Psychiatrists: The new "psychologists with prescription privileges"?

[flerfmcgerf]

I'm enjoying being able to get into random areas of the literature during this break. I came across this editorial Psychiatry is the flagship of personalized and precision medicine: proposing an epistemic horizon to biological psychiatry and was intrigued.

The main thrust of this editorial is to show that the field of psychiatric genetics has contributed tremendously to research in psychiatry, not so much by validating any disease entity, but by showing the complexity of the biological mechanisms of these disorders and that these underpinnings may be impossible to identify. While it is impossible to demonstrate that this is a final conclusion (and I hope that I will be contradicted tomorrow), I argue that the epistemic robustness of genetic studies combined with the very complex but trivial “findings” in this field clearly define the epistemic horizon in biological psychiatry. If so, a paradigmatic shift is necessary in psychiatry. This paradigmatic shift stipulates that when a patient presents with problems of living and confides in us a rich phenomenological experience that we can help them to interpret, understand and eventually resolve, there is no need to seek biological explanations that are at best trivial and at worst unattainable. Surface phenotypes are all that we need. More than any other medical discipline, psychiatry offers a rich variety of tools to help patients recover: pharmacotherapy, various psychotherapy techniques, and a wide range of psychosocial/holistic help. In this sense, I think that psychiatry is the flagship of precision and individualized medicine, and not the archaic discipline that we often tend to depict in our grants, papers and presentations. In fact, it may be that the rest of medicine needs to emulate some components of this model rather than psychiatry trying to carve out a place within the medical disciplines.

I haven't been as broadly exposed to the literature over the past couple of years, but I wonder how widely held this sort of view is. Basically that genome-wide association studies and biomarker studies aren't that helpful, and that psychiatry best practiced by focusing on "rich phenomenological experience" and using psychotherapy, psychosocial/holistic interventions, and meds (although I mixed up the order there). In my limited understanding of the state of healthcare (noting this is in a Canadian journal), it doesn't seem likely that roles will change much soon in the U.S., but if this view that we can't do much on the biological side of things does gain traction, what will psychiatrists do? And how might that affect what psychologists do?

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[Fan_of_Meehl]

That which was old...is new once more.

 

[R. Matey]

I read it mainly as a honest admission of how the RDoC efforts are going. Psychiatry is medicine though so I think biological research will (and should) continue to be a part of the program, but maybe not to the exclusion of phenomenological research and treatments.

 

[Fan_of_Meehl]

I read it mainly as a honest admission of how the RDoC efforts are going. Psychiatry is medicine though so I think biological research will (and should) continue to be a part of the program, but maybe not to the exclusion of phenomenological research and treatments.

I'm so glad that we're on the edge of a sea change. Even in the area of psychotherapy, I believe the 'protocol-for-syndrome' = 'apex of clinical care' model is going the way of the Dodo bird as well...in time, at least.

I think one of the most profound failings of the fixed, exclusive categorical ('disease') model of psychological dysfunction (and the attendant implied 'specified medical course of treatment' for said 'diagnosis' (like you're prescribing a preset number of pre-arranged psychotherapy sessions with pre-arranged content like some damned course of antibiotics or something)) is the presumption that all you gotta do is just specifically determine the exact 'locus' of the root cause/ pathology (like some metaphorical tumor or fixed constellation of symptoms/traits or behavioral patterns) and then apply the associated 'evidence-based treatment recipe' and you'll fix the problem. Any research/intervention line of efforts predicated on this presumption is going to ultimately be like trying to empty out a tub of bathwater with your bare hands while your fingers are extended. As my great mentor Foghorn Leghorn might say, you're "gonna see a WHOLE lotta CHOPPIN' but not a lotta WOOD FLYIN', boy!"

The thing is (and Stephen C. Hayes and Stefan Hofmann are really hammering this point on with the new focus on process-based case formulation and therapy), in most cases, there is no simplistic single locus of causality causing all the pathology and there is, therefore, no course of pre-specified psychotherapeutic technology, steps/algorithms, or agendas that--if applied to a client whom we encouraged to 'hold still and be treated' by the professional'--is going to effect a 'cure' or even reliable clinical improvement.

We're dealing with SYSTEMS that interact across multiple levels of analysis (physiological state of the individual, behavior of the individual, thoughts/beliefs of the individual, social contacts of the individual, social systems, etc.). We have to uncover the idiographic (specific to the individual) lawful relations between those systems and make educated guesses with respect to the directional and bi-directional influences (which are often reciprocal rather than unidirectional) including the essential POSITIVE AND NEGATIVE FEEDBACK loops in the system. Then we have to share this model (sometimes, one little bit at a time) to a client who is likely to be (at that moment) anywhere along an absolute CONTINUUM of readiness for behavior change all the way from pre-contemplation (isn't even aware or open to the possibility that their patterns of thinking or behavior are or even COULD BE the problem) to action (or maintenance of behavior change). Put bluntly, a protocol won't to S*** for someone who still believes that everyone else is the problem. A medication intervention won't do D*** for a patient who doesn't think they need it and won't take it.

Basically, the medical model (metaphor) is a really poor metaphor for properly conceptualizing and intervening with respect to mental illness and its fallout. After banging our heads against that wall for several decades and spending billions of dollars chasing that fantasy, some folks are starting to realize this.

 

[PsyDr]

I'm so glad that we're on the edge of a sea change. Even in the area of psychotherapy, I believe the 'protocol-for-syndrome' = 'apex of clinical care' model is going the way of the Dodo bird as well...in time, at least.

I think one of the most profound failings of the fixed, exclusive categorical ('disease') model of psychological dysfunction (and the attendant implied 'specified medical course of treatment' for said 'diagnosis' (like you're prescribing a preset number of pre-arranged psychotherapy sessions with pre-arranged content like some damned course of antibiotics or something)) is the presumption that all you gotta do is just specifically determine the exact 'locus' of the root cause/ pathology (like some metaphorical tumor or fixed constellation of symptoms/traits or behavioral patterns) and then apply the associated 'evidence-based treatment recipe' and you'll fix the problem. Any research/intervention line of efforts predicated on this presumption is going to ultimately be like trying to empty out a tub of bathwater with your bare hands while your fingers are extended. As my great mentor Foghorn Leghorn might say, you're "gonna see a WHOLE lotta CHOPPIN' but not a lotta WOOD FLYIN', boy!"

The thing is (and Stephen C. Hayes and Stefan Hofmann are really hammering this point on with the new focus on process-based case formulation and therapy), in most cases, there is no simplistic single locus of causality causing all the pathology and there is, therefore, no course of pre-specified psychotherapeutic technology, steps/algorithms, or agendas that--if applied to a client whom we encouraged to 'hold still and be treated' by the professional'--is going to effect a 'cure' or even reliable clinical improvement.

We're dealing with SYSTEMS that interact across multiple levels of analysis (physiological state of the individual, behavior of the individual, thoughts/beliefs of the individual, social contacts of the individual, social systems, etc.). We have to uncover the idiographic (specific to the individual) lawful relations between those systems and make educated guesses with respect to the directional and bi-directional influences (which are often reciprocal rather than unidirectional) including the essential POSITIVE AND NEGATIVE FEEDBACK loops in the system. Then we have to share this model (sometimes, one little bit at a time) to a client who is likely to be (at that moment) anywhere along an absolute CONTINUUM of readiness for behavior change all the way from pre-contemplation (isn't even aware or open to the possibility that their patterns of thinking or behavior are or even COULD BE the problem) to action (or maintenance of behavior change). Put bluntly, a protocol won't to S*** for someone who still believes that everyone else is the problem. A medication intervention won't do D*** for a patient who doesn't think they need it and won't take it.

Basically, the medical model (metaphor) is a really poor metaphor for properly conceptualizing and intervening with respect to mental illness and its fallout. After banging our heads against that wall for several decades and spending billions of dollars chasing that fantasy, some folks are starting to realize this.

Now rant about the absence of “therapeutic confrontation”.

 

[Fan_of_Meehl]

I tend to get out of the way and let the patient's reality do the 'confronting.' It's fully sufficient.

 

[R. Matey]

I'm so glad that we're on the edge of a sea change. Even in the area of psychotherapy, I believe the 'protocol-for-syndrome' = 'apex of clinical care' model is going the way of the Dodo bird as well...in time, at least.

I think one of the most profound failings of the fixed, exclusive categorical ('disease') model of psychological dysfunction (and the attendant implied 'specified medical course of treatment' for said 'diagnosis' (like you're prescribing a preset number of pre-arranged psychotherapy sessions with pre-arranged content like some damned course of antibiotics or something)) is the presumption that all you gotta do is just specifically determine the exact 'locus' of the root cause/ pathology (like some metaphorical tumor or fixed constellation of symptoms/traits or behavioral patterns) and then apply the associated 'evidence-based treatment recipe' and you'll fix the problem. Any research/intervention line of efforts predicated on this presumption is going to ultimately be like trying to empty out a tub of bathwater with your bare hands while your fingers are extended. As my great mentor Foghorn Leghorn might say, you're "gonna see a WHOLE lotta CHOPPIN' but not a lotta WOOD FLYIN', boy!"

The thing is (and Stephen C. Hayes and Stefan Hofmann are really hammering this point on with the new focus on process-based case formulation and therapy), in most cases, there is no simplistic single locus of causality causing all the pathology and there is, therefore, no course of pre-specified psychotherapeutic technology, steps/algorithms, or agendas that--if applied to a client whom we encouraged to 'hold still and be treated' by the professional'--is going to effect a 'cure' or even reliable clinical improvement.

We're dealing with SYSTEMS that interact across multiple levels of analysis (physiological state of the individual, behavior of the individual, thoughts/beliefs of the individual, social contacts of the individual, social systems, etc.). We have to uncover the idiographic (specific to the individual) lawful relations between those systems and make educated guesses with respect to the directional and bi-directional influences (which are often reciprocal rather than unidirectional) including the essential POSITIVE AND NEGATIVE FEEDBACK loops in the system. Then we have to share this model (sometimes, one little bit at a time) to a client who is likely to be (at that moment) anywhere along an absolute CONTINUUM of readiness for behavior change all the way from pre-contemplation (isn't even aware or open to the possibility that their patterns of thinking or behavior are or even COULD BE the problem) to action (or maintenance of behavior change). Put bluntly, a protocol won't to S*** for someone who still believes that everyone else is the problem. A medication intervention won't do D*** for a patient who doesn't think they need it and won't take it.

Basically, the medical model (metaphor) is a really poor metaphor for properly conceptualizing and intervening with respect to mental illness and its fallout. After banging our heads against that wall for several decades and spending billions of dollars chasing that fantasy, some folks are starting to realize this.

I take it you're a fan of good ole' T. Szasz as well as Meehl?

 

[gohogwild]

Totally disagree. GWA studies are awesome. The best argument I've read is the book Blueprint by Robert Plomin. I feel like this is basically saying "GWA studies are pointless because it's too complex and the research isn't complete". OK? This is the kind of research that neuro, physio, endo, genetics, is going to pursue anyways, so why not let it affect clinical practice if it applies?
I really disagree with the idea that "phenotypes are all we need". How'd that phenotype come about, then, and what makes you so sure that, that gives you the info on what drugs to throw at it?
Science is not prescriptive or directly related to CBT & anti-pharm practices (nor does it reinforce diagnostic categories, I would argue!), all of these things can coexist.

 

[gohogwild]

Now rant about the absence of “therapeutic confrontation”.

Gestalt? Or a special PsyDr technique? Either way, we'll need a handbook.

 

[Fan_of_Meehl]

I take it you're a fan of good ole' T. Szasz as well as Meehl?

Not really. Honestly not that familiar with his work (in a direct sense). I know he wrote the 'Myth of Mental Illness' book way back in the day. There have been and will continue to be numerous critics of the medical model of mental illness.

 

[R. Matey]

Not really. Honestly not that familiar with his work (in a direct sense). I know he wrote the 'Myth of Mental Illness' book way back in the day. There have been and will continue to be numerous critics of the medical model of mental illness.

Ah, ok. The metaphor arguments he makes that book are similar to yours above, but the critique there is more squarely aimed at psychoanalysis. At least that's my memory. Anyways, I think you're right--the same problematic metaphors totally applies to treatment-for-syndrome psychotherapy, as it does medicalizing the problems of life though there is the same or similar danger in throwing up your hands and saying that everything works, as the common factors people do. Szasz had also few satisfying arguments on this front from what I recall.

IMHO, good therapy on a process level is likely a good mix of support and challenge, like any other healthy relationship. Beyond that, there are basically either cognitive (e.g., change your outlook) or behavioral (e.g., do something different) techniques. There are certain techniques in those two buckets that work better than others, like there are chess openings that are decidedly dumb or why garlic doesn't go on ice cream. Whether we call that medicine, art, education, or just life is an interesting, but probably unresolvable question.

 

[Fan_of_Meehl]

Ah, ok. The metaphor arguments he makes that book are similar to yours above, but the critique there is more squarely aimed at psychoanalysis. At least that's my memory. Anyways, I think you're right--the same problematic metaphors totally applies to treatment-for-syndrome psychotherapy, as it does medicalizing the problems of life though there is the same or similar danger in throwing up your hands and saying that everything works, as the common factors people do. Szasz had also few satisfying arguments on this front from what I recall.

IMHO, good therapy on a process level is likely a good mix of support and challenge, like any other healthy relationship. Beyond that, there are basically either cognitive (e.g., change your outlook) or behavioral (e.g., do something different) techniques. There are certain techniques in those two buckets that work better than others, like there are chess openings that are decidedly dumb or why garlic doesn't go on ice cream. Whether we call that medicine, art, education, or just life is an interesting, but probably unresolvable question.

Couldn't agree more. The upfront way I (eventually) put it is THERAPY = SELF-CHANGE, either changes in how you think/believe or in how you act. That's what it ultimately boils down to.

 

[smalltownpsych]

Totally disagree. GWA studies are awesome. The best argument I've read is the book Blueprint by Robert Plomin. I feel like this is basically saying "GWA studies are pointless because it's too complex and the research isn't complete". OK? This is the kind of research that neuro, physio, endo, genetics, is going to pursue anyways, so why not let it affect clinical practice if it applies?
I really disagree with the idea that "phenotypes are all we need". How'd that phenotype come about, then, and what makes you so sure that, that gives you the info on what drugs to throw at it?
Science is not prescriptive or directly related to CBT & anti-pharm practices (nor does it reinforce diagnostic categories, I would argue!), all of these things can coexist.

Yeah, it’s usually a problem when the pendulum swings too far in one direction. We love to do that as humans and in psychology\psychiatry it seems we have a new answer for everything every few years or so. I think its safe to say that no one perspective or treatment is ever going to be the answer for all.

 

[smalltownpsych]

I'm enjoying being able to get into random areas of the literature during this break. I came across this editorial Psychiatry is the flagship of personalized and precision medicine: proposing an epistemic horizon to biological psychiatry and was intrigued.



I haven't been as broadly exposed to the literature over the past couple of years, but I wonder how widely held this sort of view is. Basically that genome-wide association studies and biomarker studies aren't that helpful, and that psychiatry best practiced by focusing on "rich phenomenological experience" and using psychotherapy, psychosocial/holistic interventions, and meds (although I mixed up the order there). In my limited understanding of the state of healthcare (noting this is in a Canadian journal), it doesn't seem likely that roles will change much soon in the U.S., but if this view that we can't do much on the biological side of things does gain traction, what will psychiatrists do? And how might that affect what psychologists do?

I really hope that psychiatrists continue moving back to the interpersonal. I have no fear that this will get in the way of what we do. I think that our primary expertise in the psychological and their primary expertise in the biological will continue to provide direction for the field. There is more than enough work for both.

 

[Ollie123]

I think its important to separate out what is scientifically useful from what is clinically useful.

I'd maintain that RDoC needed to happen, but I never had any illusions I was going to see it have a major influence on clinical practice in this short a timeline. Possibly not even in my lifetime. GWAS studies have not provided any clinically actionable information to date (at least for bread & butter psychiatry diagnoses) to my knowledge, but I don't think that means we need to give up on them. We always knew psychiatric diagnoses were going to be polygenic and likely involve complex interactions with environmental factors - I think you'd be hard-pressed to find a geneticist who disagrees with that. Comparatively newer discoveries (epigenetics) make this even more complex.

Eventually, I think we'll meet somewhere in the middle on these issues. I don't think it will be within the next 10 years. It could be 50 or it could be 500.

 

[PsyDr]

I think its important to separate out what is scientifically useful from what is clinically useful.

I'd maintain that RDoC needed to happen, but I never had any illusions I was going to see it have a major influence on clinical practice in this short a timeline. Possibly not even in my lifetime. GWAS studies have not provided any clinically actionable information to date (at least for bread & butter psychiatry diagnoses) to my knowledge, but I don't think that means we need to give up on them. We always knew psychiatric diagnoses were going to be polygenic and likely involve complex interactions with environmental factors - I think you'd be hard-pressed to find a geneticist who disagrees with that. Comparatively newer discoveries (epigenetics) make this even more complex.

Eventually, I think we'll meet somewhere in the middle on these issues. I don't think it will be within the next 10 years. It could be 50 or it could be 500.

It would have been nice, if the APA used a behavioral approach to "the decade of the brain". That approach would have really improved the interest
in psychotherapy.

 

[Ollie123]

It would have been nice, if the APA used a behavioral approach to "the decade of the brain". That approach would have really improved the interest
in psychotherapy.

For sure. I think failure to consider behavior (loosely defined...including more nuanced cognitive endophenotypes) is one of the big reasons psychiatric genetics has not proven very fruitful. I think the odds of us finding a specific gene that increases attentional engagement with reward cues is infinitely higher than the odds of us finding a specific gene that codes for "depression" or "substance use disorder." Throw in the error variance on behavioral tasks, the fact that GWAS is often not-really-genome-wide, involves some imputation and is its own moving target of precision (to the folks who don't read genetics literature - surprise! Biosciences have measurement error too) and the fact that even attentional engagement to reward cues is probably too far upstream and you have a problem, but you've got a fighting chance.

Of course, getting behavioral data on 250,000 people isn't exactly easy. Getting it in a way where half your data isn't unusable garbage because of poor data collection practices and similar issues is even harder. Heck, even the ABCD study had to throw out like 250ish people because they programmed one of the tasks wrong. This is why it hasn't been done.

Same principles apply to neuroimaging and myriad other things.

We'll get there. Just slowly.

 

[Fan_of_Meehl]

For sure. I think failure to consider behavior (loosely defined...including more nuanced cognitive endophenotypes) is one of the big reasons psychiatric genetics has not proven very fruitful. I think the odds of us finding a specific gene that increases attentional engagement with reward cues is infinitely higher than the odds of us finding a specific gene that codes for "depression" or "substance use disorder." Throw in the error variance on behavioral tasks, the fact that GWAS is often not-really-genome-wide, involves some imputation and is its moving target of precision (to the folks who don't read genetics literature - surprise! Biosciences have measurement error too) and the fact that even attentional engagement to reward cues is probably too far upstream and you have a problem, but you've got a fighting chance.

Of course, getting behavioral data on 250,000 people isn't exactly easy. Getting it in a way where half your data isn't unusable garbage because of poor data collection practices and similar issues is even harder. Heck, even the ABCD study had to throw out like 250ish people because they programmed one of the tasks wrong. This is why it hasn't been done.

Same principles apply to neuroimaging and myriad other things.

We'll get there. Just slowly.

Agreed. With tech advancements it's a whole lot easier to collect massive amounts of raw data but the real hat trick is to extract useful information from the massive heaps. For that, you need sophisticated theories and adherence to a philosophy of science broad enough to appreciate the fact that eliminative materialism/ reductionism doesn't solve all problems via brute force methods.

 

[Dr. Nikki]

I'm enjoying being able to get into random areas of the literature during this break. I came across this editorial Psychiatry is the flagship of personalized and precision medicine: proposing an epistemic horizon to biological psychiatry and was intrigued.



I haven't been as broadly exposed to the literature over the past couple of years, but I wonder how widely held this sort of view is. Basically that genome-wide association studies and biomarker studies aren't that helpful, and that psychiatry best practiced by focusing on "rich phenomenological experience" and using psychotherapy, psychosocial/holistic interventions, and meds (although I mixed up the order there). In my limited understanding of the state of healthcare (noting this is in a Canadian journal), it doesn't seem likely that roles will change much soon in the U.S., but if this view that we can't do much on the biological side of things does gain traction, what will psychiatrists do? And how might that affect what psychologists do?

I don't know what things look like in Canada but in the US (at least in my experience) psychiatrists are seeing patients (maybe) once a month for 15-20 minutes, doing in-depth MSEs, doing trial and error with different meds and assessing for side effects, etc. I think it's a nice idea to be open minded but not very realistic unfortunately.

I agree with some of the other comments I don't think these ideas are mutually exclusive we can continue to advance science and also be flexible in our approach. The more states that make it possible for psychologists to prescribe also matters.