Through the Times With Glen O. Gabbard, M.D.

Apr 01, 2005

Dr. Gabbard discusses using psychotherapy and psychiatry combined, how media portray psychiatrists and why Tony Soprano does the things he does.

Psychiatric Times

April 2005

Vol. XXII

Issue 4

In his work as an academician, clinician, researcher and author, Glen O. Gabbard, M.D., advocates practicing an integrative approach to psychiatry and treating the patient as a whole person.

Currently, Gabbard is Brown Foundation Chair of Psychoanalysis and professor in the department of psychiatry and behavioral sciences at Baylor College of Medicine in Texas and director of the Baylor Psychiatry Clinic. Yet, psychiatry and psychoanalysis have been pursuits since childhood.

"When I was about 10, I remember my mother reading Freud and discussing The Interpretation of Dreams at the dinner table. A lot of conversations revolved around psychoanalytic ideas," he told Psychiatric Times. In fact, "my mother [Lucina Paquet Gabbard] wrote a book on a psychoanalytic interpretation of Harold Pinter's plays [Dream Structure of Pinter's Plays: a Psychoanalytic Approach 1976; Fairleigh Dickinson University Press]."

For Gabbard, psychiatry and drama have been inextricably intertwined. He attended Northwestern University, University of Texas and Eastern Illinois University during his undergraduate years, majoring in theater.

"I found that much of my interest in drama was the psychology of the characters in the play. That drew me into wanting to know what motivated people."

In 1975, Gabbard graduated from Rush Medical College. He then went on to complete his residency at the Karl Menninger School of Psychiatry in 1978 and his psychoanalytic training at the Topeka Institute for Psychoanalysis in 1984.

"One of the things that I noticed as a psychiatric resident was that patients often responded to medication, but they still had enormous problems left in their lives. I realized that to really help people you have to address the whole person and do both psychotherapy and medication."

Gabbard served on the staff of the Menninger Clinic for 26 years, where he spent five years as director of the Menninger Hospital and seven years as the Bessie Walker Callaway Distinguished Professor of Psychoanalysis and Education in the Karl Menninger School of Psychiatry and Mental Health Sciences.

He has maintained his interest in psychoanalysis and is joint editor-in-chief of the International Journal of Psychoanalysis and training and supervising analyst at the Houston/Galveston Psychoanalytic Institute. Most recently, he wrote the fourth edition of Psychodynamic Psychiatry in Clinical Practice (2005; American Psychiatric Publishing, Inc.), and coedited the Oxford Textbook of Psychotherapy (2005; Oxford University Press) and the American Psychiatric Publishing Textbook of Psychoanalysis (2005; American Psychiatric Publishing, Inc.).

Although an international expert in psychoanalysis and psychotherapy, Gabbard has warned against dualism. "As we contemplate the shape of psychiatry in the 21st century, one of the greatest risks we face is reductionism," he wrote in the British Journal of Psychiatry (Gabbard, 2000). He continued:

Specifically, psychiatry is at risk of becoming a house divided against itself, with psychosocial specialists in one camp and neuroscientists in another. While we know that mind and brains are inseparable, our literature and our practice do not always reflect that.

"There is a great need in training programs to teach all of psychiatry, so that we avoid a reductionistic approach that doesn't take the whole person into account," Gabbard told PT. "I think everybody loves to oversimplify things. There is a great risk of genetic reduction that leaves out how the early environment shapes the expression of the gene."

More specifically, he wrote (Gabbard, 2000):

The sequence of a gene, or the template function, is not affected by environmental experience, but the transcriptional function of the gene--the ability of a gene to direct the manufacture of specific proteins--is certainly responsive to environmental factors and regulated by those influences ... The impact of environmental factors on gene expression explains why there are phenotypic differences between identical twins and discordance for such illnesses as schizophrenia.

"We need to teach in psychiatry programs that there is ongoing interaction between genes and environment and that interaction continues into adult life where both genetic vulnerability and environmental stressors have an impact on the shape of the psychopathology we see and the patient's personality," he told PT.

There is a move back to recognizing the central importance of psychotherapy, according to Gabbard. He explained that the Psychiatry Residency Review Committee of the Accreditation Council for Graduate Medical Education in 2001 required that residents must be competent in five specified psychotherapies: brief therapy, cognitive-behavioral therapy (CBT), psychodynamic therapy, supportive therapy, and combined psychotherapy and psychopharmacology. To assist training directors with the new requirements, the Task Force on Competency established work groups for each psychotherapy to develop sample competencies.

"That's a reflection of the pendulum swinging back," he explained.

Despite efforts to retain psychotherapy as an integral part of a psychiatrist's training and identity, Gabbard acknowledged that managed care organizations will continue to coerce psychiatrists to do brief medication management visits instead of psychotherapy.

"There will be constant pressure to get psychotherapy from low-cost providers like bachelor's level or master's level allied mental health professionals, because of managed care influence," he said. The way that many psychiatrists have already acted to counteract that pressure "is to simply not work in managed care situations and to [only] see private pay patients."

"There is always a stigma about psychotherapy as being nothing more than hand-holding. So we need to continue to do research on the efficacy of psychotherapy and how it changes the brain, in order to convince skeptics that it really is a legitimate treatment like medication," he said. "Many studies show the impact on the brain of psychotherapy, so this is a burgeoning field of research."

Gabbard credits advances in neurosciences, particularly in imaging techniques, with helping to demonstrate that psychotherapy affects brain function. One of the first was the study by Baxter et al. (1992). The researchers used positron emission tomography (PET) to investigate local cerebral metabolic rates for glucose (LCMRG1c) in patients with obsessive-compulsive disorder before and after treatment with either fluoxetine (Prozac) or behavior therapy. After treatment, LCMRG1c in the head of the right caudate nucleus was decreased significantly compared with pretreatment values in responders to both drug and behavior therapy.

More recently, Brody et al. (2001) examined baseline regional metabolic abnormalities and metabolic changes from pretreatment to posttreatment in 24 patients with major depressive disorder (MDD). The patients and 16 control participants underwent resting 18F-fluorodeoxyglucose (FDG) PET scanning before and after 12 weeks. Between scans, patients with MDD were treated with either paroxetine (Paxil) or interpersonal psychotherapy (based on patient preference), while controls underwent no treatment. Patients with MDD had regional brain metabolic abnormalities at baseline that tended to normalize with treatment, and the regional metabolic changes appeared similar with both forms of treatment.

Even though psychotherapy may induce changes in the brain, it does not mean that medications are expendable, according to Gabbard (2000). He pointed out that psychotherapy and psychotropic drugs should often be used in combination.

For example, in one study, 681 patients with chronic forms of major depression were treated with nefazodone (Serzone) (Bristol-Myers Squibb discontinued manufacturing Serzone in May 2004--Ed.), cognitive-behavioral analysis system of psychotherapy (CBASP) or a combination (Nemeroff et al., 2003). Overall, the effects of the antidepressant alone and psychotherapy alone were equal and significantly less effective than combination treatment. Among those with a history of early childhood trauma, psychotherapy alone was superior to antidepressant monotherapy.

With regard to psychotherapy over the last 20 years, Gabbard noted that there is a much greater emphasis now on psychotherapy research and a much greater interest in integrating diverse perspectives, such as CBT and psychodynamic therapy.

"We realize that it is more important to help the patient than to be pure to a theory," he added.

In his own research, Gabbard has had a long-standing interest in borderline personality disorder (BPD) and has been conducting studies involving psychotherapy and hospital treatment of that condition.

"We have quite a bit of data that two forms of psychotherapy work for borderline personality disorder, that is, dynamic therapy and dialectical behavior therapy," he said.

Gabbard's current research involves using functional neuroimaging to look at differences in thinking between patients with BPD and controls as they relate to differences in areas of brain activation. He is seeking to correlate the "the inner world of the patient with borderline personality disorder to functional neuroimaging markers, so we can try to link mind and brain."

"We're in the middle of the project," he said, "so it will be a long time before the data are collected and published."

During his career, Gabbard has published some 20 books and more than 200 papers. While many of the books and papers are on psychodynamic psychiatry, countertransference issues and BPD, he took time to psychoanalyze psychiatry's relationship with the entertainment industry. With his brother, Krin Gabbard, Ph.D., a professor in the department of comparative literature and cultural studies at the State University of New York at Stony Brook, he wrote Psychiatry and the Cinema in 1987 (University of Chicago Press) and came out with a second edition in 1999 (American Psychiatric Press). In 2002, he wrote The Psychology of the Sopranos: Love, Death, Desire and Betrayal in America's Favorite Gangster Family (Basic Books).

"Filmmakers tend to use psychiatrists according to the needs of the plot, and they don't really give a damn about accuracy," Gabbard told PT. "So there are many ridiculous portrayals and an occasional good one." One of the rare good ones, he said, was when Vanessa Redgrave played a fairly realistic and sympathetic therapist in the 1999 film Girl, Interrupted.

More than being a prolific author, Gabbard served on the editorial board of the American Journal of Psychiatry until January of this year, and he currently serves on a number of other editorial boards, including the Journal of Sex & Marital Therapy. In 1989, he joined the editorial board of PT and has been on the board ever since. Over the years, he has contributed numerous articles and just last year began writing and editing a column called "Mentoring."

In his first column in March 2004, Gabbard recalled how during his residency, he had no plans to be an academic psychiatrist or to attempt to write journal articles.

"My vision," he wrote, "was of a hard-working psychiatrist in private practice, taking all comers and wrestling with the demons that torture the human soul. However, my residency director required a graduation paper before we residents could receive our diplomas."

So Gabbard wrote his first paper, and with encouragement from a faculty member, submitted it to a journal for publication. He was "dumbfounded" when it was accepted. Thinking back over the incident, Gabbard realized that a critical dimension of his relationship with this early mentor was "that she believed in me."

Similarly, Gabbard believes in the many residents he has mentored. In turn, they have recognized his expertise and compassion. For several years, he received the Teacher of the Year Award at the Karl Menninger School of Psychiatry and Mental Health Sciences. In 2002, 2003 and 2004 he received an Outstanding Teacher Award from the graduating Baylor psychiatric residents. In 1992, he was named PT Teacher of Year.

When asked what qualities make a good teacher, Gabbard responded, "Humility. You need to convey to students that you don't know everything and that you, too, struggle all the time in your work with patients. Then, they feel freer to bring up their doubts, their uncertainties and their mistakes. You want to convey an atmosphere that it is all right to make mistakes and that you won't be humiliated for it."

References

Baxter LR Jr, Schwartz JM, Bergman KS et al. (1992), Caudate glucose metabolic rate changes with both drug and behavior therapy for obsessive-compulsive disorder. Arch Gen Psychiatry 49(9):681-689.

Brody AL, Saxena S, Stoessel P et al. (2001), Regional brain metabolic changes in patients with major depression treated with either paroxetine or interpersonal therapy: preliminary findings. Arch Gen Psychiatry 58(7):631-640 [see comments].

Gabbard GO (2000), A neurobiologically informed perspective on psychotherapy. Br J Psychiatry 177:117-122.

Nemeroff CB, Heim CM, Thase ME et al. (2003), Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma. Proc Natl Acad Sci U S A 100(24):14293-14296.

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