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The Brain vs. the Mind: Has Freud Slipped?

Think Tank Transcripts:Psychiatry versus Drugs

ANNOUNCER: 'Think Tank' has been made possible by Amgen, arecipient of the Presidential National Medal of Technology. Amgen,bringing better, healthier lives to people worldwide throughbiotechnology.

Additional funding is provided by the John M. Olin Foundation, theRandolph Foundation, and the Lynde and Harry Bradley Foundation.

MR. WATTENBERG: Hello, I'm Ben Wattenberg. Was Sigmund Freudright? Is most mental illness rooted in childhood trauma, oftensexual trauma? That Freudian view has shaped much of the modernworld. Now a new school of scientists say many disorders of the mindare really physical diseases of the brain and can often be treatedwith new drugs.

Joining us to sort through the conflict and the consensus are fournoted psychiatrists: Peter Kramer, associate professor of psychiatryat Brown University and author of the best-selling book, 'Listeningto Prozac'; Fred Goodwin, former director of the National Institutefor Mental Health and now director of the Center on Neuroscience,Behavior and Society at George Washington University; DanielWeinberger, chief of the National Institute of Mental Health'sClinical Brain Disorders Branch and co-author of 'The Neurology ofSchizophrenia'; and Milton Viederman, professor of clinicalpsychiatry at Cornell Medical College, and an attending psychiatristat the New York Hospital.

The topic before this house: The brain versus the mind -- hasFreud slipped? This week on 'Think Tank.'

What do you think of when you hear the word 'psychiatry'? Does itconjure up an image of a taciturn therapist listening to the recalledchildhood nightmares of his or her patient?

Well, times have changed. Much of the treatment of mental illnesshas gone high tech. Proponents of the so-called new biology say thatdisorders like depression, schizophrenia and manic compulsivebehavior are often caused by physical or chemical defects in thebrain. The cure is not years of talk therapy, but treatment with newdrugs.

For example, the drug Prozac relieves depression by increasing thechemical serotonin in the brain. Doctors have prescribed Prozac tomore than 11 million people worldwide. Defenders of traditional talktherapy praise the new scientific advances, but stress thatdoctor-patient communication is still crucial. They worry that toomany doctors will rush to prescribe potent medicines without firsttrying to talk through their patients' problems.

Gentlemen, doctors, first question, starting with you, Dr. FredGoodwin. Is Freud slipping?

MR. GOODWIN: I think the image of Freud in the Woody Allen senseis slipping, and appropriately so. Psychotherapy is not slipping.Actually, in a way, the evolution of drugs has been a gift topsychotherapy because it's taken away some of the things thatpsychotherapy didn't do so well in -- schizophrenia, manic depressiveillness.

What you see today is psychotherapy being used more focused, morebriefly, with the medically ill and with the severely ill psychiatricpatients, but in combination, not instead of medications.

MR. WATTENBERG: Dr. Dan Weinberger.

MR. WEINBERGER: My sense is that rather than slipping, things arechanging. The field is changing. All fields of medicine are changing.We have made remarkable strides in understanding the human body, howit functions and how it malfunctions. This has happened inpsychiatry. We have a much more in-depth sense of mental function andmental illness than we had in Freud's time. And I think to ourbenefit, as a result of these kinds of changes, the field isevolving.

The question I think that we are asking as a field is, what needsto evolve most rapidly, and where does most of the emphasis have tobe placed?

MR. WATTENBERG: Okay. Dr. Milton Viederman.

MR. VIEDERMAN: The question really poses a false dichotomy. Thatis to say, the dichotomy between psychotherapy and biologicalpsychiatry. Freud himself believed ultimately that mental illnesscould be reduced to biological factors. Moreover, he was not at all abeliever in the idea that environmental factors uniquely influencedevelopment. He felt constitutional factors were very important. So,in essence, Freud himself was a participant in the current evolutionof psychiatry.

MR. WATTENBERG: All right. Dr. Kramer, Peter Kramer.

MR. KRAMER: I think the scope of biological interventions hasexpanded so that now it is possible to do things biologically, evenfor the very minor mental disorders and for nearly normal people,maybe for normal people. And that makes for very excitingpsychotherapy. That is, you can sometimes allow patients to altertheir perspective through the use of medicine and integrate thatalteration into the psychotherapy.

So, based on intellectual ferment alone, these ought to be veryexciting days for psychotherapy. I think insurance companies andexternal pressures on the field may lead to a different outcome.

MR. WATTENBERG: Well, now, are you sort of all closing ranks, asprofessionals like to do? I mean, you had a system of treatment whereat times people went four or five times a week for an almost infinitenumber of years psychoanalysis.

And now you have, for some of those patients at least, somebodywriting out a prescription once. Now, that is not just at the edgesor shades of gray.

MR. VIEDERMAN: Well, I think that the caricature of psychoanalysisas an infinitely long process four or five times a week, without adefined end, is really a caricature.

Psychoanalysis itself has changed enormously in recent times, bothin theory and in practice. Currently, the very idea of seeing peoplein psychoanalysis, what we call psychoanalysis, two or three times aweek for shorter periods of time, is becoming current, for one thing.

Moreover, psychoanalysis is not in opposition to the biologicalpsychiatry, in that drugs often facilitate, as Peter indicated, whathappens in analysis.

MR. WEINBERGER: I think the bigger question that we're being askedis that the tradition of psychiatry was a tradition that emerged fromcertain principles of psychological organization. And this field isevolving, like all fields of medicine and treatment in most fields ofmedicine. At the time that psychoanalysis began, it was a therapythat grew out of the efforts of certain people to understand theemergence of physical symptoms in people that didn't have physicalillness, and there were no other treatments at that time.Psychoanalysis was the best treatment on the street in Vienna at thattime for people who had paralyses that didn't explain themselves inphysical terms.

We are in a state of transition now, where there is question beingraised within the field of what are the best treatments? I think itwould be ill advised and bad practice as a physician to treat apatient with a medical illness, such as depression might turn out tobe, primarily -- we don't categorically know that yet, but a lot ofdata suggests it is. If it turns out that that's a medical conditionthat requires a medical treatment, we should counsel that patient andget to know that patient and help fashion the patient's after-care aspositively as we can, the same way a good internist would do with apatient with hypertension and diabetes and everything else, whichstudies also show --

MR. GOODWIN: Actually, the paradox now is that today, the mostdramatic evidence for the efficacy of psychotherapy are in themedically ill, you know, the enormous rates of change in recurrenceof cancer with psychotherapy, and in patients who have realbiological illnesses, like schizophrenia and manic depression. Youcan produce three- to four-fold differences, but not with traditionallong-term analysis, but with social skill training, withpsycho-education of the family. It's psychotherapy, but it's of abroader, more practical, more here-and-now focus than it would havebeen in the past.

MR. VIEDERMAN: Fred, I want to emphasize an issue here, and thenI'll come back to that problem. And the issue has to do withspecificity. The problem -- one of the things that psychoanalytictheory can contribute is an understanding, a structure forapproaching the patient, a model for thinking about that.

And what I would emphasize is this, that utilizing that model,specific treatments can be developed.

MR. WATTENBERG: How do you come in -- MR. KRAMER: Well, a couplethings. One is I -- just this past week, I was teaching the residentsabout outcome studies. And I think that the outcome studies areterrifically hard to do. And one thing to be said about them is maybethey shouldn't have been done, given the level of technology that wasapplied to them. But the broad summary --

MR. WATTENBERG: Yeah, but there's a conflict here. You aredoctors, and you know, most doctors or most pharmaceutical companieshave to -- I mean, treatment has to be certified, in thepharmaceutical case, by the Food and Drug Administration. There'speer review among doctors for certain kinds of surgery, and it's gotto show that it helps. And you are saying you don't have to show thatit helps.

MR. KRAMER: Well, I'm not -- of course one should show that ithelps, 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 aproblem that needs to be answered. I mean, we -- there are a lot ofthings we don't know in medicine, you know, outside the area ofdrugs. We don't know whether prenatal care is really all that helpfulfor -- to obstetrical outcome. We think it is, but, you know, thestudies really are hard to do.

MR. WEINBERGER: There's research showing that it's extremelyvaluable.

MR. KRAMER: Well, there's some that show that it is, some thatshow that it isn't.

MR. GOODWIN: Ben said psychotherapy in general. We need to stepback a minute, because we had to review this whole thing at NIMH forthe Clinton health task force.

MR. WATTENBERG: You were the director of the --

MR. GOODWIN: Yes.

MR. WATTENBERG: NIMH is the National Institutes of Mental Health.

MR. GOODWIN: The main government research organization. I had tobury myself in this literature for a year and a half in order to beable to present this. The things we found were straightforward. Oneis that the diagnosis of mental disorders is as good or better thanmost medical disorders, that is, the ability to agree. We can agreebetter about diagnosing depression than doctors can agree about amammogram indicating cancer.

The second thing is, in the five major mental illnesses, thetreatments were as effective as they are in areas like cardiovascularillness, but most of those treatments involved combinations ofmedication and psychotherapy, and the evidence for thepsychotherapies -- and I may have to disagree with my colleagues, butthe hard evidence that we could present to the Clinton task forcewere on cognitive therapy, behavioral therapy and --

MR. WATTENBERG: Give us just a very fast example of --

MR. GOODWIN: Cognitive therapy is helping a person restructure theway they're thinking about themselves, finding islands ofself-esteem, letting them see in very practical ways how they haveperceptions which distort their view of reality. And it works.

Behavioral therapy, for example, in my field of depression, ishaving somebody find a behavior that they do that they realize makesthem feel better when they're doing it, have them repeat that. That'sa little simple-minded, but there's a number of behaviors -- there'sdeep breathing exercises for anxiety attacks. These things work.They're short-term enough to be evaluated. And then a specific kindof interpersonal therapy, where you teach people different ways tonegotiate.

This is not going back to how you felt about your mother, althoughhow you felt about your mother may be affecting how you'renegotiating.

MR. KRAMER: I'm continually shocked --

MR. VIEDERMAN: But interpersonal therapy has some relationship tothe structure of analytic therapy --

MR. GOODWIN: Yes, I agree.

MR. VIEDERMAN: -- although I agree that it's very frustrating --

MR. WEINBERGER: Before you get too shocked --

MR. KRAMER: Let me get shocked for a minute because I am --

MR. GOODWIN: Peter, I was only talking about the literature. Iwasn't talking about what I believe as a clinician. And I agree withyou, doctors --

MR. KRAMER: Well, let's talk about what we believe as cliniciansfor a moment, because I am genuinely shocked.

MR. GOODWIN: I agree with you, doctors practice a lot of things --

MR. WATTENBERG: I love seeing psychiatrists arguing. Peter.

MR. KRAMER: I think it would be frightful if, all of a sudden, wewere to throw out what to me is the most highly developed technologyin psychiatry, which is insight-oriented dynamic psychotherapy,traditional psychotherapy.

MR. WATTENBERG: Whoa, hold on. You must put that in American,right.

MR. KRAMER: Traditional psychotherapy, based in a broad sense onFreud's principles, I think is still the most developed technologywithin psychiatry, and most useful for the minor common disorders.

MR. WATTENBERG: And yet you have written the leading popular book,at least, about the use of drugs, 'Listening to Prozac.'

MR. KRAMER: That's right. I think that medicine has entered thatsame arena where psychotherapy traditionally has been -- minordisorders, problems of personality, and it's necessary to say that wecan influence a lot of those problems biologically.

MR. WEINBERGER: My concern is, and I think that how this debategets started and what the public and the managed care companies,which -- we don't really talk about this, but fuel this debateultimately; it's economics that makes this question be asked rightnow -- what they're demanding of us is that we look very criticallyat what works and what doesn't work.

We as a field, I don't think should be defending a citadel. Weshould not be defending psychotherapy. We should be defending ourpatients, their illness and their need for treatment, and we shouldbe what is best by way of treatment for them. So to answer yourquestion --

MR. WATTENBERG: So the people who are less severely ill, you canjust -- 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 anythingelse. That's fine.

MR. WEINBERGER: I think Peter's book answered the question verynicely. It illustrated something that we've all experienced aspractitioners, that we can see a patient who has the archivalneurotic syndrome that was the basis of many of Freud's fundamentalwritings, something called obsessive compulsive neurosis, a conditionthat psychoanalysis built itself around in many, many ways --

MR. VIEDERMAN: In part.

MR. WEINBERGER: -- in many, many ways --

MR. VIEDERMAN: Yes.

MR. WEINBERGER: -- for good reason, because it's a condition withvery rich internal mind dynamics. Many patients, despite years ofpsychoanalysis, have remarkable responses to a medication such asProzac. When you see this clinically, you can't not, as Peter did, Ithink, and it instigated him to write this book, take pause aboutthat, and say, my, my, my, this makes us have to re -- and that's notto say --

MR. WATTENBERG: All right, now hold it. I want to read you anoutstanding piece of psychiatric literature. This comes from aBroadway musical, 'West Side Story,' that came out in 1957. And it'sa song that juvenile delinquents sing to the infamous Officer Krupke,and it says: 'Our mothers are all junkies, our fathers are alldrunks. Golly, Moses, naturally we're punks. Gee, Officer Krupke,we're very upset. We never had the love that every child ought toget. We ain't no delinquents, we're misunderstood. Deep down insideof us, there is good, there is good.'

Now, this is sort of the essence of political Freudianism. Youknow, it's not my fault.

MR. VIEDERMAN: Oh, no.

MR. WATTENBERG: Or it's not his fault or it's not anybody's fault.

MR. VIEDERMAN: No, no.

MR. WATTENBERG: I say political.

MR. VIEDERMAN: I don't know what that means.

MR. GOODWIN: But it's a risk. You're right, it's a risk that --

MR. WATTENBERG: Let us talk about --

MR. VIEDERMAN: That's not Freud's view.

MR. WATTENBERG: Okay, well, let -- it's my view of Freud's view.

MR. VIEDERMAN: Let's get him off the hook.

MR. WEINBERGER: If you're saying that environment has an effect,we know environment has an effect. And environment has an effect onthe biology of the individual, and it has an effect on the psychologyof the individual.

MR. GOODWIN: If you have a handicap and a wheelchair, you stillhave 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 acollaborator in that treatment. Having something wrong with you doesnot absolve you of human accountability.

An alcoholic -- we know that early-onset alcoholism is verygenetic, and people get it after their first drink often. But itstill takes a courageous act of will every day for that alcoholic notto drink, and some do and some don't.

MR. WATTENBERG: But the question that we see in the policycommunity all the time now, and specifically, for example, on thatquestion of alcoholism, is if the alcoholism allegedly isn't thefault of the person, does the society owe him a living?

MR. KRAMER: You can make the argument that the biological viewmakes society more responsible. Let's say it's discovered, which itmore or less has been, that putting people in terrible socialcircumstances affects the biology of their brain. In that case, youmight say society is more liable than if it merely affects theirpsychology. It's not clear that the Freudian view is a liberal view.It may be that the biological view will have liberal aspects.

MR. WEINBERGER: Part of where this gets so confusing is that wehave conflated, in our thinking about public and social psychiatryand psychology, illnesses with human variations in personality andbehaviors. And what Freudian psychiatry has been very helpful at,Freudian psychology, is understanding the vagaries of a number ofways that people react to circumstances.

But it has not been helpful in understanding the basicunderpinnings of disease. And there are diseases that we callpsychiatric diseases, such as major depression, schizophrenia, panicdisorder, and some of the other obvious conditions where thinkingabout psychogenesis, that is, the causation of the disease beingrooted fundamentally within these constructs of psychological origin,has not proven to be the case. But that's a very different issue --

MR. VIEDERMAN: Absolutely, Dan. We're in agreement.

MR. WEINBERGER: Right. It's a very different issue thanunderstanding that people come by their personalities honestly. Themore we have begun to understand the complexities of geneticinformation that people inherit from their ancestors, the more we'vecome to realize that people inherit predispositions to react to theirenvironment in certain ways. And we're increasingly becoming --having the wherewithal to appreciate that some people may cruisethrough environments for reasons having to do with their biology thatfor other people, because of their biology, are devastating.

MR. VIEDERMAN: It seems to me what you're doing is that you'remixing frames of reference. There is a question of moral judgment andresponsibility. This is what Fred was talking about. That is separatefrom motivational systems and dynamics. If you are motivated to killsomeone because you want to kill your father, should you therefore beexcused from responsibility for that crime? No one would argue thatthe moral issues and those values are separate issues.

MR. GOODWIN: Go back to your antisocial kid. They used to say thatcrime was due to poverty. In fact, the great majority of poor peopledon't commit crime. It's stigmatizing the poor to make it intopoverty. In fact, if you look at what predicts it, about 80 percentof all the youth violent crime is 7 percent of the youth -- norelationship to race, no relationship to poverty. The onlyenvironmental 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 wehave to think carefully about what is -- what are we subsidizing?

MR. WATTENBERG: Are we buying out-of-wedlock birth?

MR. WEINBERGER: If you ask the question about where Freud slipped,I think this gets closer to where he slipped, and I don't know thatit was his slip, really. It was his apostles that slipped. He madethe 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 thatmany people heard -- it may not have been offered, but many peopleheard it -- that all of society's ills could be explained and perhapsmollified in Freudian terms. That was a slip; that's not correct.

MR. VIEDERMAN: And I think that's true. But I want to go back tosomething that Dan said, because I think it'll clarify the discussionright now.

MR. WATTENBERG: We're running a little out of time.

MR. VIEDERMAN: And that is the issue of the relationship betweenbiology and environment. That's what's running through ourdiscussion. We're all in agreement on this. We know that kids areborn with temperaments. We can measure them at the beginning. They'revery different.

We also know that genes don't simply determine behavior. Genesoffer a range of possibility for interaction with the environment.And so the ultimate product is a mixture of the two, and thescientific problem is to tease apart the contributions of both ofthese factors. And Freud would have said that.

MR. WATTENBERG: Peter, do you want to come in --

MR. KRAMER: I think we're a little out ahead of ourselves inbelieving that we really have biological answers to either social orindividual problems, just as we were a ways ahead of ourselves interms of psychotherapy, and that we really have models for biologicalsolutions more than we have evidence that our biological models arecorrect.

MR. 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 ofgo around the horn, starting with you, Dr. Goodwin, which is, just inbrief, what do you agree upon and disagree upon within this group oryour field?

MR. GOODWIN: My main concern about this discussion and argument isit may give the impression that there's not a consensus. There is aconsensus in psychiatry. And our knowledge base is as solid as anyother 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 lookingat its best when it's combined with medication. Treating people withschizophrenia requires medication. Depression, severe depressionrequires medication. But psychotherapy looks good when it's helpingmedication.

MR. WATTENBERG: Dan.

MR. WEINBERGER: Well, let me just say, what I agree with, and Idon't know whether it's been articulated, is that psychiatry, whichis nothing new for psychiatry, experiences itself as under siege. Myown sense is that what the field all agrees on is that mental illnessisn't going away, it's a very serious problem, patients have veryserious illnesses, and that we have much more effective treatmentsnow for these illnesses than we ever did.

What's on the horizon, I believe, is we will understand, at a muchmore fundamental, scientific level, the biology of these disorders,how patients are born with dispositions that are much more elaboratethan just whether they're passive or aggressive, but very subtlydefined predispositions at the level of neurobiology that make themrespond to a variety of environmental circumstances. This will giveus the wherewithal to intervene more judiciously at the biologicaland environmental side.

MR. WATTENBERG: In other words, there are more new drugs comingalong.

MR. WEINBERGER: Many, many more new drugs.

MR. WATTENBERG: All right, Dr. Viederman, Milton Viederman.

MR. VIEDERMAN: Well, I think that we have a consensus about theessential issues because we did focus on the issue of environmentversus genetics and constitution. That is central. I want to expressa concern, really. And that is that my own experience is that thepower of words is a very central feature of the role of the doctorand that the current pressures, understandable, are now pushing us tominimize that, and the consumer complaint that they don't haverelationships with doctors is going to accelerate in the context ofour inability to engage patients. MR. WATTENBERG: Dr. Peter Kramer,last shot.

MR. KRAMER: I think that these are intellectually tremendouslyexciting times for psychiatry. I don't know that in 10 years or 20years our models of what is illness and what is health will look justthe way they look now. My main concern is that, in that process, wenot lose this wonderful technology, which I think of as a technologyand not just counseling, of psychotherapy in all its variety.

MR. WATTENBERG: Okay. Thank you, Dr. Kramer, Dr. Goodwin, Dr.Viederman, and Dr. Weinberger.

And thank you. As you know, we enjoy hearing from our audiencevery much. So please do send your comments and questions to: NewRiver Media, 1150 17th Street, N.W., Suite 1050, Washington, DC,20036. Or we can be reached via electronic mail at thinktv@aol.com.

For 'Think Tank,' I'm Ben Wattenberg.

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Additional funding is provided by the John M. Olin Foundation, theRandolph Foundation, and the Lynde and Harry Bradley Foundation. END

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