"Of Two Minds" The hubris of US psychoanalytic psychiatry led to the loss of its throne

 

 

I read “Of Two Minds” by anthropologist Tanya Luhrmann on the schism in American psychiatry between “biomedical” and psychodynamic schools of practice in US psychiatry. It was recommended by Crystal McGuire ( @moonrise1014 ) on Twitter.  “Biomedical” in the book refers to the model of making a diagnosis and offering the indicated treatment – usually medication but also can refer to a therapist (like the rest of medicine) but not covered in the book is how it evolved into a biopsychosocial model which also focussed on psychosocial aspects of the case in a broader formulation or that the biomedical model was often combined with medical humanism inspired by Osler and Hippocrates – “better to know the person with the disease than the disease”. Psychodynamic psychiatry is a therapy-based approach involving many regular sessions and trying to understand the reasons for the patient’s problems using a psychodynamic model. An interesting book let down by loaded arguments in the final chapter that ignores its strengths in describing the practices of American psychiatry particularly in the 90s and earlier. The author caught the period of dramatic change brought on by health insurance companies adopting managed care practices that drastically reduced costs especially in mental health. This accelerated the decline of psychodynamic psychiatry as health insurance companies increasingly refused to pay for psychodynamic therapy for outpatients and especially inpatients.

There appears to have been a “two-hit” knock to the once dominant psychodynamic school in US psychiatry (I’m referring to the psychiatry profession not the wider mental health provider system nor to other professions such as non-medical psychotherapists). As a Brit it’s interesting to see the large differences with practice in the UK compared to the US. Szasz in his article criticising the “myth” of mental illness criticised the overreach of psychiatry claiming to be able to fix every social problem. It seems he was referring to psychodynamic psychiatry for this issue but most of his other criticisms are aimed at “biomedical” psychiatry.

The first hit to psychodynamic psychiatry was a multiple assault. Antipsychiatry criticisms of diagnosis – such as the now discredited Rosenhan study- and the conventional psychiatry study demonstrating New York psychiatrists had an idiosyncratic view of schizophrenia compared to European psychiatrists led to demands for a better diagnostic system with higher degrees of agreement between clinicians (inter-rater reliability). This ended up in the DSM American diagnostic system moving from one based on psychodynamic theories to one less based on theory and being more descriptive with a focus on increased inter-rater reliability. Another issue was that some clinical problems such as severe depression, schizophrenia or bipolar disorder just did not respond well to psychodynamic therapy if not given medication first. (The famous Osheroff case where the psychodynamic psychiatrists persisted with therapy for agitated depression instead of trying medication set an important clinical precedent). The development of effective medication for psychiatric problems in the 50s eventually led to “biomedical” psychiatry getting an increasing role in care provision and with the multiple factors described plus the hubristic nature of psychodynamic psychiatry resulted in “biomedical” psychiatry gaining dominance. There was still co-existence between the two schools. Further developments in medications that were easier to take (such as SSRI antidepressants) and increased ability to measure brain function favoured the “biomedical” model.

The next major hit came from managed care and cost-cutting in the 90s. They demanded evidence of effectiveness based on research using diagnosis and other shared characteristics with large numbers of patients in each study before agreeing to spend on treatments especially expensive treatments like psychodynamic psychiatry (seeing a psychiatrist from once to four times weekly for a 50-minute hour is much more expensive than seeing a psychiatrist for 15-30 minutes every few months in the “biomedical” model). Psychodynamic inpatient care lasting several months of intensive therapy was much more expensive than treating with medication which is often effective within weeks (though some conditions respond better to psychodynamic approaches and others better to “biomedical” approaches). Unable to provide the evidence to justify the increased expense led to massive cuts in health insurance pay-outs for psychodynamic psychiatry.

So, what are the lessons for any type of mental health core model? Note this isn’t discussion about the effectiveness of psychodynamic therapy. This is about psychiatrists who used the psychodynamic model in the US up until the 90s. I’m not saying that psychoanalytic treatments don’t’ help people nor that psychoanalytic therapy has no strengths or good points.

The main lesion is hubris leads to downfall. This hubris led to several problems

·       Blaming everything else but the treatment model when it didn’t work for an individual patient – for example saying the doctor was too scared to get emotionally close to the patient

·       A blindness to professional arrogance – everything was explained away by an opinion reinforced by authority that was unchallengeable. If the resident was later for morning meeting they would be told by the psychoanalytic supervisor it wasn’t because they had only 3 hours sleep during on call it was because they unconsciously did not want to attend

·       Antipathy towards other alternative models. The use of medication was regarded as a crutch or an addiction. They ignored that some patients needed medication to improve their mental state (and could then benefit from psychotherapy if they chose)

·       Lack of interest in more modern research methods and preferring older methods such as case studies meant that when managed care came in demanding evidence using modern research methods they had nothing to defend their methods from the cost-cutting axe. The lesson for all models of care is that they must be aware of what type of information those who purchase services want and provide it.

·       Unable to see what was helpful for seeing small numbers of private practice patients – often from similar affluent backgrounds to the psychiatrists – would not work for public hospital patients. These were in great numbers, poor and suffered from additional multiple social adversities. Arguably both types of psychiatry ignored the need for interventions acting on the social realities of these patients – though biopsychosocial psychiatry practised in multidisciplinary teams is better at doing so.

 

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