Copyright 2008 Group for Advancement of Psychiatry (GAP) The Social Brain Model for Psychiatry:...

Copyright 2008 Copyright 2008

Group for Advancement of Psychiatry Group for Advancement of Psychiatry (GAP)(GAP)

The Social Brain Model for The Social Brain Model for Psychiatry: Historical Psychiatry: Historical

Background Background Research CommitteeResearch Committee

Group for the Advancement of Group for the Advancement of Psychiatry (GAP)Psychiatry (GAP)

Russell Gardner & John LooneyRussell Gardner & John LooneyOther committee members: Beverly Sutton, Other committee members: Beverly Sutton,

John Beahrs, Fred Wamboldt, Alan Swann, Jacob John Beahrs, Fred Wamboldt, Alan Swann, Jacob Kerbeshian, Johan Verhulst, Michael Schwartz, Kerbeshian, Johan Verhulst, Michael Schwartz,

Carlo Carandang, Doug Kramer, Morton SoslandCarlo Carandang, Doug Kramer, Morton Sosland

Copyright 2008 Group for Advancement of Psychiatry (GAP)

Copyright SLACK IncorporatedCopyright SLACK Incorporated

Used with PermissionUsed with Permission

Reprint web siteReprint web site

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Russell Gardner, Jr., The Social Brain, Russell Gardner, Jr., The Social Brain, Psychiatric Annals, 35(10), pp 778-Psychiatric Annals, 35(10), pp 778-

786, 2005.786, 2005.


Research Committee HistoryResearch Committee History

►The GAP Research Committee:The GAP Research Committee: Possesses distinguished history Possesses distinguished history Significant past contributions Significant past contributions

►Family research and therapyFamily research and therapy►SchizophreniaSchizophrenia►Rehabilitation psychiatryRehabilitation psychiatry

►Previous chairman included: Previous chairman included: Jerry M. Lewis Jerry M. Lewis Robert Cancro Robert Cancro Zebulon Taintor Zebulon Taintor


BeginningBeginningGardner, Koliatsos, & Dorn met Nov Gardner, Koliatsos, & Dorn met Nov

1996 & listed 8 principles for a 1996 & listed 8 principles for a basic science of psychiatrybasic science of psychiatry

1. Psychiatry now has no basic 1. Psychiatry now has no basic science in the medical pattern science in the medical pattern through which the diseases through which the diseases represent dysfunctional variations represent dysfunctional variations of normal body processesof normal body processes

2. But such pathophysiological 2. But such pathophysiological mechanisms should be sought as a mechanisms should be sought as a primary aim of our workprimary aim of our work


Onset principles (ii)Onset principles (ii)

3. Cellular-molecular processes are 3. Cellular-molecular processes are variations at another conceptual level variations at another conceptual level of activities of the whole organism of activities of the whole organism notably and powerfully including its notably and powerfully including its social arrangements which we social arrangements which we agreed on are largely mediated by agreed on are largely mediated by the brainthe brain


Onset principles (iii)Onset principles (iii)4. Emergent properties at the higher 4. Emergent properties at the higher

levels of the organism can’t be levels of the organism can’t be predicted by full & complete predicted by full & complete knowledge of the “lower” level knowledge of the “lower” level although reductionist attempts to although reductionist attempts to explain the phenomena partially in explain the phenomena partially in this way is a powerful conceptual this way is a powerful conceptual and scientific endeavorand scientific endeavor


Onset principles (iv)Onset principles (iv)5. Top-down and bottom-up 5. Top-down and bottom-up

approaches to investigating such approaches to investigating such pathology refer to integrative pathology refer to integrative approaches that contrast to the top-approaches that contrast to the top-up avenue that considers only up avenue that considers only behavior & the bottom-down behavior & the bottom-down avenue that considers only cellular-avenue that considers only cellular-molecular activitiesmolecular activities


Onset principles (v)Onset principles (v)

6. Conceptualizing basic plans that are 6. Conceptualizing basic plans that are putatively foundation to both putatively foundation to both pathology and normality is a highly pathology and normality is a highly useful exerciseuseful exercise

7. That is, pathology is highlighted 7. That is, pathology is highlighted when the behavioral state is when the behavioral state is deployed at the wrong time and deployed at the wrong time and wrong place or normality if it works wrong place or normality if it works to enhance an individual’s to enhance an individual’s adaptationadaptation


Onset principles (vi)Onset principles (vi)

8. This distinctly differs from the often 8. This distinctly differs from the often inadvertant “pathologizing” of normal inadvertant “pathologizing” of normal behavior; thus to talk of a leader as behavior; thus to talk of a leader as manic or hypomanic when describing his manic or hypomanic when describing his or her elated, animated, energetic, and or her elated, animated, energetic, and sleepless ways is wrong in that the basic sleepless ways is wrong in that the basic plan involved is then undercut and plan involved is then undercut and underemphasized; leaders are not underemphasized; leaders are not pathological unless there is something pathological unless there is something disadvantageous and maladaptive about disadvantageous and maladaptive about the way it is expressed.the way it is expressed.


GAP Research Committee GAP Research Committee Consensus StatementConsensus Statement

►Academic Psychiatry Academic Psychiatry 2002;26: 219:2002;26: 219: The Social Brain: A Unifying Foundation The Social Brain: A Unifying Foundation

for Psychiatry for Psychiatry By (listed alphabetically): Cornelis Bakker, By (listed alphabetically): Cornelis Bakker,

Russell Gardner, Jr., Vassilis Koliatsos, Russell Gardner, Jr., Vassilis Koliatsos, Jacob Kerbeshian, John Guy Looney, Jacob Kerbeshian, John Guy Looney, Beverly Sutton, Alan Swann, Johan Beverly Sutton, Alan Swann, Johan Verhulst, Karen Dineen Wagner, Frederick Verhulst, Karen Dineen Wagner, Frederick Wamboldt, & Daniel R. Wilson Wamboldt, & Daniel R. Wilson


Transition: added Transition: added backgroundbackground

►Guests had included Robert Michels, Guests had included Robert Michels, Zebulon Taintor, J. Anderson Thomson, Zebulon Taintor, J. Anderson Thomson, Wagner Bridger, & Michael SchwartzWagner Bridger, & Michael Schwartz

►Residents-in-Training who have been Residents-in-Training who have been GAP fellows and served as committee GAP fellows and served as committee members are Vassilis Koliatsos, members are Vassilis Koliatsos, Thomas Shoaf, John Barker, Morton Thomas Shoaf, John Barker, Morton Sosland & Daniel Mayman. Another Sosland & Daniel Mayman. Another guest resident-in-training not a GAP guest resident-in-training not a GAP fellow was Betsy Ciarimbolifellow was Betsy Ciarimboli


Social Brain ConsensusSocial Brain Consensus Beginning of quote from Beginning of quote from Academic PsychiatryAcademic Psychiatry

► The Research Committee of the Group for The Research Committee of the Group for Advancement of Psychiatry (GAP), a specialty Advancement of Psychiatry (GAP), a specialty think-tank, has addressed psychiatry's need think-tank, has addressed psychiatry's need for a unifying scientific foundation. for a unifying scientific foundation. Such a foundation would consider the disorders Such a foundation would consider the disorders

commonly treated by psychiatrists in terms of the commonly treated by psychiatrists in terms of the physiological baseline from which they depart, physiological baseline from which they depart, much as heart disease is understood as deviation much as heart disease is understood as deviation from normal cardiac function. from normal cardiac function.

The relevant physiological focus for psychiatry is The relevant physiological focus for psychiatry is the social brain.the social brain.


Definition of Social BrainDefinition of Social Brain

► The social brain is defined by its function; The social brain is defined by its function; namely, the brain is a body organ that namely, the brain is a body organ that mediates social interactions while also serving mediates social interactions while also serving as the repository of those interactions. as the repository of those interactions. The concept focuses on the interface between The concept focuses on the interface between

brain physiology and the individual's environment. brain physiology and the individual's environment. The brain is the organ most influenced on the The brain is the organ most influenced on the

cellular level by social factors across development; cellular level by social factors across development; in turn, the expression of brain function in turn, the expression of brain function determines and structures an individual's personal determines and structures an individual's personal and social experience. and social experience.


Organizing MetaphorOrganizing Metaphor

►The social brain framework may have The social brain framework may have greater direct impact on the understanding greater direct impact on the understanding of some psychiatric disorders than others. of some psychiatric disorders than others. However, it helps organize and explain all However, it helps organize and explain all

psychopathology. psychopathology. ►A single gene-based disorder like Huntington disease A single gene-based disorder like Huntington disease

is expressed to a large extent as social dysfunction. is expressed to a large extent as social dysfunction. ►Conversely, traumatic stress has structural impact Conversely, traumatic stress has structural impact

on the brain, as does the socially interactive process on the brain, as does the socially interactive process of psychotherapy.of psychotherapy.


Brain DevelopmentBrain Development

► Brains, including human brains, derive from Brains, including human brains, derive from ancient adaptations to diverse environments ancient adaptations to diverse environments and are themselves repositories of and are themselves repositories of phylogenetic adaptations. phylogenetic adaptations. In addition, individual experiences shape the In addition, individual experiences shape the

brain through epigenesis, i.e., the expression of brain through epigenesis, i.e., the expression of genes is shaped by environmental influences. genes is shaped by environmental influences. ►Thus, the social brain is also a repository of Thus, the social brain is also a repository of

individual development. individual development. On an ongoing basis, the brain is further refined On an ongoing basis, the brain is further refined

through social interactions; plastic changes through social interactions; plastic changes continue through life with both physiological and continue through life with both physiological and anatomical modifications. anatomical modifications.


Contrast to BiopsychosocialContrast to Biopsychosocial

► In contrast to the conventional In contrast to the conventional biopsychosocial model, the social brain biopsychosocial model, the social brain formulation emphasizes that all psychological formulation emphasizes that all psychological and social factors are biological. and social factors are biological.

► Non-biological & non-social psychiatry cannot Non-biological & non-social psychiatry cannot exist. exist. Molecular and cellular sciences offer fresh and Molecular and cellular sciences offer fresh and

exciting contributions to such a framework but exciting contributions to such a framework but provide limited explanations for the social facets provide limited explanations for the social facets of individual function. of individual function.


Requirements of ModelRequirements of Model

► The social brain formulation is consistent with current The social brain formulation is consistent with current research and clinical data. Moreover, it ultimately research and clinical data. Moreover, it ultimately must:must: unify the biological, psychological and social factors in unify the biological, psychological and social factors in

psychiatric illness, psychiatric illness, dissect components of illness into meaningful functional dissect components of illness into meaningful functional

subsets that deviate in definable ways from normal subsets that deviate in definable ways from normal physiology,physiology,

improve diagnostic validity by generating testable clinical improve diagnostic validity by generating testable clinical formulations from brain-based social processes, formulations from brain-based social processes,

guide psychiatric research and treatment,guide psychiatric research and treatment, provide an improved language for treating patients as well as provide an improved language for treating patients as well as

educating trainees, patients, their families and the public, andeducating trainees, patients, their families and the public, and account for the role of interpersonal relationships for brain account for the role of interpersonal relationships for brain

function and health.function and health.


In conclusion,In conclusion,► The concept of the brain as an organ that manages The concept of the brain as an organ that manages

social life provides significant power for psychiatry's social life provides significant power for psychiatry's basic science. basic science. Burgeoning developments in neural and genetic areas put Burgeoning developments in neural and genetic areas put

added demands on the conceptual structures of psychiatry. added demands on the conceptual structures of psychiatry. Findings from such incoming work must be juxtaposed and Findings from such incoming work must be juxtaposed and

correlated with the behavioral and experiential facets of correlated with the behavioral and experiential facets of psychiatry to give it a complete and rational basis. psychiatry to give it a complete and rational basis.

► Psychiatry's full and unified entry into the realm of Psychiatry's full and unified entry into the realm of theory-driven and data-based medical science has theory-driven and data-based medical science has been overdue. been overdue. The social brain concept allows psychiatry to utilize The social brain concept allows psychiatry to utilize

pathogenesis in a manner parallel to practice in other pathogenesis in a manner parallel to practice in other specialties.specialties.

End of quote from End of quote from Academic PsychiatryAcademic Psychiatry 2002 2002


What’s the problem?What’s the problem?

► If we propose the social brain If we propose the social brain conception as a solution, what is the conception as a solution, what is the problem? problem? Psychiatry’s quick change in conceptual Psychiatry’s quick change in conceptual

base that took place over the last half of base that took place over the last half of the twentieth century.the twentieth century.


Turnaround Summarized.Turnaround Summarized.

► 20th century research on drugs & definition 20th century research on drugs & definition of disorders altered professional & public of disorders altered professional & public opinion so that psychiatry turned a sharp opinion so that psychiatry turned a sharp corner with massive changes in practice corner with massive changes in practice over 1/4over 1/4thth century century

► Many reasons contributedMany reasons contributed1.1. Discontent with unsupported theories for how its Discontent with unsupported theories for how its

disorders had resulted and should be treated, a disorders had resulted and should be treated, a situation differing from the rest of medicine more situation differing from the rest of medicine more secure in its heritage and approach to science. secure in its heritage and approach to science.

2.2. A practical second factor included publication of A practical second factor included publication of DSM-IIIDSM-III in 1980 (and its successors later). in 1980 (and its successors later).


More facets of quick More facets of quick turnaroundturnaround

3.3. Operationalized definitions of disorders provided Operationalized definitions of disorders provided checklists for diagnosis checklists for diagnosis ► Many use besides psychiatrists with little attention Many use besides psychiatrists with little attention

to nicetiesto niceties► Limited by often arbitrarily worked out clinical Limited by often arbitrarily worked out clinical

approximations approximations

4.4. Professionals & public learned that new & Professionals & public learned that new & powerful medications possessed striking efficacypowerful medications possessed striking efficacy► Sophisticated drug trials made findings persuasiveSophisticated drug trials made findings persuasive► More gradually, powerful side effects also gained More gradually, powerful side effects also gained

attentionattention► Clinical guidelines more cautious about drug therapyClinical guidelines more cautious about drug therapy22


Transformation continuedTransformation continued

6.6. Unsupported undocumented treatment model Unsupported undocumented treatment model blamed “crooked or insufficient molecules” blamed “crooked or insufficient molecules” ► Pharmaceuticals appeared as verified packaged Pharmaceuticals appeared as verified packaged

therapies therapies ► Cheap because “less expensive” professional timeCheap because “less expensive” professional time

► Resulted in the now standard “med-check” Resulted in the now standard “med-check”

7.7. Reluctance to fund professional treatment Reluctance to fund professional treatment pervaded medical scene pervaded medical scene

8.8. For therapies not using drugs, payers noted that For therapies not using drugs, payers noted that people other than psychiatrists could do the work. people other than psychiatrists could do the work. ► With less expensive training, they could charge less With less expensive training, they could charge less ► Or happily accept lesser fees from 3Or happily accept lesser fees from 3rdrd party payers party payers


Relationshipless psychiatryRelationshipless psychiatry

►Goal of “relationshipless” psychiatry Goal of “relationshipless” psychiatry gained standinggained standing ““Better business” results if same or Better business” results if same or

adequate results come from cheaper adequate results come from cheaper packaged treatment for molecular packaged treatment for molecular deficiencies, deficiencies, ►e.g., “chemical imbalances,” e.g., “chemical imbalances,”

Brief physician visits combined with non-Brief physician visits combined with non-physician therapists for non-drug physician therapists for non-drug treatmentstreatments


““Untoward side effects”Untoward side effects”

►These accompanied benefits from These accompanied benefits from massive business-focused massive business-focused transformation of psychiatric medicinetransformation of psychiatric medicine

►Deficient core metaphors hold sway Deficient core metaphors hold sway For psychiatrists, other professionals, the For psychiatrists, other professionals, the

business ends of payers, multinational business ends of payers, multinational corporations and the public corporations and the public

Specialty deprofessionalizedSpecialty deprofessionalized►With lessened results for patientsWith lessened results for patients


““Untoward side effects”Untoward side effects”

►Popular metaphors focus on a Popular metaphors focus on a molecular level of analysis that molecular level of analysis that possesses no support in research possesses no support in research findingsfindings

►Other subsequently developing data Other subsequently developing data underline the importance of utilizing underline the importance of utilizing an alternative, multiply layered model an alternative, multiply layered model of the central organ of psychiatry that of the central organ of psychiatry that we label the “social brain”we label the “social brain”


Problems:Problems: Norbert EnzerNorbert Enzer

►“… “… When I began as an oral examiner When I began as an oral examiner in both General and Child Psychiatry in both General and Child Psychiatry [about 1970], I fretted about the [about 1970], I fretted about the narrowness of candidates’ knowledge narrowness of candidates’ knowledge in the sciences basic to psychiatry and in the sciences basic to psychiatry and their reliance on impressions and their reliance on impressions and poorly documented, often very limited, poorly documented, often very limited, experience, unsubstantiated theory, or experience, unsubstantiated theory, or fuzzy clinical data.fuzzy clinical data.


Problems:Problems: Norbert Enzer Norbert Enzer (cont.)(cont.)

►““As I step aside, my concerns are quite As I step aside, my concerns are quite different. Now I am distressed by the different. Now I am distressed by the rigid, often insensitive, approach of so rigid, often insensitive, approach of so many candidates towards patients, their many candidates towards patients, their preoccupation with the details of preoccupation with the details of diagnostic criteria, their focus on trivial diagnostic criteria, their focus on trivial information and seeming lack of concern information and seeming lack of concern for or understanding of the unique person for or understanding of the unique person who is their examination patient.” who is their examination patient.”


PlanPlan

►Present state of affairs compare Present state of affairs compare with those of approximately a quarter with those of approximately a quarter

century ago using the dimensions of century ago using the dimensions of (1) (1) the nature of knowledge the nature of knowledge (theory vs data-(theory vs data-

based)based)

(2) (2) clinical skills in application of professional clinical skills in application of professional knowledge knowledge (open-ended vs checklist-based (open-ended vs checklist-based interviews)interviews)


Nature of KnowledgeNature of Knowledge

►Earlier, relevancy stemmed from theory.Earlier, relevancy stemmed from theory. Theory = professionally applicable Theory = professionally applicable

information came from a framework of information came from a framework of detailed accumulated opinions about mind-detailed accumulated opinions about mind-workings workings

Established facts did not prove nor disprove Established facts did not prove nor disprove speculationspeculation

►Stemmed from psychoanalytic theoryStemmed from psychoanalytic theory From Freud’s & others’ work with relatively From Freud’s & others’ work with relatively

few patientsfew patients


Results of Theory-Based Results of Theory-Based ThinkingThinking

► Viewed retrospectively, extrapolating to more Viewed retrospectively, extrapolating to more general conclusions entailed significant risk for general conclusions entailed significant risk for the durability of the conclusions the durability of the conclusions

►Not all of the American psychiatry’s Not all of the American psychiatry’s accumulated knowledge a quarter-century ago accumulated knowledge a quarter-century ago involved such theoryinvolved such theory

► But those components holding greatest sway But those components holding greatest sway did until well after mid-century – augmented did until well after mid-century – augmented by leadership in academic departmentsby leadership in academic departments


Clinical skillsClinical skills

►Complex “metapsychology” theory failed Complex “metapsychology” theory failed to foster or to even allow measurements to foster or to even allow measurements by standard scientific methods. by standard scientific methods.

►Nevertheless we feel that it led to clinical Nevertheless we feel that it led to clinical skills that assessed reasonably well the skills that assessed reasonably well the structure and function of patients and structure and function of patients and their minds through depth-interviewing. their minds through depth-interviewing.

►Psychiatric clinicians gained expertise in Psychiatric clinicians gained expertise in interviewing. interviewing.


Clinical skills (ii)Clinical skills (ii)

► Core clinical skills gained in this manner helped Core clinical skills gained in this manner helped establish trusting alliances with patients and establish trusting alliances with patients and assessed mental functioning at multiple levels. assessed mental functioning at multiple levels.

► A common belief held that some individuals had A common belief held that some individuals had more innate abilities for interviewing in depth more innate abilities for interviewing in depth

► This echoes present research on psychotherapy This echoes present research on psychotherapy effectiveness – now massive in quantity – that effectiveness – now massive in quantity – that people vary considerably in such effectiveness people vary considerably in such effectiveness For example, possession of a “third ear” once For example, possession of a “third ear” once

positively described an able therapist or an apt positively described an able therapist or an apt student. student.


Psychotherapy Research Psychotherapy Research

►By contrast, research on psychotherapy By contrast, research on psychotherapy had previously assumed that had previously assumed that psychotherapy could be studied using a psychotherapy could be studied using a drug study model drug study model

►This metaphor:This metaphor: Held that a “pure preparation” of Held that a “pure preparation” of

psychotherapy psychotherapy ►Parallel to a chemical compoundParallel to a chemical compound

When identically applied, caused a same When identically applied, caused a same result result


Psychotherapy Research Psychotherapy Research Results Results

►Bruce WampoldBruce Wampold33 surveyed controlled surveyed controlled psychotherapy research: psychotherapy research: Showed “medical model” of Showed “medical model” of

psychotherapy, as he calls it, emphatically psychotherapy, as he calls it, emphatically does not resemble the mechanical ideal; does not resemble the mechanical ideal;

Does not resemble antibiotic-like resultsDoes not resemble antibiotic-like results►Research results confirmed treater-Research results confirmed treater-

variability indeed plays major roles in variability indeed plays major roles in outcomeoutcome


Why variability in treater-Why variability in treater-talent?talent?

►Ability to understand another person in Ability to understand another person in depth may relate to early pain in the depth may relate to early pain in the helper’s lifehelper’s life

►Lives of mental health professionals Lives of mental health professionals shows many suffered psychological shows many suffered psychological pain pain

►Does such developmental pain make Does such developmental pain make one more sensitive to the patient? one more sensitive to the patient?


Clinical SkillsClinical Skills

►However the student learned clinical However the student learned clinical skills, desired abilities: skills, desired abilities: Hinge on skill in depth-interviewing Hinge on skill in depth-interviewing Clinician understanding at multiple levelsClinician understanding at multiple levels

►Most importantly:Most importantly: How did the clinician come to resonate How did the clinician come to resonate

with how the patient felt?with how the patient felt? How to connect “inside the patient’s How to connect “inside the patient’s

skin”? skin”?


Social Fears of PsychiatristsSocial Fears of Psychiatrists

►Lay people showed awareness of this Lay people showed awareness of this kind of skill in the common fear about kind of skill in the common fear about psychiatrist professionals: psychiatrist professionals: In past times, people in social situations In past times, people in social situations

feared that a psychiatrist would “read” feared that a psychiatrist would “read” their minds their minds

Less often encountered presentlyLess often encountered presently


Things Have Changed.Things Have Changed.

►Now psychiatry possesses a body of Now psychiatry possesses a body of knowledge based more on a reliably knowledge based more on a reliably ascertained data-base (descriptive ascertained data-base (descriptive psychiatry)psychiatry)

►Data categorize symptoms Data categorize symptoms ►On check lists this means that clinicians On check lists this means that clinicians

make consistent diagnoses systematically make consistent diagnoses systematically Less information missed from open-ended, free-Less information missed from open-ended, free-

flowing interviews typical of the psychoanalytic-flowing interviews typical of the psychoanalytic-psychotherapeutic interviewing style psychotherapeutic interviewing style


Things have changed (ii)Things have changed (ii)

►Present clinician takes into Present clinician takes into consideration advances consideration advances Brain function at anatomical, chemical & Brain function at anatomical, chemical &

molecular levels molecular levels Plus on behavioral and interpersonal levelsPlus on behavioral and interpersonal levels

►A current trainee in psychiatry must A current trainee in psychiatry must amass enormous amounts of data from amass enormous amounts of data from disparate disciplines to understand disparate disciplines to understand patient problemspatient problems


Qualities of Change Qualities of Change

►Field changed Field changed From theory-derived clinician sensitivity to From theory-derived clinician sensitivity to

individual patientindividual patient Moved to use of empiric data on other Moved to use of empiric data on other

patients patients

►New data that the clinician must now use New data that the clinician must now use changed the optimal interview: changed the optimal interview: Instead of interviewing in depth with Instead of interviewing in depth with

understanding on multiple levels, the understanding on multiple levels, the clinician uses a criteria-list interviewclinician uses a criteria-list interview


Fear of psychiatrist changedFear of psychiatrist changed

►A new common fear about A new common fear about psychiatrists illustrates the change: psychiatrists illustrates the change: The lay public knows so well the The lay public knows so well the

Diagnostic and Statistical Manual Diagnostic and Statistical Manual that that

►New social connections now worry, “I New social connections now worry, “I am afraid you will find me in ‘the am afraid you will find me in ‘the book’.”book’.”


Four ExamplesFour Examples

►Other examples illustrate change over Other examples illustrate change over time time Show pendulum-swing extremesShow pendulum-swing extremes

►Pendulum-swings may stem from a Pendulum-swings may stem from a lack of a core prevailing metaphor lack of a core prevailing metaphor Such might dampen swings Such might dampen swings The “social brain” model or image may do The “social brain” model or image may do

thisthis


Example 1: John Looney in Example 1: John Looney in trainingtraining

► Committee member John Looney recalled Committee member John Looney recalled training in a psychoanalytically based child training in a psychoanalytically based child study centerstudy center

► Parents of children referred to a prestigious Parents of children referred to a prestigious pre-school day program often had pre-school day program often had professional status at the nearby universityprofessional status at the nearby university

► All understood that study of the children All understood that study of the children would entail psychoanalytic techniques during would entail psychoanalytic techniques during day careday care

► Study framework for a given child entailed the Study framework for a given child entailed the Metapsychological Profile, a detailed Metapsychological Profile, a detailed instrument for plotting of the topographical instrument for plotting of the topographical structure of the mindstructure of the mind


Setting of Previous EraSetting of Previous Era

► Committee member John Looney recalled Committee member John Looney recalled training in a psychoanalytically based child training in a psychoanalytically based child study centerstudy center Parents of children referred to a prestigious pre-Parents of children referred to a prestigious pre-

school day program often had professional status school day program often had professional status at the nearby universityat the nearby university

All understood that study of the children would All understood that study of the children would entail psychoanalytic techniques during day careentail psychoanalytic techniques during day care

Study framework for a given child entailed the Study framework for a given child entailed the Metapsychological Profile, a detailed instrument for Metapsychological Profile, a detailed instrument for plotting of the topographical structure of the mindplotting of the topographical structure of the mind


The Trainee PresentsThe Trainee Presents

►Looney presented to intimidating Looney presented to intimidating professors a 70-page profile of a 5-year professors a 70-page profile of a 5-year old boy old boy Framework for detailed description Framework for detailed description

included structural components of the included structural components of the boy’s mind and his commonly used boy’s mind and his commonly used mechanisms of defensemechanisms of defense

Results to guide a plan for treatment using Results to guide a plan for treatment using frequent analytically oriented sessionsfrequent analytically oriented sessions


The FollowupThe Followup

► After rotating off, Looney queried a After rotating off, Looney queried a successor colleague successor colleague Team members had felt embarrassed Team members had felt embarrassed When the child’s pediatrician diagnosed When the child’s pediatrician diagnosed

attention deficit hyperactivity disorderattention deficit hyperactivity disorder►Put the child on methylphenidate Put the child on methylphenidate ►With rapid marked improvement in all areas. With rapid marked improvement in all areas.

Looney had made good empathic contact with Looney had made good empathic contact with the child and understood him on multiple levels, the child and understood him on multiple levels, ►Yet the framework had reduced formulation-adequacy Yet the framework had reduced formulation-adequacy

► This illustrates one extreme of a pendulum This illustrates one extreme of a pendulum swingswing


Opposite Pendulum SwingOpposite Pendulum Swing

► Candidates seemed stuck in Candidates seemed stuck in DSMDSM When Oral ABPN Boards were still doneWhen Oral ABPN Boards were still done

►According to board examiners additional to Enzer According to board examiners additional to Enzer (quoted at the beginning)(quoted at the beginning)

Patients gain understanding only with respect Patients gain understanding only with respect to how they meet criteria for particular to how they meet criteria for particular diagnosesdiagnoses

► Candidates possess little understanding of Candidates possess little understanding of patients “as people” patients “as people” Show small interest in how patients feel Show small interest in how patients feel


Example 2. Looney in present Example 2. Looney in present practicepractice

►A prestigious professor in another A prestigious professor in another department asked for referral after department asked for referral after losing his wifelosing his wife Felt sad, had lost function. Felt sad, had lost function.

►Referral to highly regarded younger Referral to highly regarded younger colleague colleague Recent graduate from that training Recent graduate from that training

program program Special interest in mood disordersSpecial interest in mood disorders


Result of referralResult of referral

►When queried later, the professor told his When queried later, the professor told his troubled annoyance:troubled annoyance: Had been interviewed for twenty minutes Had been interviewed for twenty minutes

►Then received prescription for an SSRIThen received prescription for an SSRI►Took SSRI and experienced modest reliefTook SSRI and experienced modest relief

► Patient felt absence of something Patient felt absence of something fundamental:fundamental: ““I went hoping she would understand my painI went hoping she would understand my pain ““Understanding my pain did not mean giving me Understanding my pain did not mean giving me

Prozac and seeing me a month later”Prozac and seeing me a month later”


Example 3. Experienced Example 3. Experienced PsychiatristPsychiatrist

► Experienced psychiatrists shifted to Experienced psychiatrists shifted to descriptive, data-based practice descriptive, data-based practice

► A young man plaintiff in a medical malpractice A young man plaintiff in a medical malpractice lawsuit against a hospital psychiatrist: lawsuit against a hospital psychiatrist: Felt mistreated when under behavioral restrictions Felt mistreated when under behavioral restrictions

►Wished to “get back” at the treating psychiatristWished to “get back” at the treating psychiatrist

► Experienced evaluating psychiatrist did not Experienced evaluating psychiatrist did not recognize demonization of the hospital recognize demonization of the hospital clinician clinician Contrastingly idealized the evaluating doctor Contrastingly idealized the evaluating doctor

►Both typify patients with Borderline Personality Disorder Both typify patients with Borderline Personality Disorder


Evaluation Used Checklist Evaluation Used Checklist

► Patient’s attorney argued:Patient’s attorney argued: Patient developed PTSD and Borderline Patient developed PTSD and Borderline

Personality Disorder from the hospitalization. Personality Disorder from the hospitalization.

► The evaluator confirmed this The evaluator confirmed this Simply went over checklists, noting criteriaSimply went over checklists, noting criteria Did not use in-depth interview Did not use in-depth interview

►Evaluating psychiatrist overlooked neediness and Evaluating psychiatrist overlooked neediness and dependency dependency

These plus the idealization meant that the These plus the idealization meant that the patient wished to please the evaluator patient wished to please the evaluator ►Answered affirmatively questions put to himAnswered affirmatively questions put to him


Deleterious Outcome Deleterious Outcome

►This mistake caused him to testify This mistake caused him to testify contrary to other evaluating contrary to other evaluating psychiatrists psychiatrists Who had done detailed and careful Who had done detailed and careful

interviews aiming at as much objectivity interviews aiming at as much objectivity as possibleas possible

►The jury accepted not the checklist The jury accepted not the checklist conclusions but the more extensive conclusions but the more extensive findings findings


Example 4. Jerry M. Lewis Example 4. Jerry M. Lewis Report Report

► I interviewed a middle aged man clearly I interviewed a middle aged man clearly showed depression at a conferenceshowed depression at a conference despite a smile on his face despite a smile on his face

►After we chatted about the conference, I After we chatted about the conference, I told him that I wished to try to told him that I wished to try to understand how it felt to him, what was understand how it felt to him, what was it like insideit like inside

►““First of all, you’ve got to understand I’m First of all, you’ve got to understand I’m a recovering alcoholic.”a recovering alcoholic.”


Querying Feelings Querying Feelings

► JML: “And how does it feel for you to JML: “And how does it feel for you to be a recovering alcoholic?”be a recovering alcoholic?”

►Patient: “Well, I don’t know – that’s Patient: “Well, I don’t know – that’s just who I am. First and foremost I’m a just who I am. First and foremost I’m a recovering alcoholic.”recovering alcoholic.”

► JML: “More than anything else you feel JML: “More than anything else you feel yourself to be a recovering alcoholic.”yourself to be a recovering alcoholic.”

►Patient: “Yes.”Patient: “Yes.”


Sitting with the FeelingsSitting with the Feelings

► JML: “Can you help me understand what else JML: “Can you help me understand what else there is, what in addition it feels to be you.”there is, what in addition it feels to be you.”

► Patient: “Well, let me think. I guess next I’d say Patient: “Well, let me think. I guess next I’d say I’m depressed. I’ve got what they call a major I’m depressed. I’ve got what they call a major depression –.”depression –.”

► JML: “And that feels bad – ”JML: “And that feels bad – ”► Patient: “Yeah.” Patient: “Yeah.”

Tears come to his eyes, smile disappears, sighs Tears come to his eyes, smile disappears, sighs deeplydeeply

Silence grows—his silence fills the conference room. Silence grows—his silence fills the conference room.

► After seconds, JML: “I can feel the silence now.” After seconds, JML: “I can feel the silence now.”


The DSM “Cover”The DSM “Cover”

►We sit there quietly and move from sadnessWe sit there quietly and move from sadness► JML: “Let’s see if I’ve got it right. Inside – JML: “Let’s see if I’ve got it right. Inside –

what it feels like to be you is that you’re a what it feels like to be you is that you’re a recovering alcoholic and you’re depressed.”recovering alcoholic and you’re depressed.”

►Patient: “Yeah, doctor, you’ve got it.”Patient: “Yeah, doctor, you’ve got it.”► JML: “Is there anything else about what it JML: “Is there anything else about what it

feels like to be you?”feels like to be you?”►Patient: “No, I think we covered it all.”Patient: “No, I think we covered it all.”


Inferred Previous ExperienceInferred Previous Experience

►Patient’s prior experiences with Patient’s prior experiences with psychiatrists molded an expectation: psychiatrists molded an expectation:

►Psychiatrists wish to understand Psychiatrists wish to understand patients as diseases patients as diseases

►Parallel to “the gall-bladder in room Parallel to “the gall-bladder in room 307” 307” A designation familiar from most doctors’ A designation familiar from most doctors’

training in teaching hospitalstraining in teaching hospitals


Outside ForcesOutside Forces

►A psychiatrist evaluating for a lawsuit A psychiatrist evaluating for a lawsuit using only a using only a DSM-IVDSM-IV check-list check-list Shows effect of legal system on practice Shows effect of legal system on practice Criteria-based presentations in court Criteria-based presentations in court

make easier arguments for binary legal make easier arguments for binary legal settlementsettlement

So legal system embraced So legal system embraced DSM-IIIDSM-III+ +


Financial FactorsFinancial Factors

►Constrictions in the financial support Constrictions in the financial support for psychiatric services impacted for psychiatric services impacted practicepractice

►Third party payers care little about the Third party payers care little about the depth of understandingdepth of understanding Does not matter whether a psychiatrist Does not matter whether a psychiatrist

develops an understanding of the patient develops an understanding of the patient Nor patient gaining more understandingNor patient gaining more understanding


Business Model of CareBusiness Model of Care

►Assume pathology located on Assume pathology located on molecularly:molecularly:

►Criteria-based assessment Criteria-based assessment medication medication Reduced clinician cost when done quicklyReduced clinician cost when done quickly Model for much 3Model for much 3rdrd-party reimbursement-party reimbursement Document minimally adequate resultDocument minimally adequate result Minimum cost Minimum cost good business good business


Perfect StormPerfect Storm

► I.I. DSM DSM-change-change► II.II. Prevailing medication use Prevailing medication use ► III.III. Changed health care economicsChanged health care economics

These resulted in changed present These resulted in changed present practice practice ►Facilitated by industry-fostered molecular Facilitated by industry-fostered molecular

metaphors metaphors ►These also pervaded all medicineThese also pervaded all medicine


ParadoxParadox

►Economic factors foster de-emphasis Economic factors foster de-emphasis of interpersonal skills and talents of interpersonal skills and talents

►But empathy, ability to relate to But empathy, ability to relate to people, warmth, a positive personality people, warmth, a positive personality Turn out to weigh heavily in controlled Turn out to weigh heavily in controlled

psychotherapy resultspsychotherapy results Play important roles in various practice Play important roles in various practice

modes modes


Baby Thrown With BathwaterBaby Thrown With Bathwater

►Psychiatry turned rapidly and unwisely Psychiatry turned rapidly and unwisely from wisdom learned earlier under the from wisdom learned earlier under the influences of theory-driven practiceinfluences of theory-driven practice A baby thrown out with the bathwater A baby thrown out with the bathwater Adding to this, molecular metaphors Adding to this, molecular metaphors

►Widely accepted though unsupported Widely accepted though unsupported ►Facilitated acceptance of widespread drug-use Facilitated acceptance of widespread drug-use

Rationales for limiting reimbursements Rationales for limiting reimbursements hastened transitionhastened transition


Educated Social BrainEducated Social Brain

►Yet social skills of a good clinician Yet social skills of a good clinician stem stem From that person’s educated social brain, From that person’s educated social brain,

►A body-organ conditioned and shaped A body-organ conditioned and shaped Over evolutionary time as well as Over evolutionary time as well as Within the lifetime Within the lifetime Including the experience of professional Including the experience of professional

trainingtraining


Psychiatric Disorders = Social Psychiatric Disorders = Social ProblemsProblems

►All psychiatric disorders represent All psychiatric disorders represent variations in social interactions variations in social interactions

►These hinge on variations in These hinge on variations in development and development and

►Malfunction of the social brain organ. Malfunction of the social brain organ. See other chapters for more detailSee other chapters for more detail


Educational RequirementEducational Requirement

►Psychiatrists need to know the social Psychiatrists need to know the social brain organ in greater depth brain organ in greater depth On all levels of analysis and On all levels of analysis and Then to turn that knowledge Then to turn that knowledge And learn more adequately problems of And learn more adequately problems of

troubled people as well as troubled people as well as To treat them more skillfully and To treat them more skillfully and

effectivelyeffectively


Irreversible Changes ButIrreversible Changes But

►A ratchet-wheel turn makes old style A ratchet-wheel turn makes old style leisurely interviews historical leisurely interviews historical

►But even brief contacts with patients But even brief contacts with patients reflect enormous information-exchanges reflect enormous information-exchanges This includes how that the social-focused organ This includes how that the social-focused organ

works in the body of the patient as well as works in the body of the patient as well as In the body of the clinicianIn the body of the clinician

►Plus more accurate and telling metaphors Plus more accurate and telling metaphors may augment more appropriate practice may augment more appropriate practice


References:References:

► Enzer, Norbert B.: Letter dated 3/5/2002 to Steve Enzer, Norbert B.: Letter dated 3/5/2002 to Steve Schreiber, Executive Vice President, American Schreiber, Executive Vice President, American Boards of Psychiatry and Neurology (ABPN). Boards of Psychiatry and Neurology (ABPN). ABPN ABPN UpdateUpdate. 8:#2, Spring 2002, page 4.. 8:#2, Spring 2002, page 4.

► Crane, G.C. and Gardner, R. (Eds) Crane, G.C. and Gardner, R. (Eds) Psychotropic Psychotropic Drugs and Dysfunctions of the Basal Ganglia. A Drugs and Dysfunctions of the Basal Ganglia. A Multidisciplinary Workshop.Multidisciplinary Workshop. Public Health Service, Public Health Service, U.S. Government Printing Office, Washington, D.C., U.S. Government Printing Office, Washington, D.C., 1969.1969.

► Wampold, Bruce:Wampold, Bruce:The Great Psychotherapy Debate: The Great Psychotherapy Debate: Models, Methods, and Findings.Models, Methods, and Findings. Mahwah, NJ: Mahwah, NJ: Lawrence Erlbaum Associates, Publishers, 2001.Lawrence Erlbaum Associates, Publishers, 2001.

► Lewis JM: Lewis JM: The Monkey-Rope: A Psychotherapist’s The Monkey-Rope: A Psychotherapist’s Reflections on RelationshipsReflections on Relationships. Larchmont, NY: Bernel . Larchmont, NY: Bernel Books, 1996.Books, 1996.

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