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.

Psychotherapy research

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 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

The voice of psychotherapy within the APA Assembly

The APA Assembly is an organization with a membership structure based on the number of psychiatrists in identified geographic areas of the United States and Canada. During the age of the brain, the APA Assembly created a new category of membership for representatives of APA-allied organizations. This change has ensured a voice within the Assembly of a diverse range of subspecialty organizations with particular skills and interests (eg, the American Academy of Psychiatry and the Law). Among the Assembly's allied organizations are several with interest in individual, group, and family therapy, including the American Academy of Psychoanalysis and Dynamic Psychiatry and the American Psychoanalytic Association.

The APA Assembly has often been called "the conscience of the APA." Inclusion of representatives of allied organizations has helped ensure a place for the voices of psychotherapy and other subspecialties within the APA governance structure.

The work of COPP and the RRC In 1996, in recognition of the dwindling role of psychotherapy within psychiatric practice and psychiatric residency training, the then president-elect of the APA, Harold Eist, appointed the APA Commission on Psychotherapy by Psychiatrists (COPP). In 2002, in a downsizing of APA components, the Commission was preserved but reconfigured as a committee reporting to the APA Council on Quality Care. Members of COPP represent a range of psychotherapeutic orientations—including CBT and psychodynamic, interpersonal, and group therapy--and they focus on shared interests and concerns.

COPP has met with success in advocating for the place of psychotherapy within clinical training and psychiatric practice. Recognizing the neurobiologic orientation of many residents and practicing psychiatrists, COPP initially collected and promulgated a body of evidence showing that psychotherapy was associated with changes in the brain and that it was an effective form of treatment for several disorders.

Not long after COPP was founded the RRC established core competencies for 5 schools of psychotherapy, including brief psychotherapy, supportive psychotherapy, combined medication and psychotherapy, CBT, and psychodynamic psychotherapy. Furthermore, the RRC gave the psychotherapy core competencies special status, mandating that residency programs ensure residents are measurably proficient in psychotherapy by the end of their training.

However, many departments of psychiatry found it difficult to teach all 5 core competencies, in part because they were depleted of psychotherapeutically oriented clinicians during the age of the brain. In the first several years after the introduction of the RRC core competencies in psychotherapy, pressures began to emerge within some residency programs to teach certain competencies while omitting others. Given the complexity of teaching psychodynamic psychotherapy and the decrease in sophisticated faculty able to teach it, psychodynamic psychotherapy was often at risk of being omitted.

By 2003, independent of the work of the RRC, members of COPP began to examine the structure of the 5 psychotherapy competencies. Each of the competencies was developed by a different committee with relatively little overlap of membership, and each came from different levels of abstraction, resulting in relatively little parallel structure from one competency to another. In addition, concerned about the pressures to teach only some of the competencies in psychotherapy and particularly about the trend toward omitting training in psychodynamic psychotherapy, COPP began to explore the possibility of integrating and simplifying the competencies while linking them to the existing evidence base.

The result of this effort by COPP has been the development of a still evolving, integrated, unified, 3-part psychotherapy competency model based on past research regarding common factors in teaching psychotherapy across schools¹⁵ and evidence from recent comparative psychotherapy process research.^16,17 The resulting "Y"-psychotherapy model has a stem consisting of common factors in psychotherapy (eg, basic assumption of cure, negotiating an alliance, empathic listening). The competencies in supportive and brief psychotherapy and combined medication and psychotherapy are also included in the stem of the Y. The model then diverges into the 2 branches of the Y, using data from Blagys and Hilsenroth.^16,17 The branches contrast 6 evidence-based core features of CBT that differentiate it from psychodynamic psychotherapy (Table 1) with 6 evidence-based core features of psychodynamic psychotherapy that differentiate it from CBT (Table 2).

The model has been well received by training directors and residents at several professional meetings. Residents have stated their appreciation for the way the model integrates and makes sense of competing schools of therapy while avoiding historical competition between schools that they often experience as the struggles of a previous generation.

Recently the RRC completed a revision of the psychotherapy competencies, reducing them to 3 psychotherapies: CBT, psychodynamic, and supportive. This change is highly consistent with the thrust of the Y-psychotherapy model. Currently, the Y-psychotherapy model is being revised to match the changes made by the RRC. (A PowerPoint presentation on the Y-Psychotherapy model is available by e-mail from the author of this article: eric.plakun@austenriggs.net.)

To be sure, the age of the brain emphasizes neurobiology, the medical model, and biologic treatments. Nevertheless, psychotherapy is alive and well in the age of the brain, garnering new attention and interest in psychiatric practice and training. Psychotherapy remains an important part of the identity, skill set, and training of psychiatrists.

References:

References

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