Orne, M. T. The search for specific treatments in psychiatry. In J. P. Brady, J. Mendels, M. T. Orne, & W. Rieger (Eds.), Psychiatry: Areas of promise and advancement: A bicentennial volume of the University of Pennsylvania. New York: Spectrum, 1977. Pp.237-247.
MARTIN T. ORNE
A large number of topics have been covered today, reflecting not only the eclectic interests of our department but even more the broad variety of approaches that characterize psychiatry itself. As one reviews what we have heard, one may well ask what is the science underlying psychiatry -- biochemistry, neurobiology, experimental or social psychology, the psychodynamic study of the individual, the systematic exploration of behavior, or, if we extend our interests to aspects of psychiatry not directly touched upon today but equally relevant to some colleagues, sociology, group dynamics, or other aspects of the social sciences? As one considers these questions, other closely related issues come to mind. For example, should psychiatry continue to be viewed as a branch of medicine, or might it more appropriately be seen as a form of applied social science? To address these questions in any systematic fashion is not possible in a brief paper (though hardly easier in a longer one); I would instead like to suggest why these apparently divergent points of view do indeed fit into one
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department, that despite their apparently disparate nature they are alike in crucial ways, and that this very similarity is the essential core of academic psychiatry now and in the future.
It has long been fashionable to assert that medicine in general and psychiatry in particular are as old as man: That from time immemorial healers have recognized the importance of psychological factors in disease, that the will to live has long been acknowledged as a crucial component of the patient's ability to survive debilitating illness, and that great physicians since antiquity have stressed the importance of the patient's confidence in his physician and his faith in his eventual cure.
Modern observers, while crediting both ancient and primitive medicine with insight into the importance of psychological factors, also emphasize that the remedies employed were rarely effective and that the bulk of the improvement is best understood as the individual's response to nonspecific factors in the treatment process. This phenomenon, today subsumed under the concept of the placebo effect, is conceptualized as the major therapeutic factor of early medicine. Frank 1 brings together an impressive set of observations to demonstrate such nonspecific factors as the core element of all psychotherapeutic healing. Despite the scholarly and effective way in which this point of view is documented, it has not met with much enthusiasm or acceptance in the field. Perhaps if we consider the development of modern psychiatry it will become clear why the emphasis on the importance of nonspecific factors, regardless of its validity, is unlikely to be accepted as it relates to one's own discipline.
The core of this issue was already evident in the controversies surrounding the work of Franz Anton Mesmer shortly before the French Revolution. It seems appropriate to a Bicentennial meeting to recall that the distinguished group of scientists, commissioned by the King of France to investigate the claims of Mesmer and his students, was headed by the founder of our university -- and of much else in Philadelphia -- Benjamin Franklin. In the negative report which dismissed these claims, the commissioners acknowledged that many individuals obtained relief from mesmeric treatment, but since the evidence for the existence of a magnetic fluid was wanting, such cures were best understood as the product of mere imagination. Note that there was no controversy concerning the fact that the individuals obtained relief. The issue was joined on the question of the mechanism by which this relief was obtained. Both the mesmerists and the commissioners focused almost exclusively on the question of whether there was a magnetic force.
When the commission decided there was no animal magnetism, it was prepared to dismiss the matter even though its members recognized that many individuals had been helped by what we would today call nonspecific factors in treatment. It is of interest that Mesmer himself was not only implicitly aware of the effect of suggestion but recognized that psychological factors could be of
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great importance; however, he refused to concern himself with such matters, preferring to deal with "truly scientific" issues such as the effect of the stars on man's destiny and animal magnetism.
The modern reader finds it as hard to understand how the mesmerists could fail to recognize the profound nonspecific factors in their treatment as how their detractors were able to ignore the evidence that many individuals were significantly aided by the mesmerists' procedures. In fact, it has always been more important to scientific medicine that we understand why someone is sick and the mechanisms by which cure is to be effected than whether the treatment works. A good clinician is of course prepared to advise his patients to do something which he has empirically found to be effective, but some rational explanation for the treatment is essential if it is to be accepted by the medical establishment. Far from failing to recognize nonspecific factors, the physician of antiquity realized that a broad range of psychological factors could exert salutary influences on the patient's illness and that all kinds of nonprofessional procedures had their advocates. The quack of today has his counterpart in antiquity; similarly, the Christian Scientist of today has his counterpart in both primitive and ancient religions, and such nonmedical healers had their share of cures. What distinguishes the physician from the priest or the quack is neither his good intentions nor even his effectiveness but rather his efforts to understand rationally both the affliction of his patient and the procedures with which he hopes to bring relief.
Today, with the development of a strikingly effective science of medicine, it is hard for us to remain aware how recent a development this is. Less than a hundred years ago homeopathy presented a formidable challenge to the pharmacological therapies of the day -- though the latter were based on scientific principles which were not only accepted at that time but have in good part remained the basis for the effective pharmacology of today. It is inconceivable to the competent physician today to purposively prescribe homeopathic dosages of an antibiotic or any of the other of the specific therapeutic agents. Yet there was a time not long ago when pharmacology as an applied science was sufficiently ineffective, and the drugs used were sufficiently toxic, that the results of general supportive measures, good hygiene, and essentially no medication were as good or better than those attained by scientific medicine. I emphasize this point because the successful application of scientific principles to many parts of medicine has led us to believe inappropriately that scientific medicine is of necessity the most effective medicine. While in the long run this will be true, at any given point the outstanding clinician will greatly transcend the results obtained by the strict application of scientific principles. It is one thing to recognize ECT is effective in relieving certain depressed states -- it is another to understand why and how.
Certainly in psychiatry, given the profound consequences of nonspecific ef-
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fects, outcome measures can only be used as one of a number of related criteria for the development of a rational treatment. Incidentally, it is well to remember that scientific medicine has not succeeded in alleviating all of man's ailments as effectively as is the case with, for example, bacterial infections. Thus I had always felt troubled by the very limited amount of scientific data upon which to base treatment until one day I sought relief for low back pain. It did not take long for me to come to the realization that, contrary to my previous doubts, psychiatry was indeed an exact science!
Modern psychiatry has many roots. In this context, however, I would like to focus on two such roots in particular. Freud, who came to psychiatry by way of neurology and had studied extensively with both Charcot and Bernheim, initially used hypnotic procedures in an effort to explore the specific trauma which he believed to be causally related to hysteria. Though he used hypnosis with great success in his early cases, he abandoned the procedure in favor of free association. While undoubtedly this decision was multidetermined, it is interesting to note his profound awareness of suggestive effects and the powerful role they may play in the patient's recovery. Though he had used hypnosis specifically to recover forgotten material, he must nonetheless have been intuitively aware that by actively rejecting hypnotism he could clearly dissociate his procedure from what he saw as the nonspecific treatment of the hypnotists.
He asserted that he had developed a specific treatment for hysteria -- free association -- leading to the recall and subsequent interpretation of repressed traumas which, when brought into conscious awareness, would lose the power to disturb the individual, much as an abscess when drained becomes harmless. Freud did vastly more than to propose a specific treatment for neuroses. In effect, he sought to develop a general theory of man. The main psychodynamic formulations are too well known to require review here. It is of interest, however, that the basic evidence for the validity of his views was not so much their inherent plausibility but rather the claim that the application of these theories in psychotherapeutic treatment led to the permanent cure of troubled individuals.
Freud's theories exerted a profound effect on the entire intellectual community and his ideas became widely known and accepted, particularly in those countries and in those segments of society where the Protestant ethic was the norm. There they led to the acceptance of psychological causality much in the way Marx's works had led to the acceptance of economic causality and the Age of Reason had earlier led to the recognition of physical causality.
In the United States especially, psychodynamic concepts not only had a direct impact on psychiatry, but they also caused the psychiatrist to be viewed as being able to contribute to an understanding of all aspects of human existence -- as a kind of social philosopher. Individual psychiatrists were willing, even eager, to fulfill the role in which they were cast, and the range of phenomena that was defined as within the purview of psychiatry was progressively enlarged.
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Some of the consequences of this development did not become apparent until fairly recently and are issues to which we will return later.
The other antecedent of modern psychiatry was by way of the alienist and the mental hospital superintendent. Thus Kraepelin had sought to bring order into the chaos of mental illness by presenting a classification of mental diseases based upon careful clinical descriptions. By providing for some form of reasonable classification, one of the major requirements for scientific consideration was met, and while the virtue of psychiatric classification is currently under attack in some quarters, the only real issues are the appropriateness and the utility of particular classifications (and possibly the deleterious consequences of misused classification). Certainly progress toward an understanding of psychiatric problems presupposes rational classification.
It was Wagner von Jauregg's Nobel prize-winning observation that fever therapy brought about a cure in cases of syphilitic insanity that served to document the power of Kraepelinian classification and led to an era of therapeutic optimism which, incidentally, extended to the schizophrenias, for which no specific treatment had been evolved. What mattered is that a specific treatment -- in this case of a physical condition which led to a clearly defined form of previously irreversible psychosis -- had been discovered. It became reasonable to suppose that other forms of major psychoses might have equally identifiable physical causes which could ultimately be relieved by specific therapies. This point of view, basic to biological psychiatry, ultimately has led not only to the identification of some other specific physically caused psychiatric problems such as porphyria but also to effective physical treatments of many depressions and mania. While controversy persists concerning the relative significance of psychological and environmental as opposed to biochemical and biological factors in psychiatry, both psychodynamically oriented and biologically oriented psychiatrists emphasize the specific nature of their own particular treatment. However, the biological psychiatrist is quick to emphasize the nonspecific factors associated with dynamic therapies, while dynamic therapists point to similar problems in biological psychiatry.
In recent years psychiatry has begun to be influenced by a point of view that originated from the laboratory rather than the clinic. Taking its roots partly in Pavlov's studies of classical conditioning and more firmly in the work of American psychologists based on the perspectives of Watson, Thorndike, and Skinner, an effort is being made to systematically apply principles of learning to the modification of behavior in man. Not only does this point of view try to avoid the complexities of psychodynamic formulations, but it prefers to avoid any concern with what goes on in an individual's private world. It is argued that since we can never know what someone really thinks, it is best to avoid unnecessary inference about his thoughts and limit ourselves to what he says or what he does -- i.e., observable events.
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Rather than focusing on the patient's ideation in order to help him understand and thus alter undesirable behavior, behavior therapy focuses on the systematic study of the environmental contingencies which cause a behavior to be increased or decreased in its frequency. Rather than seeing himself as treating a mental disorder which we call a phobia, the behavior therapist would see himself as seeking to modify a series of behaviors that the patient finds undesirable. He looks to systematic laboratory research with both animals and man as the scientific basis for his efforts and tries to adapt the scientific model to the realities of the clinic. A careful behavioral history is developed, with a detailed assessment of ongoing behavior. Most important, specific aspects of the behavior to be modified are used as criterion measures of the treatment's effectiveness.
In well-designed behavioral studies, predictions are made that specific changes in environmental contingencies will bring about specified modifications in the target behavior. Some behavior therapists feel it is essential not only to show that the predicted changes occur -- as, for example allowing an agoraphobic to move further and further into an open space -- but also that there will be a recurrence of symptoms if the original environmental contingencies are reinstated.
Based on the kind of data outlined above, behavior therapists have emphasized the specific therapeutic effects of their treatment as opposed to nonspecific changes seen with psychotherapy (e.g., Sloane et al). 2 While there is no doubt that there are important conceptual differences between the behavioral and the psychodynamic therapists, as the scope of behavior therapy has enlarged it has become increasingly necessary to deal with more molar units of behavior. By the same token, a number of psychodynamic therapists have sought to operationalize many of the concepts which had not previously been spelled out in observable terms. As I have argued elsewhere, 3 modern psychodynamic viewpoints and the more recent developments in behavior therapy have come to approximate each other far more than is generally realized. Thus, behavior therapists now use more molar units of analysis while psychodynamic therapists have begun to better operationalize not only their concepts but also outcome measures. Indeed, therapists of both persuasions have much to gain by closer contact with one another and by learning to distinguish between the many semantic barriers and the far fewer substantive areas of disagreement.
Modem psychiatry cannot afford to exclude the biological approach, the insights derived from psychodynamic studies, or the understanding that can be gained from behavioral analyses. Each of these approaches has laid claim to having the specific treatments of psychiatry, each with some legitimacy. By the same token, none has an understanding so profound and none is able to do without the nonspecific components of treatment sufficiently easily to fully preempt the other points of view. Regardless of some important conceptual differences, each of these positions shares a commitment to the development of scientific psychiatry. Though we may disagree about the approach, we share the belief that our
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future must lie in the systematic understanding of specific factors responsible for specific effects.
Such a statement sounds almost like a platitude, and certainly a few years ago it would have been banal. Unfortunately, our department's shared conviction that psychiatry must remain dedicated to scientific principles, that its goal must be the rational understanding of irrational processes, and that systematic research will continue to play a crucial role in the development of our discipline is not shared by all mental health professionals. Furthermore, there is considerable controversy today about the role of psychiatry in modern society, the kinds of skills that should be taught as part of psychiatric training, and for that matter, even whether psychiatry should continue to be considered a part of medicine.
Such questions do not generally tend to concern biological psychiatry. The need for a broad medical and biological background is obvious, and the kinds of skills which medical school teaches are clearly relevant to the biological aspects of the psychiatrist's activity. The conceptual model is based on traditional medical thinking, and the therapies fall within the mold of medical practice. Biological psychiatry tends to address problems of immediate medical or biological relevance rather than broader social issues. At first blush one would think it would be immune from some of the pressures more obvious in other parts of psychiatry. For better or for worse, however, the treatments of biological psychiatry are subject to attack, partly from within their own discipline and even more from without. Whether one wishes to consider the appropriateness of electroconvulsive therapy, the use of analeptic drugs with hyperactive children, or even the mere contemplation of studying the possible relationship of genetic factors to violence, the field finds itself embroiled in complex ethical and medico-legal questions. All too often ethical and moral considerations are inappropriately juxtaposed to the search for scientific understanding, totally ignoring the fact that no sensible evaluation of the ethical problems is possible without adequate knowledge of the facts.
Behavior therapists similarly have tended to focus their interest on the treatment of very specific problems and have not for the most part expressed themselves on broader social issues. Behavior therapy has nonetheless become the bête noire of the liberal point of view. Stimulated, no doubt, by visions of Huxley and Orwell, behavior therapy is credited by some with a degree of proficiency that exceeds the fondest fantasies of its greatest enthusiast; it is also criticized for dehumanizing man as well as being a potential tool in the hands of an authoritarian state. Educating the layman -- and our own profession -- will in the final analysis be the most effective answer to such attacks. Particularly, a greater awareness of the modern behaviorist's focus on self-management and self-control, where an individual learns to utilize the tool of behavior therapy to accomplish goals he himself must define, will go far toward clarifying some of the more obvious misconceptions. Except for insisting on the vocabulary of
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learning theory and the commitment to conceptualize motivation without reference to the self, behavior therapists have done little to justify the unfortunate manner in which some segments of the public perceive this approach.
The dynamic approach, which has been the mainstream of American psychiatry since World War II, had been responsible for the remarkable acceptance of psychiatry as a treatment and, implicitly, as a social philosophy as well. This very success is perhaps most responsible for some of the difficulties we face today. Psychological motivation became increasingly widely accepted, not only in serious novels but in plays, films, television dramas, and even in the pulp magazines. Psychiatrists tended to be seen as appropriate commentators on a remarkably broad range of topics ranging from how to raise children to how to avoid wars, from what constitutes mental health to what constitutes a healthy politician. Psychiatrists as individuals tended to be all too willing to accept the role of "expert on everything concerning man" thrust upon them by a public seeking guidance, having lost faith in its religious leaders. With increasing acceptance of psychiatry, there was an increasing demand for psychotherapeutic services, a demand difficult to satisfy by a limited number of psychiatrists, nor was it possible to rapidly increase the available number. Not surprisingly, other disciplines, most notably social work and clinical psychology, provided therapeutic service. During this period remarkably little effort was made to document the effectiveness of psychotherapeutic procedures. Somehow it was assumed that the techniques worked, and practically all effort went into descriptive technical writing and the careful training of a select number of therapists.
The emphasis on the tremendous need for services -- and the tacit assumption that effective treatment for a wide range of psychological difficulties was available -- ultimately led to the creation of mental health centers. While powerful forces in psychiatry had sought to assert medicine's monopoly on psychotherapy, the degree to which the demand for service exceeded that which could be satisfied by the limited supply of psychiatrists ultimately doomed the effort to failure. Not only had psychiatry lost its battle to prevent the private practice of psychiatry by other disciplines, but the staffing needs of mental health centers greatly accelerated the trend to nonmedical therapists -- indeed, to the deprofessionalization of psychotherapy. The same studies which had shown that the orientation of the psychotherapist and the amount of training were not necessarily crucial factors, and which had earlier been ignored by the field, now served as justification for the indigenous worker. When questions were raised, it was generally argued that the need for psychotherapeutic services was so great that we could not waste the time to prove which procedures worked or even whether psychotherapy made any difference.
Psychiatry, which had originally been responsible for the mental health act, had increasing difficulty in maintaining a leadership role; ironically, because psychiatry had created an excessive demand for its services, communities came to
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feel that psychiatric services were not uniquely necessary. As community psychiatry evolved, the notion of the psychiatrist's role evolved with it. It made obvious sense to consider the prevention of mental illness within the purview of the psychiatrist's activity. It was then argued that social problems such as the war in Vietnam or racial discrimination were causally related to mental illness. It followed that some colleagues would see it as appropriate to their role as psychiatrists to address these problems as their primary responsibility. While I do not doubt either the importance of such problems or the legitimacy of addressing them as a citizen, they have never been shown to be causally related to mental illness. Nonetheless, some colleagues argued not only that this was the case but that the urgency to find a remedy to these social problems was so great that we could not dilute our efforts by documenting the relationship to mental illness.
While the psychiatrist's role became increasingly diffuse within the mental health movement, the area of psychotherapy became increasingly confused. New therapies began to proliferate. Only some of these, however, have been oriented toward the treatment of neuroses; an increasing number of therapeutic efforts are being presented as means of facilitating an individual's development and growth. While psychotherapy as such, and particularly psychoanalysis, had long been recognized as a means of facilitating individuation, its basic legitimacy continued to stem from its role as a medical treatment.
The new group of quasi-therapies did not seek such legitimacy. Techniques developed from the encounter group movement and from Gestalt therapy which focus primarily on the virtue of expressing emotion (with little concern for insight in the traditional sense) have proliferated. These procedures extending the rationale of Rogers' nondirective psychotherapy explicitly reject the therapist's responsibility for the patient's welfare. Ironically, these new therapies present themselves as consumer-oriented by giving individuals what they seek. One does not need to be ill or troubled to join a T-group; one might do so because one is jaded or bored, because one is curious, or for whatever other private reason. The group leader refuses to take responsibility for the welfare of the individual members of the group. If the insight that is gained is helpful or pleasant or interesting -- all to the good; if it is intolerable and the individual becomes overtly ill, it is unfortunate -- caveat emptor. Some even argue it would have happened anyway and maybe it was good to have the breakdown.
We could go on to look at some of the strains within modern psychiatry and its changing role within contemporary society. There is no doubt that society as a whole is in a state of flux. Under these conditions, any group of individuals who set themselves up as arbiters of health will of necessity be controversial. It seems to me that psychiatrists as a group have hardly ever concerned themselves systematically with health. We tend to be experts in matters concerning individuals who are troubled or who trouble others, and for one reason or another come to
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our attention. From such a data base we can hardly hope to solve the complex problems of modern society. Obviously we must concern ourselves with knowing where we stand, what we believe, and why we believe it, both as thinking members of our society and equally so as psychiatrists. However, it behooves us to recognize that psychiatry is not a combination of all the social sciences, that the discipline of sociology has concerned itself far more systematically than we ever have with the systematic study of social groups, that the discipline of anthropology has concerned itself far more effectively than we have with the systematic study of relatively small, isolated non-Western groups, and that the discipline of psychology has long concerned itself with systematically evolving laws of human thinking and behavior. It is neither necessary nor desirable that we try to reinvent the wheel.
Clearly psychiatry will remain a field in flux. I would propose, however, that a continuing and hopefully considerably closer tie to medicine will in the final analysis be the most pragmatic approach to our search for identity. If one accepts the notion that there is no truly relevant training for a psychotherapist, medicine does provide the experience of dealing with life-and-death matters, often helpful in the therapeutic enterprise. Further, it prevents the need for the psychiatrist to limit himself to psychotherapy, particularly crucial with the development of psychopharmacology. I find it difficult to believe that it is desirable to create a group of therapists who do not have access to medication when appropriate, and while having completed medical school by no means guarantees the individual's ability to understand current work on psychobiology, it does tend to give him a fighting chance. As important as any of these issues, however, is the fact that medicine has provided useful and traditional guidelines to appropriate ethical behavior to deal with the difficult and complex social problems encountered in psychiatric practice. In a changing world a humanistic tradition that has survived changing mores and changing technology should not casually be discarded.
If from this perspective we reflect upon the substantive contributions in this volume, the points of view that we share become clearer. All of us share the conviction that we work within the framework of medical science. Whether we see ourselves primarily as clinicians or primarily as scientists, we believe that in the final analysis scientific understanding will lead to better clinical practice, and in the meanwhile we also need to practice the art of medicine. The search for specific treatment need not and should not prevent us from using techniques we have found empirically useful but as yet are unable to document in a satisfactory manner. What distinguishes the academic psychiatrist from others should not be the lack of respect for clinical skills nor an unwillingness to recognize the merits of clinical lore, and certainly not a personal lack of clinical skills. It is the belief that knowledge is better than opinion and that there are generally accepted rules whereby one can tell the difference. It is the conviction that a field should not
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be judged by the effectiveness of its great clinicians but rather by the effectiveness of the mediocre practitioner. It is the view that the future of psychiatry does not lie in a progressively sloppier application of unproven and untested ideas to ever larger numbers of people, nor in the promulgation of personal points of view in the guise of scientific wisdom. Rather, the task of academic psychiatry is the careful delineation of what is known from what is not known, using whatever procedures and techniques seem best to further our understanding of basic psychobiological processes. Such a systematic effort will in our view ultimately increase our effectiveness in treating the clinical problems encountered in practice.
References
1. Frank JD: Persuasion and Healing: A Comparative Study of Psychotherapy. Baltimore, The Johns Hopkins Press, 1961.
2. Sloane RB, Staples FR, Cristol AH, et al.: Psychotherapy versus Behavior Therapy. Cambridge, Harvard University Press, 1975.
3. Orne MT: Psychotherapy in contemporary America: its development and context,
in Handbook of Psychiatry, Vol. 5. Edited by Arieti S, Freedman DX, Dyrud JE,
New York, Basic Books, 1975, Treatment, pp. 3-33.