be in the future for psychedelic-assisted psychotherapy.

is a family physician, a certified therapist, and medical and therapeutic services director at 

Do you have patients who might benefit from MDMA-assisted psychotherapy? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

A growing body of scientific evidence suggests that mind-altering drugs, combined with psychotherapy, are effective treatments for some of the most stubborn psychiatric disorders.

What Does the Future Hold for Psychedelic-Assisted Psychotherapy?

For several years my colleagues and I have pursued a simple question with profound implications for psychiatric practice: how does psychotherapy work? We want to capitalize on major advances in our understanding of the neural basis of memory, emotion, and emotion-memory interactions. If we could start to explain the basic mechanism of action behind psychotherapy, then maybe we could understand how to conduct psychotherapy more effectively, with the ultimate goal of working with our patients to produce lasting changes in their mental health.

Recent studies have made important discoveries about the neural mechanisms underlying memory. Four are of particular interest. First, memories are not fixed entities; rather, they enter a labile state whenever they are reactivated, and can be modified or updated with new information during a 4 to 6 hour window after 

 Second, specific episodic (event) memories and semantic (generalizable knowledge) memories are highly inter-related in that they share neural mechanisms, and the latter are a distillation of the 

 Third, memories that are emotionally charged are remembered better than 

 And fourth, the activation of emotion appears to be a necessary ingredient of successful outcomes in 

Drawing upon these observations, my colleagues and I hypothesized that there were 3 key ingredients to lasting change in psychotherapy: 1) activating problematic memories and the associated painful affect; 2) concurrently engaging new emotional experiences that change old memories through reconsolidation; 3) reinforcing the strength of new memories and their semantic structures by practicing new ways of behaving and experiencing the world in a variety of contexts. In a 2015 article in a leading neuroscience 

 we briefly discussed the application of this model to 4 different psychotherapy modalities, including behavioral, cognitive behavioral (CBT), emotion focused (EFT), and psychodynamic psychotherapies..

Diving Into the Research—and the Clinical Implications

Realizing that there was much more to say about this new way of understanding change in psychotherapy, my colleagues and I published an edited volume, with multiple contributors, that both explains the basic science of memory and outlines a clinical application of our model. The new book, 

Neuroscience of Enduring Change: Implications for Psychotherapy

, expands upon the previous work in 3 sections.

 The basic science section includes chapters on emotion, memory, emotion-memory interactions, the role of language in shaping emotion and memory, and the role of sleep in memory consolidation and reconsolidation. The clinical section includes chapters from leading experts in psychodynamic psychotherapy, CBT, EFT, coherence therapy, and integrative approaches. Each author considers the role of memory reconsolidation in both psychotherapy and in achieving lasting personal change. The final section includes chapters on recurrent maladaptive patterns, a computational neuroscience perspective on the proposed model, and a discussion of a proposed preclinical and clinical research agenda.

Considerable effort was made within and across chapters to promote cross-fertilization between basic science and clinical application. Although it is written for neuroscience-oriented mental health clinicians, all psychotherapists, psychotherapy researchers, and scientists interested in memory, emotion, and their clinical application will find new ideas and practical advice in this book. An independent 

If one takes this model seriously it could influence psychiatric practice in several ways. For example, it is useful to consider how interventions might be adjusted in therapies that have stalled or have failed. Rather than talking about feelings with the goal of promoting insight, it is also important to experience feelings, especially the old painful feelings from which individuals have protected themselves for years, and to juxtapose these feelings with corrective emotional experiences.

Another clinical implication emerges from the observation that consolidation of emotional memories occurs primarily during REM sleep. Because reconsolidation may work in the same way, medications that inhibit REM sleep may be counterproductive to enduring change in psychotherapy. It is therefore important to know that selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitor, tricyclics, and benzodiazepines inhibit REM sleep, whereas trazodone, buproprion, and 

. The book describes these and other implications and provides a fresh perspective on how psychotherapy practice may be optimized and integrated in psychiatric care.

My interest in this topic emerged over the course of my 35-year career as an academic psychiatrist. I was initially trained as a clinical psychiatrist and psychodynamic psychotherapist and have continued to practice and supervise residents ever since. I was also fortunate enough to receive research training (resulting in a PhD in experimental psychology) that focused on cognitive neuroscience and functional neuroimaging of emotion. I have found the dialogue between the basic science of psychiatry and its clinical application to be particularly enriching and informative.

In my role as educator, I have become well acquainted with the challenges (eg, significant differences in the theoretical backgrounds, mindset, and clinical interventions required by these different approaches) psychiatry residents face in developing competence in CBT, psychodynamic psychotherapy, and supportive psychotherapy. Because there is a strong interest in finding common factors and common mechanisms across psychotherapy modalities, it occurred to me that a systems neuroscience perspective could provide an integrative mechanistic framework that would highlight commonalities instead of divergences. Moreover, the goal of integrating pharmacotherapy and psychotherapy is likely to be advanced by explaining how each works in brain-based terms. In my efforts to develop a new brain-based model of change in psychotherapy, I have been fortunate to have remarkable collaborators, including Lynn Nadel, PhD, Emeritus Professor of Psychology at the University of Arizona (a pioneer in the newly emerging understanding of memory).

It is important to emphasize that we have not yet established that change in psychotherapy occurs through memory reconsolidation. One of the conclusions of our book is that a focus of intervention is recurrent maladaptive patterns, which can be understood as an expression of schemas. Schematic memory is a type of semantic memory and, as an area of neuroscientific investigation, it is relatively new. It remains to be demonstrated empirically that schematic memories can be updated with emotional information. If so, it must then be determined whether this applies to psychotherapy. Although research of this type is still underway, it might be argued that it is important to consider the clinical implications of this model if it were true.

is professor of psychiatry, psychology, and neuroscience at the University of Arizona.

1. Phelps EA, Hofmann SG. Memory editing from science fiction to clinical practice. 

2. Ryan L, Hoscheidt S, Nadel L. Perspectives on episodic and semantic memory retrieval. In: Dere A, Easton J, Huston J, Nadel L, eds. 

3. Kalbe F, Schwabe L. Beyond arousal: Prediction error related to aversive events promotes episodic memory formation. 

4. Lane RD, Ryan L, Nadel L, Greenberg L. Memory reconsolidation, emotional arousal, and the process of change in psychotherapy: New insights from brain science. 

5. Auszra L, Greenberg LS, Herrmann I. Client emotional productivity-optimal client in-session emotional processing in experiential therapy. 

7. Kramer U. Review of “Neuroscience of Enduring Change: Implications for Psychotherapy.” 

8. Doghramji K, Jangro WC. Adverse effects of psychotropic medications on sleep. 

9. Borbély AA, Mattmann P, Loepfe M, Strauch I, Lehmann D. Effect of benzodiazepine hypnotics on all-night sleep EEG spectra. 

A brain-based perspective could explain how and why psychotherapy leads to enduring change. 

The Neural Mechanisms Behind Effective Psychotherapy

Existing treatments for posttraumatic stress disorder (PTSD) are few in number and, too often, ineffective. Although still classified as a Schedule I drug, methylenedioxymethamphetamine (MDMA) has improved symptoms PTSD in 

In this Mental Health Minute, Tiago Reis Marques, MD, PhD, shares the results of 

, in which the MDMA-assisted arm of the study outperformed the placebo by 35%. He revisits the history of MDMA and looks to the future, when this Schedule I drug may be approved as a legal treatment.

is a senior clinical fellow on the Faculty of Medicine at Imperial College London, an instructor at the Institute of Psychiatry in King’s College, and the CEO of Pasithea Therapeutics.

Would you prescribe a psychedelic like MDMA? 

The latest trial results for MDMA-assisted therapy are in—and they are eye-catching.  

New Hope for PTSD Treatment?

Psychodynamic psychotherapy has receded into the background in many residency programs. But according to Richard D. Lane, MD, PhD, psychotherapy is not only foundational to the history of psychiatry—it still has a lot to offer.

In this Mental Health Minute, Lane uses a brain-based perspective to reimagine how psychotherapy works. In his latest book, 

, he collects the latest neuroscientific research on how psychotherapy works and translates the scientific findings into ideas for effective clinical practice.

is Professor of Psychiatry, Psychology, and Neuroscience at the University of Arizona.

How should neuroscience inform psychiatric practice? 

Key neural mechanisms are responsible for emotion, memory consolidation, and lasting personal change. 

What Are the Neuroscientific Secrets to Successful Psychotherapy?

“There’s more to trauma than physicality,” Rachel Yehuda, PhD told attendees at the 2021 American Psychiatric Association (APA) Annual Meeting. “For decades we have been talking about how to integrate pharmacotherapy with psychotherapy. But we haven’t understood how to do it.” 

For patients with posttraumatic stress disorder (PTSD), one possibility is combining therapy and mind-altering drugs, like 3,4-methyl​enedioxy​methamphetamine (MDMA), panelists explained.

Mark Bates, PhD, former branch chief for Psychological Health Promotion in the Department of Defense’ Psychological Health Center of Excellence, presented findings from 6 phase 2 trials of combined MDMA and psychotherapy in the 

 The studies included 103 participants who had experienced treatment-resistant PTSD symptoms on average for more than 15 years.

Participants progressed through several types of sessions in all of the studies. First, participants and clinicians conducted an initial, 90-minute interview, preparing the participants for the MDMA-assisted sessions and discussing their PTSD. Then participants underwent 8-hour MDMA-assisted or placebo sessions. During this time, participants wore eyeshades and listened to music, and had the option of discussing their troubling experiences.

The participants who received MDMA experienced an altered mental state, which was believed to make the discussion easier on them as compared with those in the placebo group. “One of the most important features,” Bates said, “is this reduced fear response in combination with increased empathy, trust, and closeness. In the words of one participant, ‘it’s like being in a box full of puppies.’ You can actually feel safe to bring up things that were otherwise very uncomfortable.”

Participants and therapists debriefed for 90 minutes the day after the MDMA session. Integration, Bates explained, helps “the patients retrieve and consolidate much of what happened during the dosing session and integrate it into their daily lives.”

The results of the studies were encouraging, he reported. Among participants who received MDMA, 56% no longer met PTSD criteria by the end of the study and, at a 12-month follow-up, that number rose to 67%.

New research find altered states of consciousness may allow veterans and other patients with PTSD to face unspeakable experiences and find peace. 

Psychotherapy

From Classic and Critical to Integrative Psychiatry: Dan J. Stein, MD, PhD, DPhil

Psychotherapy as a Medical Treatment

What Does the Future Hold for Psychedelic-Assisted Psychotherapy?

The Neural Mechanisms Behind Effective Psychotherapy

New Hope for PTSD Treatment?

What Are the Neuroscientific Secrets to Successful Psychotherapy?

Looking to the Future of MDMA-Assisted Psychotherapy

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