Informed
Refer to: Callaway E: Psychiatry today (Informed Opinion). West J Med 122:349-354, Apr 1975
OPINION
Psychiatry Today ENOCH CALLAWAY, MD, San Francisco
ALMOST 20 YEARS AGO the late Ralph Gerard began a talk on "Psychiatry Today" with a story about a minister preaching on the virtues of the church. At the high point in his sermon the preacher swung into full metaphor and said, "So the mother church stands, with one foot rooted firmly in the fertile earth of the holy scriptures and the other raised to Almighty God." Gerard was referring to psychiatry's ungainly posture which, twenty years ago, was due to the growing gap between neurobiology and psychoanalytically oriented psychology. If 20 years ago psychiatry was being split, today it's being drawn and quartered, for in addition to neurobiology and analytic psychology, which had to be reconciled at that time, we now have social and community psychiatry and, most recently, what I will call the exotic disciplines. Toward the end of World War II, the classical psychoanalytic approach had come to dominate the field of psychiatry. During the period it remained dominant, it also became relatively stagnant (as is often the case with a dominant dogma), and it's hard to point out major advances in psychoanalytic theory or practice within the past 20 years. The elegant structure of Freudian metaFrom the Department of Psychiatry, University of California, San Francisco; and the Langley Porter Neuropsychiatric Institute, San Francisco. Presented at "The Brain and Its Potential," Berkeley, California, March 1974. Reprint requests to: E. Callaway, MD, Langley Porter Neuropsychiatric Institute, 401 Parnassus Ave., San Francisco, CA 94143.
psychology has so far failed to live up to its initial promise as a source of testable hypotheses, although the game may not be over yet. At the time of Gerard's talk 20 years ago, potent psychologically-active medications had begun to produce a dramatic increase in the importance of neurobiological approaches. Studies of these psychoactive chemicals became a major force in developing modem theories of neurohumoral transmission. Those theories have in their turn given rise to repeated promises, unfortunately still unfulfilled, of a rational psychopharmacology. Psychopharmacology then, like psychoanalysis, has developed an elegant pseudotheoretical basis but remains, in fact, an empirical art.
The social and political approaches have made the greatest inroads in the past ten years. They have claimed an increasing share of the space in major psychiatric journals,l but that is far from the most noticeable effect they have had. The most dramatic change in psychiatry in the past five years is the wholesale closing of mental hospitals. Neurobiologists can claim some credit because effective antipsychotic medication has played its part, but more important forces have come from social and political action. Social action psychiatrists are certainly empiricists. On the other hand, their attention to social roles and political rights has resulted in questioning some of the psychiatric treatment mythology. THE WESTERN JOURNAL OF MEDICINE
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Finally, we come to what I have called exotic disciplines. Neurochemistry (psychedelic drugs), physiology (biofeedback), and social events (the hippie movement) all are calling serious scientific and psychiatric attention to what five thousand years of eastern thought has to offer, but so far most of the leading people are neither scientists nor psychiatrists. Examples are Carlos Castaneda, Gurdjieff, the Maharishi Mehesh Yogi and Werner Erhard. The roots of the exotic approaches are religious (using that word in its eastern meaning), but modern justifications are principally empirical ("Try it-you'll like it"). A promise of' rational theoretical and scientific integration can be found in the increasing new points of contact between exotic disciplines, neurobiology, psychopharmacology, conditioning, and electrophysiology. These four aspects of psychiatry can be used to conjure up an image of the blind scholars from the elephant legend.* The first is a traditional analyst with beard, cigar and steel-rimmed glasses, still seated behind his Edwardian couch. The second wears a white coat and is surrounded by all the equipment of modern technology. The third is a young man who may be wearing either a gray flannel suit or peace beads, depending on the group he wants to influence. Last, we have the guru in his saffron robe, leading his disciples into the mystery of primal screams, Gestalt encounters or cosmic consciousness. All are making great promises; each can offer some empirical support for the practices he urges, and none has a comprehensive theoretical basis which provides testable predictions of therapeutic interest. Finally, around this Tower of Babel one finds the working psychiatrists. They deal with problems that individual people bring to them, often trying anything that gives promise of helping so that they can "heal a few, aid more and comfort all." In short, when we come to the problem of treating people, we have plenty of theories to give our art the pretense of scientific respectability, but basically our theories have little to do with our practice. Usually they serve only as mnemonic devices for our observations, and empiricism remains 90 percent of the game. The chaotic state of psychiatry today has resulted in certain symptoms. Like most psychiatric *An ancient parable concerns four blind wise men studying an elephant. One scholar touched the tail and said, "The elephant is like a rope"; another, a leg and said "The elephant is like a post." The third touched a flank and said, "The elephant is like a wall." The fourth, at the trunk, said, "You are all lying. The elephant is a kind of snake."
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symptoms, they serve a purpose. They are understandable, even forgivable, but they must be overcome if growth is to occur. The most crippling symptom is a kind of intellectual tunnel vision. Each approach tends to develop a narrow view of things that excludes all other approaches. This is encouraged by the temper of the times and today's booming market for oversimplification. As a result, we find classic psychological theorists who see all pathology as a consequence of parent-child relationships. There are some neurobiologically oriented people who loudly proclaim that "the couch is out," and argue that the mind will cure itself of any psychological disorder given good nutrition and healthy brain biochemistry. Social and political pundits are equally in possession of the only answer. They see mental illness as entirely the result of faulty socioeconomic systems, or even as simply a myth perpetrated by the establishment and its medical lackeys. The exotic disciplines are too new to have developed extensive dogma in this country, and indeed some of their exercises-such as the Zen koans-seem designed to exercise mistrust in logical syllogisms. Be that as it may, a few of the American exponents of Transcendental Meditation are already making extravagant claims. Narrow views spare one from disturbing facts and lead to the construction of grand theories that promise everything to everyone. Behind the baroque theoretical facade of current psychiatric theories there are some empirical rules that work, but each collection of empirical rules is almost obscured by the theoretical overgrowth it stimulates. However, at the points of contact between "schools," the myths and dogmas sometimes become testable. One of these points of contact has occurred between Skinnerian behavior modification and Freudian analysis. First, consider the Skinnerian approach. This views the brain as a black box, the mind as a trivial epiphenomenon and the social sphere as a big operant-conditioning apparatus. Nevertheless, its theories have generated novel therapeutic approaches. First, however, as an exercise, think how you would fit Skinnerian practices into the outline that I have sketched. Is it neurobiology, as in rats running through mazes to test for psychochemical effects? Is it politicalsocial, as embodied in Walden Two- or in Ullman's book, Institution and Outcomes? Is it just disguised analytic psychology? (I have seen a Jungian analyst and an orthodox behavior modi-
PSYCHIATRY TODAY
fier approach the same clinical program in embarrassingly similar fashions.) Or is it the entering wedge of the exotic disciplines? Operant conditioning of physiological functions (biofeedback) has played a major role in legitimizing some exotic practices such as yoga and Zen. This could be worked into a multiple-choice exam question that would be no more bizarre than some of the other either/or positions found in contemporary psychiatry. At the interface between behavior modification and analysis, we find an example of how approaching the mind on a different tack can test an old, apparently untestable theory. Freudian theory postulated that neurotic symptoms in general, and phobias in particular, serve both to discharge and to ward off unconscious conflicts, and so are essential to the patient so long as the conflict remains. Thus, if symptoms were removed without resolving the underlying conflict, other symptoms would have to be subs-tituted. In practice, analysis aimed at resolving conflicts so that if a symptom disappeared, one could assume the conflict was resolved. If the symptom returned, it proved that the conflict was not resolved, and circularly proved the symptom-substitution theory. The Skinnerians, however, with their different bias, have been happily removing phobic symptoms by behavior-modification techniques for some time now. Instead of finding new symptoms arising to replace each removed phobia, they usually found the opposite-an improvement in areas of function not obviously related to the removed phobia.4 A point of contact between psychophysiology and learning-theory has led to a new discipline known as biofeedback.5 Alpha-conditioning is one example that has received considerable popular coverage. A computer gives a person very rapid information (feedback) as to his physiological state so that he can learn (be operantly conditioned) to control that state. The resulting selfinduced, altered states of consciousness frequently bear a resemblance to some of the states of consciousness used by the so-called exotic disciplines, and so we also have a point of contact with the exotic approaches, such as Transcendental Meditation. Modern social psychiatry has emphasized the hazards of having psychiatric patients play the "patient role" as defined in the usual medical and surgical scenario. Both biofeedback and Transcendental Meditation depart considerably from
the more traditional medical approaches in that in neither case is the patient really dependent upon someone else for treatment. The patient instead becomes responsible for what happens to him. The teacher of biofeedback and the meditation initiator simply introduce certain relatively simple technical manipulations which the identified patient or client may then use at his own discretion to produce an altered state of consciousness if he so chooses. I have not seen any formal published reports yet, but a group at the Institute of Living in Connecticut has been carrying on a series of experiments using these techniques, and the rumors are encouraging. A combination of Transcendental Meditation and alpha-biofeedback is being used. The control procedure is the more conventional Jacobsen Progressive Relaxation Technique. This is a much more authoritarian method of achieving relaxation, and it bears a very strong resemblance to hypnosis in that the teacher uses strong suggestion in instructing the subject how to relax. Apparently the exotic techniques produce the best clinical results. Thus we find yet another point of contact, this time between social psychiatry and the exotic approaches, and a major factor may be the healthier social role of the patient permitted by the exotic approaches. The patient is not dependent and receiving treatment, but rather is responsible for himself and for using his own senses to determine whether he is being successful at the task which he has set for himself. To continue with examples, an unexpected point of contact seems to be developing between the exotic disciplines, neurobiology and Jungian psychoanalysis. Neurobiological studies indicate specialization of the cortex, with special areas playing special roles in particular psychological processes. Recently, electrophysiological studies in normals have added support, since a psychological process presumed to use a given cortical area results in reduced background electroencephalogram (for example, alpha) and increased amplitude of specific event-related potentials (for example, evoked responses) arising from that area.6 The exotic disciplines have drawn attention to alternative modes of thought and consciousness, and some of these alternative modes are what we might expect if psychological processes were dominated by one of the specialized cortical areas.7 Cortical left-right asymmetry provides the best known example. For most of us the left side of our brain not only controls the right side of our THE WESTERN JOURNAL OF MEDICINE
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body, but also takes care of sequential, logical thought processes such as language, mathematics and similar propositional functions. The right brain (left body) is, on the other hand, the organ of those more holistic processes that are needed for music, art and intuition. That has been referred to as appositional thought by Bogen.8 Now in addition to his classification of people into extraverts and introverts, Jung had four psychological types: logical, intuitive, sensation and feeling.9 Logical clearly is left brain and intuitive is right brain. On far more speculative grounds one might suspect that the anterior half of the brain is more involved with what Jung meant by sensation, and the posterior half with what Jung meant by feeling. Pribram'0 has shown that the frontal cortex is involved with focusing down on sense data (sensation), while posterior areas (parietal and infratemporal cortex) act to sample a broader array of data for more complex evaluation (feeling). Support comes from Picton and Hillyard," who find early anterior brain evoked electrical potential changes associated with stimulus set and, later, more posterior evoked potentials associated with response set. The anterior/posterior relation to sensation/ feeling is much more speculative than the left/ right relation to logical/intuitive, but the possibilities are intriguing. Can modern electrophysiology provide convergent data for analytic psychology? If so, both would profit. For our last set of examples, we will look at some points of contact between molecular neurobiology and some of the social and psychological approaches. If I had to draw a logos for the neurobiology of 1974, it would surely be the socalled National Institutes of Health synapse. This famous diagram shows how one nerve cell sends its chemical messages to another. In the diagram the presynaptic termination of an axon from one neuron is shown synapsing with the postsynaptic dendrite of another neuron. The diagram gives the steps involved when a neurohumoral transmitter acts to carry messages from one cell to another. It shows the uptake of an amino acid by the cell, the enzyme steps that form the transmitter, the way the transmitter acts on the postsynaptic membrane when it is released in the synapse and then how it is removed from the synapse by re-uptake and by various pathways of degradative metabolism so that the system can be ready for another message. Almost all of the drugs that are known to affect the mind also operate on mechanisms of 352
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neurohumoral transmission in one way or another, modifying either the metabolism of the neurotransmitters or the various postsynaptic changes that the neurotransmitters produce. We are increasingly able to interfere more or less specifically in various steps of neurohumoral transmission, and this has made neuropharmacology a logical game of great elegance, intellectual challenge and practical reward. For a while it looked like we might be on the verge of powerful answers for clinical psychiatry. Schizophrenia, it seemed, might be due to a defect in the metabolism of the neurotransmitter called dopamine; depression, to a defect in norepinephrine, or perhaps serotonin. At the point of contact between studies of molecular biology and studies of human behavior, however, things have ceased to look quite so simple. The advent of drugs which literally knock out one or the other of these neurotransmitter systems has shed a great deal of light on some things and confusion on others, for the behavioral effects of some of these chemicals have been surprisingly small. Thus, parachloraphenolalanine (which blocks the serotonergic system) and alpha methyl paratyrosene (which depletes brain dopamine and norepinephrine) have remarkably little effect on humans.12 Another part of the story which made us feel that answers might be near at hand for the major psychoses came from the study of metabolites produced by people with major psychoses. Particularly, there were a number of changes in the metabolites of neurohumoral transmitters that occurred in mania and in depression. Just recently Post and Goodwin13 have reported that volunteer patients who were depressed but who agreed to act as though they were manic, ceased to show the pattern of metabolites characteristic of depression and began to show the pattern of metabolites characteristic of mania during this simulated mania. Although the chemicals changed, there was no concomitant change in the mood or actual clinical state of these simulating patients. Thus we see again that although chemicals can influence the mind, the mind can also influence chemicals. In the Post and Goodwin studies the subjects only simulated mania for one day. It would be interesting to find out if more prolonged simulation, with subsequent more prolonged effects on neurohumoral transmitters (behaviorally produced in this case), might not indeed have some psychological effect which failed to show up in the one-day experiments carried out so far. We
PSYCHIATRY TODAY
do not know what would happen to the mind if it were induced to chronically alter its own neurochemical milieu. To extend this one step further: the sort of society that fosters a particular kind of behavior may produce modifications in the neurochemistry of members of that society; and, by the same token, a group of people who inherit a particular neurochemical makeup may form a society which is, in part, molded by their particular neurochemical disposition. Most clinicians recognize that cause does not necessarily specify treatment. There may indeed be "no twisted thought without a twisted molecule." That molecule, however, may once have been twisted by genetic forces or postconceptual physiological forces, or psychological forces, or more likely some combination. We then may untwist it by using psychological input, physical and chemical input or, again, some combination. Just because the pathological chemical twist was primarily the result of some genetic factor does not mean that it may not be untwisted by some psychological manipulation, or vice versa. With luck, knowledge about any neuro-biopsychological mechanism may be turned to therapeutic advantage whether or not that mechanism had anything to do with the cause of the disorder. The intellectual trap is to assume that therapeutic success indicates cause (and so supports a narrow, bigoted viewpoint). It is obvious that when an
antipsychotic drug given by a neurobiologist helps the schizophrenic, this does not indicate that the schizophrenic was necessarily suffering from a congenital phenothiazine deficiency. It is less obvious that when a disturbed person gets along better after learning from his transactional analyst that his punitive "parent" needs to be brought under the control of his "adult," then it does not necessarily follow that he was disturbed because he actually had a punitive parent. Psychiatry is by definition a medical specialty concerned with psychological disorders. This implies that as a physician, a psychiatrist should have the ability to accept responsibility for the whole patient, and that either he should be competent in the various disciplines needed to help the patient, or else should know how to orchestrate the nonphysician specialists that are needed to supplement his skills. This is not always the case. The British often make a distinction between physicians and surgeons, refering to surgeons as "Mr." rather than "Dr.," in recognition
of the fact that the surgeon may have to limit his overview of the whole patient in order to perfect his particular operative skill. There is a tendency for some psychiatrists to narrow their interests so that they no longer operate as physicians. Again, as in the case of the surgeon, the narrow specialist may go far more deeply into his area than the physician who is always being taxed by the unpredictable needs of human beings. However, I believe that the clinician should take it as his destiny to integrate the discrepant parts that each of the blind wise men gives us. The challenge is to prevent narrow scholastic provincialism from limiting understanding. The scope of the problem, fairly faced, should lead to some humility. This will contrast with the tactics of the narrow partisans who often erect grandiose schemes that promise everything to everyone, and who end up practically playing God. It is often embarrassing to hear of psychiatrists telling professionals in other fields how to run their affairs on the basis of some wild or tenuous theoretical position. There has been an even more serious consequence, for psychiatry's tendency to oversell and underdeliver has jeopardized its relationship with the rest of medicine. Did you ever hear a physician say, "I don't believe in ophthalmology," or "I don't believe in dermatology"? Unfortunately, it's quite common to hear one say, "I don't believe in psychiatry." Perhaps that echoes those earlier disappointments with promised omnipotence that find expression in the complaint, "I don't believe in God." Psychiatry today is a bigoted, polymorph-perverse discipline. Specialists in one arcane division will not talk to those in another. When the clinician draws effective tools from a special discipline, he often takes along some pathetic pseudoscientific theory to sugarcoat the athletic empiricism. So psychiatry is an undisciplined discipline divided by advocates of special techniques. Yet it is in a position to integrate the burgeoning and diverse data on the mind into a more usable fashion, while it tidies up the mess left by its snake-oil salesmen.
Oversimplifying opportunists are always ready to cash in on the natural desire of physicians for simple answers, and of sick people for quick cures. However, David Szent Gyorgi once said that nature could not be as complicated as it seems because otherwise it would not work. The austere
theoretical structure of behavior modification shows the possibility of a scientific psychiatric therapeutics, limited as it may be. Theoretical THE WESTERN JOURNAL OF MEDICINE
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neuropharmacology is so pregnant that some viable therapeutic offspring is bound to arrive soon. The promise of rational and integrative theories arising from the interface of physiology and psychology become increasingly credible. Psychiatry may be on the verge of maturing into an openminded, modest scientifically-based branch of medicine-but it has not just yet. REFERENCES 1. Brodie KH, Sabshin M: An overview of trends in psychiatric research-1963-1972. Am J Psychiatry 130:1309-1318, Dec 1973 2. Skinner BF: Walden Two. New York, Macmillan Publishing Company, 1948 3. Ullman LP: Institution and Outcome-A Comparative Study of Psychiatric Hospitals. New York, Pergamon Press, 1967 4. Nurnberger JI, Hingtgen JN: Is symptom substitution an im-
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portant issue in behavior therapy? Biol Psychiatry 7:221-236, Dec 1973 5. Blanchard EB, Young LD: Clinical applications of biofeedback training. Arch Gen Psychiatry 30:573-592, May 1974 6. Galin D, Ellis R: Asymmetry in evoked potentials as an index of lateralized cognitive processes-Relation to EEG alpha asymmetry. Neuropsychologia (in press) 7. Ornstein RE: The Psychology of Consciousness. San Francisco, W. H. Freeman and Company, 1972 8. Bogen JE: The other side of the brain-I, II, III. Bull Los Angeles Neurol Soc 34:73-105, 135-162, 191-220, 1969 9. Wheelwright J: Psychological Types. San Francisco, C. G. Jung Institute of San Francisco, 1973 10. Pribram K: Languages of the Brain. Englewood Cliffs, New Jersey, Prentice-Hall, 1971 11. Picton TW, Hillyard SA: Human auditory evoked potentials -II. Effects of attention. Electroencephalogr Clin Neurophysiol 36:191-199, 1974 12. Mendels J, Frazer A: Brain biogenic amine depletion and mood. Arch Gen Psychiatry 30:447-451, Apr 1974 13. Post RM, Goodwin FK: Simulated behavior states-An approach to specificity in psychobiological states. Biol Psychiatry 7:237-254, Dec 1973
Refer to: Callaway E: Psychiatry today (Informed Opinion). West J Med 122:349-354, Apr 1975
OPINION
Psychiatry Today ENOCH CALLAWAY, MD, San Francisco
ALMOST 20 YEARS AGO the late Ralph Gerard began a talk on "Psychiatry Today" with a story about a minister preaching on the virtues of the church. At the high point in his sermon the preacher swung into full metaphor and said, "So the mother church stands, with one foot rooted firmly in the fertile earth of the holy scriptures and the other raised to Almighty God." Gerard was referring to psychiatry's ungainly posture which, twenty years ago, was due to the growing gap between neurobiology and psychoanalytically oriented psychology. If 20 years ago psychiatry was being split, today it's being drawn and quartered, for in addition to neurobiology and analytic psychology, which had to be reconciled at that time, we now have social and community psychiatry and, most recently, what I will call the exotic disciplines. Toward the end of World War II, the classical psychoanalytic approach had come to dominate the field of psychiatry. During the period it remained dominant, it also became relatively stagnant (as is often the case with a dominant dogma), and it's hard to point out major advances in psychoanalytic theory or practice within the past 20 years. The elegant structure of Freudian metaFrom the Department of Psychiatry, University of California, San Francisco; and the Langley Porter Neuropsychiatric Institute, San Francisco. Presented at "The Brain and Its Potential," Berkeley, California, March 1974. Reprint requests to: E. Callaway, MD, Langley Porter Neuropsychiatric Institute, 401 Parnassus Ave., San Francisco, CA 94143.
psychology has so far failed to live up to its initial promise as a source of testable hypotheses, although the game may not be over yet. At the time of Gerard's talk 20 years ago, potent psychologically-active medications had begun to produce a dramatic increase in the importance of neurobiological approaches. Studies of these psychoactive chemicals became a major force in developing modem theories of neurohumoral transmission. Those theories have in their turn given rise to repeated promises, unfortunately still unfulfilled, of a rational psychopharmacology. Psychopharmacology then, like psychoanalysis, has developed an elegant pseudotheoretical basis but remains, in fact, an empirical art.
The social and political approaches have made the greatest inroads in the past ten years. They have claimed an increasing share of the space in major psychiatric journals,l but that is far from the most noticeable effect they have had. The most dramatic change in psychiatry in the past five years is the wholesale closing of mental hospitals. Neurobiologists can claim some credit because effective antipsychotic medication has played its part, but more important forces have come from social and political action. Social action psychiatrists are certainly empiricists. On the other hand, their attention to social roles and political rights has resulted in questioning some of the psychiatric treatment mythology. THE WESTERN JOURNAL OF MEDICINE
349
PSYCHIATRY TODAY
Finally, we come to what I have called exotic disciplines. Neurochemistry (psychedelic drugs), physiology (biofeedback), and social events (the hippie movement) all are calling serious scientific and psychiatric attention to what five thousand years of eastern thought has to offer, but so far most of the leading people are neither scientists nor psychiatrists. Examples are Carlos Castaneda, Gurdjieff, the Maharishi Mehesh Yogi and Werner Erhard. The roots of the exotic approaches are religious (using that word in its eastern meaning), but modern justifications are principally empirical ("Try it-you'll like it"). A promise of' rational theoretical and scientific integration can be found in the increasing new points of contact between exotic disciplines, neurobiology, psychopharmacology, conditioning, and electrophysiology. These four aspects of psychiatry can be used to conjure up an image of the blind scholars from the elephant legend.* The first is a traditional analyst with beard, cigar and steel-rimmed glasses, still seated behind his Edwardian couch. The second wears a white coat and is surrounded by all the equipment of modern technology. The third is a young man who may be wearing either a gray flannel suit or peace beads, depending on the group he wants to influence. Last, we have the guru in his saffron robe, leading his disciples into the mystery of primal screams, Gestalt encounters or cosmic consciousness. All are making great promises; each can offer some empirical support for the practices he urges, and none has a comprehensive theoretical basis which provides testable predictions of therapeutic interest. Finally, around this Tower of Babel one finds the working psychiatrists. They deal with problems that individual people bring to them, often trying anything that gives promise of helping so that they can "heal a few, aid more and comfort all." In short, when we come to the problem of treating people, we have plenty of theories to give our art the pretense of scientific respectability, but basically our theories have little to do with our practice. Usually they serve only as mnemonic devices for our observations, and empiricism remains 90 percent of the game. The chaotic state of psychiatry today has resulted in certain symptoms. Like most psychiatric *An ancient parable concerns four blind wise men studying an elephant. One scholar touched the tail and said, "The elephant is like a rope"; another, a leg and said "The elephant is like a post." The third touched a flank and said, "The elephant is like a wall." The fourth, at the trunk, said, "You are all lying. The elephant is a kind of snake."
350
APRIL 1975 * 122 * 4
symptoms, they serve a purpose. They are understandable, even forgivable, but they must be overcome if growth is to occur. The most crippling symptom is a kind of intellectual tunnel vision. Each approach tends to develop a narrow view of things that excludes all other approaches. This is encouraged by the temper of the times and today's booming market for oversimplification. As a result, we find classic psychological theorists who see all pathology as a consequence of parent-child relationships. There are some neurobiologically oriented people who loudly proclaim that "the couch is out," and argue that the mind will cure itself of any psychological disorder given good nutrition and healthy brain biochemistry. Social and political pundits are equally in possession of the only answer. They see mental illness as entirely the result of faulty socioeconomic systems, or even as simply a myth perpetrated by the establishment and its medical lackeys. The exotic disciplines are too new to have developed extensive dogma in this country, and indeed some of their exercises-such as the Zen koans-seem designed to exercise mistrust in logical syllogisms. Be that as it may, a few of the American exponents of Transcendental Meditation are already making extravagant claims. Narrow views spare one from disturbing facts and lead to the construction of grand theories that promise everything to everyone. Behind the baroque theoretical facade of current psychiatric theories there are some empirical rules that work, but each collection of empirical rules is almost obscured by the theoretical overgrowth it stimulates. However, at the points of contact between "schools," the myths and dogmas sometimes become testable. One of these points of contact has occurred between Skinnerian behavior modification and Freudian analysis. First, consider the Skinnerian approach. This views the brain as a black box, the mind as a trivial epiphenomenon and the social sphere as a big operant-conditioning apparatus. Nevertheless, its theories have generated novel therapeutic approaches. First, however, as an exercise, think how you would fit Skinnerian practices into the outline that I have sketched. Is it neurobiology, as in rats running through mazes to test for psychochemical effects? Is it politicalsocial, as embodied in Walden Two- or in Ullman's book, Institution and Outcomes? Is it just disguised analytic psychology? (I have seen a Jungian analyst and an orthodox behavior modi-
PSYCHIATRY TODAY
fier approach the same clinical program in embarrassingly similar fashions.) Or is it the entering wedge of the exotic disciplines? Operant conditioning of physiological functions (biofeedback) has played a major role in legitimizing some exotic practices such as yoga and Zen. This could be worked into a multiple-choice exam question that would be no more bizarre than some of the other either/or positions found in contemporary psychiatry. At the interface between behavior modification and analysis, we find an example of how approaching the mind on a different tack can test an old, apparently untestable theory. Freudian theory postulated that neurotic symptoms in general, and phobias in particular, serve both to discharge and to ward off unconscious conflicts, and so are essential to the patient so long as the conflict remains. Thus, if symptoms were removed without resolving the underlying conflict, other symptoms would have to be subs-tituted. In practice, analysis aimed at resolving conflicts so that if a symptom disappeared, one could assume the conflict was resolved. If the symptom returned, it proved that the conflict was not resolved, and circularly proved the symptom-substitution theory. The Skinnerians, however, with their different bias, have been happily removing phobic symptoms by behavior-modification techniques for some time now. Instead of finding new symptoms arising to replace each removed phobia, they usually found the opposite-an improvement in areas of function not obviously related to the removed phobia.4 A point of contact between psychophysiology and learning-theory has led to a new discipline known as biofeedback.5 Alpha-conditioning is one example that has received considerable popular coverage. A computer gives a person very rapid information (feedback) as to his physiological state so that he can learn (be operantly conditioned) to control that state. The resulting selfinduced, altered states of consciousness frequently bear a resemblance to some of the states of consciousness used by the so-called exotic disciplines, and so we also have a point of contact with the exotic approaches, such as Transcendental Meditation. Modern social psychiatry has emphasized the hazards of having psychiatric patients play the "patient role" as defined in the usual medical and surgical scenario. Both biofeedback and Transcendental Meditation depart considerably from
the more traditional medical approaches in that in neither case is the patient really dependent upon someone else for treatment. The patient instead becomes responsible for what happens to him. The teacher of biofeedback and the meditation initiator simply introduce certain relatively simple technical manipulations which the identified patient or client may then use at his own discretion to produce an altered state of consciousness if he so chooses. I have not seen any formal published reports yet, but a group at the Institute of Living in Connecticut has been carrying on a series of experiments using these techniques, and the rumors are encouraging. A combination of Transcendental Meditation and alpha-biofeedback is being used. The control procedure is the more conventional Jacobsen Progressive Relaxation Technique. This is a much more authoritarian method of achieving relaxation, and it bears a very strong resemblance to hypnosis in that the teacher uses strong suggestion in instructing the subject how to relax. Apparently the exotic techniques produce the best clinical results. Thus we find yet another point of contact, this time between social psychiatry and the exotic approaches, and a major factor may be the healthier social role of the patient permitted by the exotic approaches. The patient is not dependent and receiving treatment, but rather is responsible for himself and for using his own senses to determine whether he is being successful at the task which he has set for himself. To continue with examples, an unexpected point of contact seems to be developing between the exotic disciplines, neurobiology and Jungian psychoanalysis. Neurobiological studies indicate specialization of the cortex, with special areas playing special roles in particular psychological processes. Recently, electrophysiological studies in normals have added support, since a psychological process presumed to use a given cortical area results in reduced background electroencephalogram (for example, alpha) and increased amplitude of specific event-related potentials (for example, evoked responses) arising from that area.6 The exotic disciplines have drawn attention to alternative modes of thought and consciousness, and some of these alternative modes are what we might expect if psychological processes were dominated by one of the specialized cortical areas.7 Cortical left-right asymmetry provides the best known example. For most of us the left side of our brain not only controls the right side of our THE WESTERN JOURNAL OF MEDICINE
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body, but also takes care of sequential, logical thought processes such as language, mathematics and similar propositional functions. The right brain (left body) is, on the other hand, the organ of those more holistic processes that are needed for music, art and intuition. That has been referred to as appositional thought by Bogen.8 Now in addition to his classification of people into extraverts and introverts, Jung had four psychological types: logical, intuitive, sensation and feeling.9 Logical clearly is left brain and intuitive is right brain. On far more speculative grounds one might suspect that the anterior half of the brain is more involved with what Jung meant by sensation, and the posterior half with what Jung meant by feeling. Pribram'0 has shown that the frontal cortex is involved with focusing down on sense data (sensation), while posterior areas (parietal and infratemporal cortex) act to sample a broader array of data for more complex evaluation (feeling). Support comes from Picton and Hillyard," who find early anterior brain evoked electrical potential changes associated with stimulus set and, later, more posterior evoked potentials associated with response set. The anterior/posterior relation to sensation/ feeling is much more speculative than the left/ right relation to logical/intuitive, but the possibilities are intriguing. Can modern electrophysiology provide convergent data for analytic psychology? If so, both would profit. For our last set of examples, we will look at some points of contact between molecular neurobiology and some of the social and psychological approaches. If I had to draw a logos for the neurobiology of 1974, it would surely be the socalled National Institutes of Health synapse. This famous diagram shows how one nerve cell sends its chemical messages to another. In the diagram the presynaptic termination of an axon from one neuron is shown synapsing with the postsynaptic dendrite of another neuron. The diagram gives the steps involved when a neurohumoral transmitter acts to carry messages from one cell to another. It shows the uptake of an amino acid by the cell, the enzyme steps that form the transmitter, the way the transmitter acts on the postsynaptic membrane when it is released in the synapse and then how it is removed from the synapse by re-uptake and by various pathways of degradative metabolism so that the system can be ready for another message. Almost all of the drugs that are known to affect the mind also operate on mechanisms of 352
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neurohumoral transmission in one way or another, modifying either the metabolism of the neurotransmitters or the various postsynaptic changes that the neurotransmitters produce. We are increasingly able to interfere more or less specifically in various steps of neurohumoral transmission, and this has made neuropharmacology a logical game of great elegance, intellectual challenge and practical reward. For a while it looked like we might be on the verge of powerful answers for clinical psychiatry. Schizophrenia, it seemed, might be due to a defect in the metabolism of the neurotransmitter called dopamine; depression, to a defect in norepinephrine, or perhaps serotonin. At the point of contact between studies of molecular biology and studies of human behavior, however, things have ceased to look quite so simple. The advent of drugs which literally knock out one or the other of these neurotransmitter systems has shed a great deal of light on some things and confusion on others, for the behavioral effects of some of these chemicals have been surprisingly small. Thus, parachloraphenolalanine (which blocks the serotonergic system) and alpha methyl paratyrosene (which depletes brain dopamine and norepinephrine) have remarkably little effect on humans.12 Another part of the story which made us feel that answers might be near at hand for the major psychoses came from the study of metabolites produced by people with major psychoses. Particularly, there were a number of changes in the metabolites of neurohumoral transmitters that occurred in mania and in depression. Just recently Post and Goodwin13 have reported that volunteer patients who were depressed but who agreed to act as though they were manic, ceased to show the pattern of metabolites characteristic of depression and began to show the pattern of metabolites characteristic of mania during this simulated mania. Although the chemicals changed, there was no concomitant change in the mood or actual clinical state of these simulating patients. Thus we see again that although chemicals can influence the mind, the mind can also influence chemicals. In the Post and Goodwin studies the subjects only simulated mania for one day. It would be interesting to find out if more prolonged simulation, with subsequent more prolonged effects on neurohumoral transmitters (behaviorally produced in this case), might not indeed have some psychological effect which failed to show up in the one-day experiments carried out so far. We
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do not know what would happen to the mind if it were induced to chronically alter its own neurochemical milieu. To extend this one step further: the sort of society that fosters a particular kind of behavior may produce modifications in the neurochemistry of members of that society; and, by the same token, a group of people who inherit a particular neurochemical makeup may form a society which is, in part, molded by their particular neurochemical disposition. Most clinicians recognize that cause does not necessarily specify treatment. There may indeed be "no twisted thought without a twisted molecule." That molecule, however, may once have been twisted by genetic forces or postconceptual physiological forces, or psychological forces, or more likely some combination. We then may untwist it by using psychological input, physical and chemical input or, again, some combination. Just because the pathological chemical twist was primarily the result of some genetic factor does not mean that it may not be untwisted by some psychological manipulation, or vice versa. With luck, knowledge about any neuro-biopsychological mechanism may be turned to therapeutic advantage whether or not that mechanism had anything to do with the cause of the disorder. The intellectual trap is to assume that therapeutic success indicates cause (and so supports a narrow, bigoted viewpoint). It is obvious that when an
antipsychotic drug given by a neurobiologist helps the schizophrenic, this does not indicate that the schizophrenic was necessarily suffering from a congenital phenothiazine deficiency. It is less obvious that when a disturbed person gets along better after learning from his transactional analyst that his punitive "parent" needs to be brought under the control of his "adult," then it does not necessarily follow that he was disturbed because he actually had a punitive parent. Psychiatry is by definition a medical specialty concerned with psychological disorders. This implies that as a physician, a psychiatrist should have the ability to accept responsibility for the whole patient, and that either he should be competent in the various disciplines needed to help the patient, or else should know how to orchestrate the nonphysician specialists that are needed to supplement his skills. This is not always the case. The British often make a distinction between physicians and surgeons, refering to surgeons as "Mr." rather than "Dr.," in recognition
of the fact that the surgeon may have to limit his overview of the whole patient in order to perfect his particular operative skill. There is a tendency for some psychiatrists to narrow their interests so that they no longer operate as physicians. Again, as in the case of the surgeon, the narrow specialist may go far more deeply into his area than the physician who is always being taxed by the unpredictable needs of human beings. However, I believe that the clinician should take it as his destiny to integrate the discrepant parts that each of the blind wise men gives us. The challenge is to prevent narrow scholastic provincialism from limiting understanding. The scope of the problem, fairly faced, should lead to some humility. This will contrast with the tactics of the narrow partisans who often erect grandiose schemes that promise everything to everyone, and who end up practically playing God. It is often embarrassing to hear of psychiatrists telling professionals in other fields how to run their affairs on the basis of some wild or tenuous theoretical position. There has been an even more serious consequence, for psychiatry's tendency to oversell and underdeliver has jeopardized its relationship with the rest of medicine. Did you ever hear a physician say, "I don't believe in ophthalmology," or "I don't believe in dermatology"? Unfortunately, it's quite common to hear one say, "I don't believe in psychiatry." Perhaps that echoes those earlier disappointments with promised omnipotence that find expression in the complaint, "I don't believe in God." Psychiatry today is a bigoted, polymorph-perverse discipline. Specialists in one arcane division will not talk to those in another. When the clinician draws effective tools from a special discipline, he often takes along some pathetic pseudoscientific theory to sugarcoat the athletic empiricism. So psychiatry is an undisciplined discipline divided by advocates of special techniques. Yet it is in a position to integrate the burgeoning and diverse data on the mind into a more usable fashion, while it tidies up the mess left by its snake-oil salesmen.
Oversimplifying opportunists are always ready to cash in on the natural desire of physicians for simple answers, and of sick people for quick cures. However, David Szent Gyorgi once said that nature could not be as complicated as it seems because otherwise it would not work. The austere
theoretical structure of behavior modification shows the possibility of a scientific psychiatric therapeutics, limited as it may be. Theoretical THE WESTERN JOURNAL OF MEDICINE
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neuropharmacology is so pregnant that some viable therapeutic offspring is bound to arrive soon. The promise of rational and integrative theories arising from the interface of physiology and psychology become increasingly credible. Psychiatry may be on the verge of maturing into an openminded, modest scientifically-based branch of medicine-but it has not just yet. REFERENCES 1. Brodie KH, Sabshin M: An overview of trends in psychiatric research-1963-1972. Am J Psychiatry 130:1309-1318, Dec 1973 2. Skinner BF: Walden Two. New York, Macmillan Publishing Company, 1948 3. Ullman LP: Institution and Outcome-A Comparative Study of Psychiatric Hospitals. New York, Pergamon Press, 1967 4. Nurnberger JI, Hingtgen JN: Is symptom substitution an im-
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portant issue in behavior therapy? Biol Psychiatry 7:221-236, Dec 1973 5. Blanchard EB, Young LD: Clinical applications of biofeedback training. Arch Gen Psychiatry 30:573-592, May 1974 6. Galin D, Ellis R: Asymmetry in evoked potentials as an index of lateralized cognitive processes-Relation to EEG alpha asymmetry. Neuropsychologia (in press) 7. Ornstein RE: The Psychology of Consciousness. San Francisco, W. H. Freeman and Company, 1972 8. Bogen JE: The other side of the brain-I, II, III. Bull Los Angeles Neurol Soc 34:73-105, 135-162, 191-220, 1969 9. Wheelwright J: Psychological Types. San Francisco, C. G. Jung Institute of San Francisco, 1973 10. Pribram K: Languages of the Brain. Englewood Cliffs, New Jersey, Prentice-Hall, 1971 11. Picton TW, Hillyard SA: Human auditory evoked potentials -II. Effects of attention. Electroencephalogr Clin Neurophysiol 36:191-199, 1974 12. Mendels J, Frazer A: Brain biogenic amine depletion and mood. Arch Gen Psychiatry 30:447-451, Apr 1974 13. Post RM, Goodwin FK: Simulated behavior states-An approach to specificity in psychobiological states. Biol Psychiatry 7:237-254, Dec 1973
