The authors of Integrating
Psychotherapy and Pharmacotherapy chose the rather seductive subtitle of Dissolving
the Mind-Brain Barrier.  While I
admire the audacity, almost as cheeky as Dennett’s Consciousness Explained,
the book itself, of course, does no such thing.  That gap in epistemic space is nearly as wide as the gap in
conceptual space between psychiatry’s two prevailing solitudes €“ biological and
social psychiatry, with their preferential biases toward medications or else
psychotherapies, respectively.  Are we
beginning to see encouraging signs that the Great Schism is in early stages of
repair?  Professor Beitman, in the
Preface, boldly asserts that "Psychiatry is the mind-brain
profession.  Mental health professionals
can no longer afford the dichotomy.  The
authors of this book are firmly committed to healing this conceptual
schism" (p. xi).  For my part, amen
to that.

However, the reader gets no call to
action within the psychiatric politic. 
Instead, the book is aimed at a clinical audience.  Specifically, it is aimed at psychiatry
residents, and Beitman indicates it was test-driven by a resident group at
Missouri-Columbia.  Part I of the book
is primarily a collection of clinical vignettes where combined treatment issues
are prominent.  Organized around six
topics, each chapter presents a brief introduction, a clinical case, a series
of questions for discussion, followed by a set of suggested answers to spur
further discussion.  The sections end
with the anecdotal reactions of the psychiatry residents who test-drove the
cases.  Part II of the book, far more
salient to a wider audience, discusses the current state of the literature on
combining psychotherapy with medication, devotes a chapter to
"psychodynamic neurobiology," 
and includes a chapter, more of interest to specialists, on "split
treatment," that situation where an individual receives psychiatric
medications from one practitioner and psychotherapy from another.

The first section of "Part
I:  Issues, Vignettes, and
Commentary," is "Research in Combined Treatments," and the
authors convey a critically important message: 
"Combined treatments do not uniformly produce additive
benefits" (p. 3).  Clinical lore
suggests that patients do better with both psychotherapy and medications, but
research doesn’t bear that out in an unqualified way.  Throughout the book, however, it is never qualitatively clear
what is meant by psychotherapy. 
Quantitatively, the authors are definitely talking about CBT
(cognitive-behavioral therapy), interpersonal therapy, family therapy, and
psychodynamic therapies.  But so
what?  Psychotherapy cannot be doled
out, in measured fashion, like a drug, with a guaranteed amount of active
compound, free of impurities. 
Psychotherapy depends directly on the practitioner and on that person’s
ability to form a therapeutic alliance with the sufferer.  This is both good common sense and well
borne out by psychotherapy research.  It
is, furthermore, the single biggest predictor of a good therapeutic outcome,
far outstripping the theoretical orientation or training of the therapist.[1]

Despite this, combined treatment
research, thus far, has made little effort to address the quality of the
therapy being delivered in terms of therapeutic alliance.  Instead, it resigns itself to addressing
much easier questions, such as tape review to ensure the psychotherapy model
under study is being adhered to.  The
question of model-adherence may be important, but it must necessarily take a
back seat to the overriding issue of whether the therapists in the study are
actually any good at psychotherapy, over and above being good at a particular
variety of therapy.  Beitman (and then
Thase in Part II of the book) neither acknowledges nor addresses this serious
conceptual shortcoming in combined research, a shortcoming which, I suggest,
jeopardizes the validity of the entire combined treatments research enterprise.

Section 2 on "Pharmacotherapy
During Psychotherapy" discusses the fascinating question of prescribing a
pill as a psychotherapeutic act in itself, all questions of receptor
biochemistry aside.  Beitman discusses
the various ways in which the prescription might be psychologically viewed by
the patient, from negative abandonment, through positive gift, and the
vignettes are very compelling.  However,
the question just dying to be asked goes unaddressed:  if the act of prescribing is so psychologically powerful, why
should we suppose that the active compound does anything to the mind and brain
that cannot be accounted for by psychological explanations alone?  This is not an idle question.  A Cochrane Review of antidepressants versus
active placebos (compounds which generate side effects similar to
antidepressants but are not thought to have psychopharmacological activity)
found that "differences between antidepressants and active placebos were
small. This suggests that unblinding effects may inflate the efficacy of
antidepressants in trials using inert placebos."[2]  By "unblinding," the authors refer
to the common problem of patients in the active treatment arm realizing they are
on active treatment by virtue of experiencing unusual side-effects which would
be unlikely on inert placebos. 
Essentially, when patients can’t tell if they’re on the active drug or
the placebo, their outcomes are eerily similar.

Beitman seems to inadvertently make
this point himself in Section 3, "Psychotherapy During
Pharmacotherapy," where he discusses the doctor/patient relationship,
pointing to research which reveals that "the better the relationship the
higher likelihood of a positive response to medication" (p. 35).  Even more interesting are some of the
statistics he quotes about psychiatry residents who inform their patients that
they are graduating and therefore leaving the patients in the care of others:
"about 20% of their patients worsened, 32% required medication changes,
and about 10% decided to quit their medications" (p. 36).  Sadly, Section III misses the opportunity to
wonder skeptically about psychiatric medications and makes the automatic assumption
that the medications are good.  Since
they are good, it is therefore advantageous to encourage compliance, and much
of the section discusses CBT techniques to help patients explore their
non-compliance, challenge it, and overcome it. 
But if the benefits of medication are not clearly separate from the
caring relationship itself, and if the compounds have known toxicities, why
jeopardize the known healing potential of the caring relationship by
encouraging patients to stay on medications if they have no clear wish to?  This is paternalistic, coercive psychiatry,
even though well intentioned.  Careful
skepticism towards medications and their putative mechanisms of action would
obviate many a power struggle within psychiatric clinics.

Section 5, "The Sequencing
Problem (Using Panic Disorder as an Example)," grapples with the issue of
whether to start with psychotherapy, medications, or both at once.  The research that would be required to have
definitive answers is complicated, making it hard to know what is influencing
what, and it is also expensive, making the generation of sufficient statistical
power less likely.  Therefore, much of
the time, there will be no clear guidance from literature.  Again, it will be an issue to be decided
between the treater and the sufferer, on the strength of their relationship,
patient preferences, and the treater’s skills. 
Beitman suggests situations where medications are "required"
first (schizophrenia, bipolar disorder, but again, refer to the Bola and Mosher
reference for a sharply differing opinion), where psychotherapies are
"required" first (simple phobias, uresolved grief), and where it
simply isn’t clear (post traumatic stress disorder, borderline personality
disorder).  In a wonderful vignette,
Beitman describes the treatment of a young woman with panic disorder who
developed acute paranoia while on clonazepam, just after discovering her
daughter being bullied at school.  The
case richly illustrates how a medication side-effect (disinhibition) can have
deep psychological roots from the story of the patient’s own bullied life.

Part II of the book, "Research
Perspectives, Split Treatment, and Psychodynamic Neurobiology," offers
three papers which provider deeper background reading on the topics raised in
Part I.  The review by Thase on
integrating medications with psychotherapy finds that carefully scrutinizing
the research reveals "a systematic underestimation of the additive effects
of combined treatment, especially among subgroups with more severe mental
disorders" (p. 112).  The review is
thoughtful and sophisticated.  One
notable surprise finding Thase mentions is that, although the data are limited,
prescribing psychiatrists seem to have better outcomes than prescribing primary
care physicians.  He does not speculate
as to why this might be so. 

Thase also, unfortunately, not only
espouses the well-worn psychiatric mantra that "schizophrenia or mania
should not be treated with psychotherapy alone," but goes much further and
blares that "to knowingly withhold pharmacotherapy from patients with
these disorders is tantamount to malpractice. . .when pharmacotherapy is
indicated as a life-saving treatment" (p. 132).  Notably absent from this rather dramatic assertion are the
perspectives of psychotics and manics who find themselves medicated against
their will and suffer very serious side-effects.  Unfortunately, there is no way of knowing in advance who will
benefit from neuroleptic treatment, and a very sizable minority of psychotics
gain no appreciable benefit from neuroleptic treatment.[3]  Furthermore, peer-reviewed research has
demonstrated that acute psychosis can be managed effectively without
neuroleptics through the use of caring relationships in structured settings.[4]  I find it meddlesome to have a renowned
psychiatric researcher dictate to his profession what constitutes malpractice,
especially when the issue is not at all clear-cut, and so much scientifically
well-founded difference of opinion exists in the literature.  This is psychiatric culture, not good science.

The final chapter in the book,
"Psychodynamic Neurobiology," by Professor Blinder, is an intelligent
and artful synthesis, using psychopathology as an example of how top-down and
bottom-up approaches to bridging the mind-brain gap are yielding rich results.  His analysis is far more sophisticated than
the usual "this structure mediates that phenomenon" approach and
signals a new sophistication within psychiatry, one which moves beyond
simplistic, epiphenomenal or identity monism (i.e. "Mental event x is brain event y or is caused by brain event y.").  This is the best stuff in the book and comes
closest to "dissolving the mind-brain barrier."

It is hard to make a final
assessment of this book.  It brings to
light the critical issue of the therapeutic alliance and its overriding
importance in helping suffering people to do better, whether by way of
medications, psychotherapies, or both. 
It has crisp clinical vignettes which highlight underlying conceptual
and clinical dilemmas.  It also has a
wonderful essay on the neurobiology of psychodynamics, almost worth the price
of the book on its own.  However, it
isn’t nearly critical enough of the research literature in combined therapies,
which it nevertheless claims to review. 
There is no effort to robustly define psychotherapy, no effort made to
wonder about just how much room is left for medication efficacy when
psychological factors are fully accounted for, and the bald assertion about
what constitutes malpractice is stunning. 
What the book does accomplish is to encourage deeper thinking by mental
health clinicians of all stripes about just how subtle and pervasive their
relationships are with the suffering, and it most certainly abolishes the
notion that physicians can hide behind prescription pads.  The doctor is the pill.

©
2004 Robert Tarzwell

Robert Tarzwell is a fourth year psychiatry resident
at Dalhousie University in Halifax, Nova Scotia, Canada.  His psychiatric interests include
emotion-focused psychotherapy, evolutionary accounts of psychopathology, and
the causes of madness.  His philosophical
interests include the mind-body problem, the problem of psychiatric nosology,
and the philosophy of science, particularly as it relates to the scientific
investigation of psychiatric disorders.