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Are You Heading Where the Field Is Going to Be?

May 18, 2020

Wayne Gretzky famously said he skates to where the puck is going to be, not where it has been. We should pick careers this way as well. One problem that I foresee is the predictive power needed to anticipate the course of a career compared with the path of a hockey puck. For instance, managed care was not a concept when I began my career.

Picking a career is hard because the field you pick keeps changing. The managed care example is a good one. The transformation it brought to the healthcare field was monumental, almost like changing the rules of hockey in the middle of the game. Gretzky never had to enter that variable into his calculations about the puck’s destination.

These thoughts are prompted by current discussions within psychiatry. It appears from my reading of Psychiatric News that early career psychiatrists are trying to decide where the practice of psychotherapy fits into a career in psychiatry. I find this an encouraging development since I was befuddled many years ago when the dawn of biological psychiatry became clear.

I could not understand why a doctor would want to manage medications for an entire workday, and some young psychiatrists are asking this same question. The behavioral healthcare field has changed significantly from when psychoanalysis dominated the psychotherapeutic landscape and when Tofranil and Thorazine were the best psychopharmacology had to offer.

Psychiatrists have acknowledged in the past decade that pharmacological treatments have not lived up to hopes and expectations. The 1990s were the Decade of the Brain, and the period ended without offering any big clues about the underlying biological causes of psychiatric disorders. The psychiatrist Richard Friedman wrote in the New York Times in 2015 that we face a “quandary” with such little progress:

With few exceptions, every major class of current psychotropic drugs – antidepressants, antipsychotics, anti-anxiety medications – basically targets the same receptors and neurotransmitters in the brain as did their precursors, which were developed in the 1950s and 1960s.

This timeline reveals the basis for some regrets about embracing the biological side of psychiatry. It was not based on scientific discoveries. It was based on a belief in scientific discovery and a hope that psychiatry would benefit like other medical sciences. Yet a significant investment in basic neuroscience has not generated those results. Historian Anne Harrington published a definitive work on this in 2019.

Her book Mind Fixers details how psychiatric medications were successfully billed as fixing underlying biological problems that were never found. There was reason to believe these discoveries were imminent, and yet new medications grew more from serendipity than knowledge of biological markers. The clinical bedrock has consistently remained the observation of symptoms.

It is little wonder newly trained psychiatrists are tempted to now embrace all components of the biopsychosocial model. They enter their specialty after the decade of the brain, after triumphal celebrations with the discovery of Prozac, after decades of research that cannot provide the biological basis of a single mental illness.

The National Institute of Mental Health (NIMH) invested a tiny fraction in psychotherapy research over those years. The returns have been much more promising. The path has been painful, nonetheless. My own training in psychodynamic psychotherapy turned out to be meager preparation in the 1990s for the ascendancy of brief therapy. I studied books and gave it a try, in part because managed care insisted.

Psychiatry had variations of the chemical imbalance theory, and similarly, psychotherapy had a wide array of therapy models and explanatory systems for professionals to choose from in their work. Behavioral psychology knocked psychoanalysis off its perch in the 1970s, and therapists could soon choose from empathic listening to cognitive restructuring as a path.

The short-lived dominance of brief therapy had good and bad sides to it. It effectively eradicated the belief system inherited from psychoanalysis that every patient needed to become dependent on therapy for a long-term healing process. However, the advent of insurance coverage for therapy meant that a rationale was needed to begin and end treatment, with dishonorable justifications often the result.

Psychotherapy was able to survive the assault of managed care based on research and public policy. Advocates of the different approaches to therapy were willing to subject their models to clinical research, and most of them have demonstrated positive results. Eclectic therapists may have been onto something from the beginning. The parity law then ended arbitrary limits on outpatient therapy.

An interesting parallel between psychopharmacology and psychotherapy exists in their explanatory systems. All the talk about neurotransmitters is surely true, but it may have little to do with the relative efficacy of any medication. Similarly, the intricate theories about why thoughts, feelings and behaviors change in therapy may be compelling, but they may have little to do with how any psychotherapy works.

Where does this leave new psychiatrists today? They would seem to be in a better position than older colleagues. While psychiatric medications may not be curative, they are essential for several problems and require specialists to manage them. Psychotherapy is “remarkably efficacious,” to quote the results of decades of research, and so the time to combine both approaches could not be better.

This does not mean that the medical model has lost its sway over psychiatry. Psychiatric News recently featured a debate about psychiatrists seeking to “practice at the top of their license.” It seems that to most psychiatrists this means providing medication management. A minority argue for combining psychotherapy and psychopharmacology as the pinnacle.

The encouraging conclusion in this episode of the history of science is the pivotal role of research. Psychiatry anticipated great biological discoveries and yet the research did not support that belief. On the other hand, psychotherapy is stronger now that research has shown many reasonable approaches are effective. The lesson could not be clearer: Following the data is a better strategy than leading it.

What have we learned about heading to where the field is going to be? Remember that Gretzky made his calculations during the action of the game, not in the pregame interview. One could not know in the beginning of a psychiatric career that leaders would decide to abandon psychotherapy and bet the profession on future biomedical discoveries. Yet there is always time to pivot for a better direction.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.

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