Ben Wattenberg: Hello, I’m Ben Wattenberg.
Was Sigmund Freud right?
Is most mental illness rooted in childhood
trauma, often sexual trauma?
That Freudian view has shaped much of the
modern world.
Now a new school of scientists say many disorders
of the mind are really physical diseases of
the brain and can often be treated with new
drugs.
Joining us to sort through the conflict and
the consensus are four noted psychiatrists:
Peter Kramer, associate professor of psychiatry
at Brown University and author of the bestselling
book, “Listening to Prozac”; Fred Goodwin,
former director of the National Institute
for Mental Health and now director of the
Center on Neuroscience, Behavior, and Society
at George Washington University; Daniel Weinberger,
chief of the National Institute of Mental
Health’s Clinical Brain Disorders Branch
and coauthor of “The Neurology of Schizophrenia”;
and Milton Viederman, professor of clinical
psychiatry at Cornell Medical College and
an attending psychiatrist at the New York
Hospital.
The topic before this house: The brain versus
the mind — has Freud slipped?
This week on “Think Tank.”
What do you think of when you hear the word
“psychiatry”?
Does it conjure up an image of a taciturn
therapist listening to the recalled childhood
nightmares of his or her patient?
Well, times have changed.
Much of the treatment of mental illness has
gone high tech.
Proponents of the so-called new biology say
that disorders like depression, schizophrenia,
and manic compulsive behavior are often caused
by physical or chemical defects in the brain.
The cure is not years of talk therapy, but
treatment with new drugs.
For example, the drug Prozac relieves depression
by increasing the chemical serotonin in the
brain.
Doctors have prescribed Prozac to more than
11 million people worldwide.
Defenders of traditional talk therapy praise
the new scientific advances, but stress that
doctor-patient communication is still crucial.
They worry that too many doctors will rush
to prescribe potent medicines without first
trying to talk through their patients’ problems.
Gentlemen, doctors, first question, starting
with you, Dr. Fred Goodwin.
Is Freud slipping?
Fred Goodwin: I think the image of Freud in
the Woody Allen sense is slipping — and
appropriately so.
Psychotherapy is not slipping.
Actually, in a way, the evolution of drugs
has been a gift to psychotherapy because it’s
taken away some of the things that psychotherapy
didn’t do so well in — schizophrenia,
manic depressive illness.
What you see today is psychotherapy being
used more focused, more briefly, with the
medically ill and with the severely ill psychiatric
patients, but in combination, not instead
of medications.
Ben Wattenberg: Dr. Dan Weinberger.
Daniel Weinberger: My sense is that rather
than slipping, things are changing.
The field is changing.
All fields of medicine are changing.
We have made remarkable strides in understanding
the human body, how it functions and how it
malfunctions.
This has happened in psychiatry.
We have a much more in-depth sense of mental
function and mental illness than we had in
Freud’s time.
And I think to our benefit, as a result of
these kinds of changes, the field is evolving.
The question I think that we are asking as
a field is: What needs to evolve most rapidly,
and where does most of the emphasis have to
be placed?
Ben Wattenberg: Okay.
Dr. Milton Viederman.
Milton Viederman: The question really poses
a false dichotomy.
That is to say, the dichotomy between psychotherapy
and biological psychiatry.
Freud himself believed ultimately that mental
illness could be reduced to biological factors.
Moreover, he was not at all a believer in
the idea that environmental factors uniquely
influence development.
He felt constitutional factors were very important.
So, in essence, Freud himself was a participant
in the current evolution of psychiatry.
Ben Wattenberg: All right.
Dr. Kramer, Peter Kramer.
Peter Kramer: I think the scope of biological
interventions has expanded so that now it
is possible to do things biologically, even
for the very minor mental disorders and for
nearly normal people, maybe for normal people.
And that makes for very exciting psychotherapy.
That is, you can sometimes allow patients
to alter their perspective through the use
of medicine and integrate that alteration
into the psychotherapy.
So, based on intellectual ferment alone, these
ought to be very exciting days for psychotherapy.
I think insurance companies and external pressures
on the field may lead to a different outcome.
Ben Wattenberg: Well, now, are you sort of
all closing ranks, as professionals like to
do?
I mean, you had a system of treatment where
at times people went four or five times a
week for an almost infinite number of years
of psychoanalysis.
And now you have, for some of those patients
at least, somebody writing out a prescription
once.
Now, that is not just at the edges or shades
of gray.
Milton Viederman: Well, I think that the caricature
of psychoanalysis as an infinitely long process
four or five times a week, without a defined
end, is really a caricature.
Psychoanalysis itself has changed enormously
in recent times, both in theory and in practice.
Currently, the very idea of seeing people
in psychoanalysis, what we call psychoanalysis,
two or three times a week for shorter periods
of time, is becoming current, for one thing.
Moreover, psychoanalysis is not in opposition
to the biological psychiatry, in that drugs
often facilitate, as Peter indicated, what
happens in analysis.
Daniel Weinberger: I think the bigger question
that we’re being asked is that the tradition
of psychiatry was a tradition that emerged
from certain principles of psychological organization.
And this field is evolving, like all fields
of medicine and treatment in most fields of
medicine.
At the time that psychoanalysis began, it
was a therapy that grew out of the efforts
of certain people to understand the emergence
of physical symptoms in people that didn’t
have physical illness, and there were no other
treatments at that time.
Psychoanalysis was the best treatment on the
street in Vienna at that time for people who
had paralyses that didn’t explain themselves
in physical terms.
We are in a state of transition now, where
there is question being raised within the
field of what are the best treatments.
I think it would be ill-advised and bad practice
as a physician to treat a patient with a medical
illness, such as depression might turn out
to be, primarily — we don’t categorically
know that yet, but a lot of data suggests
it is.
If it turns out that that’s a medical condition
that requires a medical treatment, we should
counsel that patient and get to know that
patient and help fashion the patient’s after-care
as positively as we can, the same way a good
internist would do with a patient with hypertension
and diabetes and everything else, which studies
also show —
Fred Goodwin: Actually, the paradox now is
that today, the most dramatic evidence for
the efficacy of psychotherapy are in the medically
ill, you know, the enormous rates of change
in recurrence of cancer with psychotherapy
and in patients who have real biological illnesses,
like schizophrenia and manic depression.
You can produce three- to fourfold differences,
but not with traditional long-term analysis,
but with social skill training, with psycho-education
of the family.
It’s psychotherapy, but it’s of a broader,
more practical, more here-and-now focus than
it would have been in the past.
Milton Viederman: Fred, I want to emphasize
an issue here, and then I’ll come back to
that problem.
And the issue has to do with specificity.
The problem — one of the things that psychoanalytic
theory can contribute is an understanding,
a structure for approaching the patient, a
model for thinking about that.
And what I would emphasize is this: that utilizing
that model, specific treatments can be developed.
Ben Wattenberg: How do you come in —
Peter Kramer: Well, a couple things.
One is I — just this past week, I was teaching
the residents about outcome studies.
And I think that the outcome studies are terrifically
hard to do.
And one thing to be said about them is maybe
they shouldn’t have been done, given the
level of technology that was applied to them.
But the broad summary —
Ben Wattenberg: Yeah, but there’s a conflict
here.
You are doctors, and you know, most doctors
or most pharmaceutical companies have to — I
mean, treatment has to be certified, in the
pharmaceutical case, by the Food and Drug
Administration.
There’s peer review among doctors for certain
kinds of surgery, and it’s got to show that
it helps.
And you are saying you don’t have to show
that it helps.
Peter Kramer: Well, I’m not — of course
one should show that it helps, but it is possible
to do studies that are invalid.
That is, it’s possible to try to apply technology
that’s not ready to a problem that needs
to be answered.
I mean, we — there are a lot of things we
don’t know in medicine, you know, outside
the area of drugs.
We don’t know whether prenatal care is really
all that helpful for — to obstetrical outcome.
We think it is, but, you know, the studies
really are hard to do.
Daniel Weinberger: There’s research showing
that it’s extremely valuable.
Peter Kramer: Well, there’s some that show
that it is, some that show that it isn’t.
Fred Goodwin: Ben said psychotherapy in general.
We need to step back a minute, because we
had to review this whole thing at NIMH for
the Clinton health task force.
Ben Wattenberg: You were the director of the
—
Fred Goodwin: Yes.
Ben Wattenberg: NIMH is the National Institutes
of Mental Health.
Fred Goodwin: The main government research
organization.
I had to bury myself in this literature for
a year and a half in order to be able to present
this.
The things we found were straightforward.
One is that the diagnosis of mental disorders
is as good or better than most medical disorders
— that is, the ability to agree.
We can agree better about diagnosing depression
than doctors can agree about a mammogram indicating
cancer.
The second thing is, in the five major mental
illnesses, the treatments were as effective
as they are in areas like cardiovascular illness.
But most of those treatments involved combinations
of medication and psychotherapy, and the evidence
for the psychotherapies — and I may have
to disagree with my colleagues, but the hard
evidence that we could present to the Clinton
task force were on cognitive therapy, behavioral
therapy and —
Ben Wattenberg: Give us just a very fast example
of —
Fred Goodwin: Cognitive therapy is helping
a person restructure the way they’re thinking
about themselves, finding islands of self-esteem,
letting them see in very practical ways how
they have perceptions which distort their
view of reality.
And it works.
Behavioral therapy, for example, in my field
of depression, is having somebody find a behavior
that they do that they realize makes them
feel better when they’re doing it, have
them repeat that.
That’s a little simple-minded, but there’s
a number of behaviors — there’s deep breathing
exercises for anxiety attacks.
These things work.
They’re short term enough to be evaluated.
And then a specific kind of interpersonal
therapy, where you teach people different
ways to negotiate.
This is not going back to how you felt about
your mother, although how you felt about your
mother may be affecting how you’re negotiating.
Peter Kramer: I’m continually shocked —
Milton Viederman: But interpersonal therapy
has some relationship to the structure of
analytic therapy —
Fred Goodwin: Yes, I agree.
Milton Viederman: — although I agree that
it’s very frustrating —
Daniel Weinberger: Before you get too shocked
—
Peter Kramer: Let me get shocked for a minute
because I am —
Fred Goodwin: Peter, I was only talking about
the literature.
I wasn’t talking about what I believe as
a clinician.
And I agree with you, doctors —
Peter Kramer: Well, let’s talk about what
we believe as clinicians for a moment, because
I am genuinely shocked.
Fred Goodwin: I agree with you.
Doctors practice a lot of things —
Ben Wattenberg: I love seeing psychiatrists
arguing.
Peter.
Peter Kramer: I think it would be frightful
if, all of a sudden, we were to throw out
what to me is the most highly developed technology
in psychiatry, which is insight-oriented dynamic
psychotherapy, traditional psychotherapy.
Ben Wattenberg: Whoa, hold on.
You must put that in American, right.
Peter Kramer: Traditional psychotherapy, based
in a broad sense on Freud’s principles,
I think, is still the most developed technology
within psychiatry and most useful for the
minor common disorders.
Ben Wattenberg: And yet you have written the
leading popular book, at least, about the
use of drugs, “Listening to Prozac.”
Peter Kramer: That’s right.
I think that medicine has entered that same
arena where psychotherapy traditionally has
been — minor disorders, problems of personality.
And it’s necessary to say that we can influence
a lot of those problems biologically.
Daniel Weinberger: My concern is — and I
think that how this debate gets started and
what the public and the managed care companies,
which — we don’t really talk about this,
but fuel this debate ultimately.
It’s economics that makes this question
be asked right now.
What they’re demanding of us is that we
look very critically at what works and what
doesn’t work.
We as a field, I don’t think should be defending
a citadel.
We should not be defending psychotherapy.
We should be defending our patients, their
illness, and their need for treatment, and
we should be what is best by way of treatment
for them.
So to answer your question —
Ben Wattenberg: So the people who are less
severely ill, you can just — you don’t
have to go two or three times a week for a
year, but you can just write out a prescription
for Prozac or anything else.
That’s fine.
Daniel Weinberger: I think Peter’s book
answered the question very nicely.
It illustrated something that we’ve all
experienced as practitioners, that we can
see a patient who has the archival neurotic
syndrome that was the basis of many of Freud’s
fundamental writings, something called obsessive
compulsive neurosis, a condition that psychoanalysis
built itself around in many, many ways —
Milton Viederman: In part.
Daniel Weinberger: — in many, many ways
—
Milton Viederman: Yes.
Daniel Weinberger: — for good reason, because
it’s a condition with very rich internal
mind dynamics.
Many patients, despite years of psychoanalysis,
have remarkable responses to a medication
such as Prozac.
When you see this clinically, you can’t
not, as Peter did, I think — and it instigated
him to write this book — take pause about
that, and say, “My, my, my, this makes us
have to re” — and that’s not to say
—
Ben Wattenberg: All right, now hold it.
I want to read you an outstanding piece of
psychiatric literature.
This comes from a Broadway musical, “West
Side Story,” that came out in 1957.
And it’s a song that juvenile delinquents
sing to the infamous Officer Krupke.
And it says: “Our mothers are all junkies.
Our fathers are all drunks.
Golly, Moses, naturally we’re punks.
Gee, Officer Krupke, we’re very upset.
We never had the love that every child ought
to get.
We ain’t no delinquents.
We’re misunderstood.
Deep down inside of us, there is good, there
is good.”
Now, this is sort of the essence of political
Freudianism.
You know, it’s not my fault.
Milton Viederman: Oh, no.
Ben Wattenberg: Or it’s not his fault, or
it’s not anybody’s fault.
Milton Viederman: No, no.
Ben Wattenberg: I say political.
Milton Viederman: I don’t know what that
means.
Fred Goodwin: But it’s a risk.
You’re right, it’s a risk that —
Ben Wattenberg: Let us talk about —
Milton Viederman: That’s not Freud’s view.
Ben Wattenberg: Okay, well, let — it’s
my view of Freud’s view.
Milton Viederman: Let’s get him off the
hook.
Daniel Weinberger: If you’re saying that
environment has an effect, we know environment
has an effect.
And environment has an effect on the biology
of the individual, and it has an effect on
the psychology of the individual.
Fred Goodwin: If you have a handicap and a
wheelchair, you still have to somehow make
your life work even though you have a handicap.
If you have a handicap that might affect your
emotional functioning, you have a responsibility
to get treatment, and you have to be a collaborator
in that treatment.
Having something wrong with you does not absolve
you of human accountability.
An alcoholic — we know that early-onset
alcoholism is very genetic, and people get
it after their first drink often.
But it still takes a courageous act of will
every day for that alcoholic not to drink,
and some do and some don’t.
Ben Wattenberg: But the question that we see
in the policy community all the time now and,
specifically, for example, on that question
of alcoholism, is: If the alcoholism allegedly
isn’t the fault of the person, does the
society owe him a living?
Peter Kramer: You can make the argument that
the biological view makes society more responsible.
Let’s say it’s discovered, which it more
or less has been, that putting people in terrible
social circumstances affects the biology of
their brain.
In that case, you might say society is more
liable than if it merely affects their psychology.
It’s not clear that the Freudian view is
a liberal view.
It may be that the biological view will have
liberal aspects.
Daniel Weinberger: Part of where this gets
so confusing is that we have conflated, in
our thinking about public and social psychiatry
and psychology, illnesses with human variations
in personality and behaviors.
And what Freudian psychiatry has been very
helpful at, Freudian psychology, is understanding
the vagaries of a number of ways that people
react to circumstances.
But it has not been helpful in understanding
the basic underpinnings of disease.
And there are diseases that we call psychiatric
diseases, such as major depression, schizophrenia,
panic disorder, and some of the other obvious
conditions where thinking about psychogenesis
— that is, the causation of the disease
being rooted fundamentally within these constructs
of psychological origin — has not proven
to be the case.
But that’s a very different issue —
Milton Viederman: Absolutely, Dan.
We’re in agreement.
Daniel Weinberger: Right.
It’s a very different issue than understanding
that people come by their personalities honestly.
The more we have begun to understand the complexities
of genetic information that people inherit
from their ancestors, the more we’ve come
to realize that people inherit predispositions
to react to their environment in certain ways.
And we’re increasingly becoming — having
the wherewithal to appreciate that some people
may cruise through environments for reasons
having to do with their biology that for other
people, because of their biology, are devastating.
Milton Viederman: It seems to me what you’re
doing is that you’re mixing frames of reference.
There is a question of moral judgment and
responsibility.
This is what Fred was talking about.
That is separate from motivational systems
and dynamics.
If you are motivated to kill someone because
you want to kill your father, should you therefore
be excused from responsibility for that crime?
No one would argue that the moral issues and
those values are separate issues.
Fred Goodwin: Go back to your antisocial kid.
They used to say that crime was due to poverty.
In fact, the great majority of poor people
don’t commit crime.
It’s stigmatizing the poor to make it into
poverty.
In fact, if you look at what predicts it,
about 80 percent of all the youth violent
crime is 7 percent of the youth — no relationship
to race, no relationship to poverty.
The only environmental thing which correlates
with it is not having a father.
And it happens in the middle class; it happens
in the urban areas.
And that’s social behavior, which I happen
to agree with you, that we have to think carefully
about what is — what are we subsidizing?
Ben Wattenberg: Are we buying out-of-wedlock
birth?
Daniel Weinberger: If you ask the question
about where Freud slipped, I think this gets
closer to where he slipped, and I don’t
know that it was his slip, really.
It was his apostles that slipped.
He made the comment that — after his trip
to America, as I’m sure you know, that America
would embrace his ideas like no other country
on earth.
It wasn’t clear that that was a compliment
on his part.
But nevertheless, probably where it slipped
was in a promise that many people heard — it
may not have been offered, but many people
heard it — that all of society’s ills
could be explained and perhaps mollified in
Freudian terms.
That was a slip; that’s not correct.
Milton Viederman: And I think that’s true.
But I want to go back to something that Dan
said because I think it’ll clarify the discussion
right now.
Ben Wattenberg: We’re running a little out
of time.
Milton Viederman: And that is the issue of
the relationship between biology and environment.
That’s what’s running through our discussion.
We’re all in agreement on this.
We know that kids are born with temperaments.
We can measure them at the beginning.
They’re very different.
We also know that genes don’t simply determine
behavior.
Genes offer a range of possibility for interaction
with the environment.
And so the ultimate product is a mixture of
the two, and the scientific problem is to
tease apart the contributions of both of these
factors.
And Freud would have said that.
Ben Wattenberg: Peter, do you want to come
in —
Peter Kramer: I think we’re a little out
ahead of ourselves in believing that we really
have biological answers to either social or
individual problems, just as we were a ways
ahead of ourselves in terms of psychotherapy,
and that we really have models for biological
solutions more than we have evidence that
our biological models are correct.
Ben Wattenberg: We have just about come to
the end of our time.
Let me ask you a question we like to ask on
this program, and sort of go around the horn,
starting with you, Dr. Goodwin, which is,
just in brief, what do you agree upon and
disagree upon within this group or your field?
Fred Goodwin: My main concern about this discussion
and argument is it may give the impression
that there’s not a consensus.
There is a consensus in psychiatry.
And our knowledge base is as solid as any
other area of medicine.
There’s lots of medicine which is an art;
some of it’s a science.
Our science is increasing.
I think the role of psychotherapy is changing.
It is often looking at its best when it’s
combined with medication.
Treating people with schizophrenia requires
medication.
Depression, severe depression requires medication.
But psychotherapy looks good when it’s helping
medication.
Ben Wattenberg: Dan.
Daniel Weinberger: Well, let me just say what
I agree with — and I don’t know whether
it’s been articulated — is that psychiatry,
which is nothing new for psychiatry, experiences
itself as under siege.
My own sense is that what the field all agrees
on is that mental illness isn’t going away,
it’s a very serious problem, patients have
very serious illnesses, and that we have much
more effective treatments now for these illnesses
than we ever did.
What’s on the horizon, I believe, is we
will understand, at a much more fundamental,
scientific level, the biology of these disorders,
how patients are born with dispositions that
are much more elaborate than just whether
they’re passive or aggressive, but very
subtly defined predispositions at the level
of neurobiology that make them respond to
a variety of environmental circumstances.
This will give us the wherewithal to intervene
more judiciously at the biological and environmental
side.
Ben Wattenberg: In other words, there are
more new drugs coming along.
Daniel Weinberger: Many, many more new drugs.
Ben Wattenberg: All right, Dr. Viederman,
Milton Viederman.
Milton Viederman: Well, I think that we have
a consensus about the essential issues because
we did focus on the issue of environment versus
genetics and constitution.
That is central.
I want to express a concern, really.
And that is that my own experience is that
the power of words is a very central feature
of the role of the doctor and that the current
pressures, understandable, are now pushing
us to minimize that.
And the consumer complaint that they don’t
have relationships with doctors is going to
accelerate in the context of our inability
to engage patients.
Ben Wattenberg: Dr. Peter Kramer, last shot.
Peter Kramer: I think that these are intellectually
tremendously exciting times for psychiatry.
I don’t know that in 10 years or 20 years
our models of what is illness and what is
health will look just the way they look now.
My main concern is that, in that process,
we not lose this wonderful technology, which
I think of as a technology and not just counseling,
of psychotherapy in all its variety.
Ben Wattenberg: Okay.
Thank you, Dr. Kramer, Dr. Goodwin, Dr. Viederman,
and Dr. Weinberger.
And thank you.
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