After six years of twice-weekly
psychotherapy sessions, Eric had plenty of Insight. But his anxiety level had
barely changed. He was still bedeviled by a ceaseless urge to wash his hands and
shameful and repetitive violent thoughts. Out of desperation and against the
wishes of his therapist, he visited my office to discuss the possibility of
medication. "I thought I could understand my way out of my obsessive compulsive
disorder," he recalled recently. "I wanted to be able to do it on my own,
What he did not remember was his
vehement opposition to psychotropic medication on the ground that it was not
natural and would change his brain chemistry. Of course he was right. Like
Eric, many patients and therapists share the view that psychotherapy is
preferable to pharmacotherapy because it is more "natural" and because it
supposedly gets to the root of the patient's problem. They are convinced that
self-understanding will bring relief, whether the problem is anxiety, depression
or obsessional thinking.
Insight is a prerequisite of
happiness, the theory goes, and well-being achieved without the hard work of
psychotherapy is artificial and inauthentic. But new evidence suggests that the
talking cure and psychotropic medication have much more in common than had been
thought. In fact, both produce surprisingly similar changes in the brain.
disorder. It hobbles patients with unwanted
often violent or sexual,
that play in the mind like a broken record. Owing to the sometimes lurid nature
of the thoughts, the treatment mainstay had for years been
oriented therapy to unlock the sexual and aggressive conflicts presumed to
underlie the symptoms. There was just one problem. That form of
rarely, if ever, worked for those patients, a point now widely accepted by most
But two seemingly different
treatments can be highly effective: a form of talk therapy called
cognitive-behavior therapy and a class of anti-depressants called selective
serotonin reuptake inhibitor antidepressants, or S.S.R.I.'s, drugs like Prozac
and Zoloft. It is well known that patients with the disorder have altered
serotonin function compared with normal controls.
Brain imaging that uses
or positron emission topography, has shown that the disorder is associated with
functional hyperactivity of the caudate nucleus; a structure buried beneath the
cerebral cortex. Some researchers hypothesize that the caudate is part of a subcortical circuit that acts as a kind of filter, sifting out extraneous
thoughts and impulses.
In obsessive-compulsive disorder,
they theorize, the subcortical filter malfunctions, allowing the unwanted
thoughts to reach the cortex and then on to consciousness.
In a study by Dr. Lewis Baxter at
the U.C.L.A. School of Medicine, patients with the disorder who responded to
either a re-uptake inhibitor like Prozac or cognitive behavior therapy over 10
weeks showed virtually the same changes in their brains, decreases in the
activities of the caudate nuclei and, thus, changes toward normal function. When
patients improved, the changes in their brains, as shown in the PET
scans, looked the same - regardless of whether they had received antidepressants
An S.S.R.I. works, in part, by enhancing the
neurotransmitter serotonin, whose activity is often abnormal in people with obsessive-compulsive disorder (OCD) and depression. Cognitive behavior therapy
focuses on changing distorted patterns of thinking.
intriguing finding from the PET scans is not limited to OCD. Two studies of
patients with depression, reported last year in The Archives of General
Psychiatry, compared the effects of interpersonal psychotherapy with an
antidepressant on brain function, as observed in PET scans. In those studies,
the depressed patients received interpersonal therapy, a short-term talk
treatment that focuses on the effects of social relationships and major life
events on mood.
study, a 12-week trial that compared an S.S.R.I., Paxil, to interpersonal
psychotherapy, Dr. Arthur Brody, also at U.C.L.A., found that depressed patients
who responded to either treatment had nearly identical changes in their brain
function, a decrease in the abnormally high activity seen in the prefrontal
cortex before treatment. In the second study, Dr. Stephen D. Martin at the
research unit of Cherry Knowle Hospital in Sunderland, England, reported that
six weeks of Effexor, an antidepressant that enhances both serotonin and
norepinephrine, and interpersonal therapy produced similar effects in those
depressed subjects who responded either to medicine or to psychotherapy. Each
had shown an Increase in the activity of the basal ganglia, a subcortical brain
Although the observed changes with psychotherapy and antidepressant were similar
in that study, they were not identical. Subjects with interpersonal therapy but
not Effexor also had activation of a brain area called the cingulate gyrus,
which responds to serotonin in the brain and has a role in regulating mood.
studies show that pharmacotherapy and psychotherapy can produce remarkably
similar effects on functional brain activity. But does that mean that
antidepressants and psychotherapy are really equivalent?
In a word, no.
Psychotherapy alone has so far
been largely ineffective for diseases like schizophrenia, where there is strong
evidence of structural, as well as functional, brain abnormalities. So it seems
that if the brain is severely disordered, then talk therapy cannot alter it.
But it is clear that talk therapy
can alter brain function. The reason may come from the elegant work of a Nobel Prize-winning psychiatrist and neurobiologist Dr. Eric Kandel. Studying the
simple and well-mapped nervous system of a sea slug, Aplysia, Dr. Kandel showed
that learning leads to the production of new proteins and, in turn, to the
remodeling of neurons. Sea slugs exposed to the controlled-learning condition
that produced long-term memory ended up with double the number of neuronal
connections as the untrained animals. In essence, Dr. Kandel has proved that
learning involves the creation of new neuronal connections.
The clear implication for humans is that
learning literally changes the structure and function of the brain.
Now it may seem a big leap from a
snail to a human. But if psychotherapy is thought of as a form of learning, then
when therapists talk to patients, they cause them to learn, perhaps changing
their brain function and, perhaps, for the long run.
In the end, Eric chose cognitive
behavior therapy and improved drastically. Through exposure to those situations
that he feared like messy dirty places, he became desensitized to them and lost
his compulsion to wash. Had he chosen an antidepressant, chances are that he
would also have improved.
If psychotherapy produces nearly
the same brain changes as pharmacotherapy, then the boundary between mind and brain
is purely artificial - even unnatural.
The reprint above adds
credibility to the idea that
when "talk therapy" fosters
learning in a client, it produces shifts in neural connections and function
similar to popular psychotropic drugs.
36 years' clinical
experience and research, I propose that...
and kids are psychologically
from early-childhood abandonment, neglect, and abuse ("trauma"),
these wounds +
toxic social environments cause most personality, mood, and social
problems like Bipolar, Borderline, and ;Obsessive-Compulsive
"disorders." That is, most "psychiatric disorders' are symptoms
of these underlying wounds + personal unawareness; and...
these wounds can be
significantly reduced by
internal Family Systems (IFS)
therapy.- i.e. by talking, rather than medicating.
prescribed psychotropic drugs change brain chemistry, but won't produce the
learning changes (new neuronal connections) that skilled psychotherapy
can. In other words, drugs may regulate mood and behavioral symptoms,
improve the personal and
environmental conditions that cause the symptoms in an adult or
related problem is the obsolete idea that nonorganic psychological "disorders"
are mental illnesses which are best treated with medicine. This is
the traditional "medical ,model" of psychiatry. The emerging belief since 1950
is that most psychological and social
problems are caused by family dysfunction, and are best reduced via
skilled personal and family (talk) therapy, not medication.
perspective, see this article and
these related research reports.