The Theater of the Brain

The play of consciousness.

"Evidence-Based" Psychiatry Is Evidence in Name Only

A call for the science of psychotherapy has taken a wrong turn.

  Sadly, I have to disagree with Emily A. Holmes, Michelle G. Craske and Ann M. Graybiel, in their article in Nature, July 16, 2014, “Psychological treatments: A call for mental-health science, Clinicians and neuroscientists must work together to understand and improve psychological treatments.” As a psychiatrist who practices intensive psychotherapy and has written a book on the subject, “Psychotherapy of Character, the Play of Consciousness in the Theater of the Brain”, I was enthusiastic to read this article, but I was quickly disappointed in the direction it took.

I completely agree that we need good science for psychotherapy and neuroscience. In truth, we need good science for psychiatry as a whole. We need good science. Science is supposed to protect us from bias and conflict of interest. As Arthur Conan Doyle said, “I never guess. It is a capital mistake to theorize before one has data. Insensibly one begins to twist facts to suit theories, instead of theories to suit facts.” Research is now geared to promote theories rather than to rigorously test them in a quest for the truth. In good science one exception proves the rule. When one comes up with a theory, one tests it by trying to disprove it, in the quest for validity. Instead, the academy has lowered its standards of proof in order to accommodate failed trials. It then falsely defines that the conclusions are "evidence-based" and the results are taken as proven facts. These faulty conclusions lead to a house of cards of fraudulent claims built on fraudulent claims, taken as truth. This is no more rampant than in psychiatry today.

This article proposes that we make psychotherapy research conform to the fraudulent and corrupt ‘evidence-based’ research of big Pharma. Psychiatry has invented a DSM-5, full of biological and genetic brain diseases for which there is no proof. Then drug trials are performed where the standards are embarrassingly low -  if 30 percent of an artificially established diagnosis is cured by placebo and the drug performs at 4 percent, this is considered proof of efficacy – 10 percent effectiveness. And these results are cherry picked since the host of failed trials are suppressed. 10 percent effectiveness, which is fraudulent, is not really a good standard for evidence. Our research in psychiatry should not replicate these criteria. The promoted idea that a pill can cure what ails us is an insult to the complexity of the human condition.

Furthermore, in order to test psychotherapy, the article supports treatments like CBT which are, in fact, not real treatments at all. Challenging a fear is obviously a necessary part of treatment of phobias, but it is not the treatment, and can only yield short term gain at best. However, they lend themselves to simplistic and false measurements that fit into the ‘evidence-based’ model. This faux quest of calling ‘rational’ short term therapy, psychotherapy, is like the following story, “Mr. Jones at night was fishing for something down a sewer drain under a street light. A passerby asked, ‘Did you drop your keys down the drain?’ ‘No, I didn’t drop them here. I dropped them down the street, but this is where the light is.’”  Ms. Clarke and Graybiel are seeking money for research which will never discover anything useful. Historically, most knowledge does not come from standard research within the academy. It usually comes from the outside where individuals are free to explore the truth from their own intuition and imagination. And then it gets tested with scientific rigor.

Neuro-scientific knowledge is currently exploding and is tremendously exciting. But there are two important pitfalls. Biological psychiatry, neurology, and neuroscience in general have preempted a claim on what is biological. They have defined biology as the domain of physical brain structure; brain organization, brain anatomy, and functional brain centers; neurotransmitters; hormones; information learned from studying brain lesions; and activated patterns of neurons that can be seen in brain scans and brain stimulations, associated with certain localized functions. Knowledge of these local functions is illuminating and important. Unfortunately, this orientation has mistaken the parts for the whole. It is a mistake to generalize about consciousness from the point of view of the contribution of local brain areas or neurotransmitters. They have ignored the brain’s most important biological manifestation of all, the organization of consciousness which results from the mappings throughout the limbic-cortex in its entirety.

Second, it has already been repeatedly shown that psychotherapy generates changes in focal brain areas. This shows that changes in the brain are the result of something rather than the cause of something. This alone demonstrates that psychiatric symptoms and suffering are not a brain problems, but a human problem. I address the fallacy of depression as a neurotransmitter disease in “No, it’s Not the Neurotransmitters Depression is not a neurological disease caused by an imbalance of Serotonin”.

For an understanding of human nature to be valid, it has to conform to the actual brain-body in its development and organization. It cannot be a pastiche of ideas that fits somebody’s theory but does not correspond to the actualities of the human genome as it orchestrates morphogenesis into the mature adult brain-body. Likewise, in order for an understanding of the operations of the brain-body to be meaningful, it has to be consonant with actualities of human life. This ought to be our enterprise. Contemporary psychiatric research does not meet these basic standards.

We need a paradigm that encompasses the neuroscience of the whole of psychiatry. In order to do so, we must  also recognize that psychotherapy is not just science, it is an art. Art is the language of human communication. Our paradigm needs to include the neuroscience of psychotherapy, as well as all the arts – theater, painting dance, literature, and music – never mind dreams, myths, and culture. Our science needs to be consistent with our biological Darwinian evolution. Our neuroscience needs to include the formation and operations of human consciousness, the formation of human character, and  the science of brain change.          

I suggest as a starting point what I present in my book as a new paradigm of consciousness and the brain which does conform to this criteria. The biological manifestation of the mapping of the entire limbic-cortex creates the organization of consciousness as a play in the theater of the brain. The “play” is an entire representational world that consists of a cast of characters who relate together by feeling, as well as plots, set designs, and landscape. It is a unified field theory of human consciousness, which includes psychiatry, neuroscience, dreams, myths, religion, and art— all elements of the same thing. It derives from and is consonant with our child rearing and culture. The “play” encompasses the ineffable human mysteries— birth, death, and the disparity between our ordinary sense of self and our intimation of a deeper authenticity. It includes as well the dark side of our nature. And finally, it holds the key to the nature of beliefs in general. Human consciousness and human nature are one and the same. The creation of our inner play by the brain is the consummation of our Darwinian human evolution.    

As a psychiatrist for the last forty years I have treated patients in the psychotherapy of character. Psychotherapy is a rewarding and effective practice that encompasses the depth and reach of human nature. It effectively heals psychiatric symptoms, and the struggles of human character. It allows for the recovery of authenticity and the capacity to love. Each of us coalesces our character as our specific genetic temperament fields responsiveness, abuse and deprivation during our formative years. This is at one with the organization of consciousness in the brain as a play. Psychotherapy operates through emotional holding with the therapist within the boundaries of the psychotherapy. This allows the patient to mourn and recover from the pain that shaped his character play. The patient then deactivates his old problematic play and writes a new one in the brain in exactly the way the character story was written in the first place. Human suffering is not a brain problem, but a human problem. Our problematic characters are manifest neuro scientifically in our brains. And when we heal, our brain changes. The psychotherapy of character is an art and a science that bridges the divide between psychotherapy and the brain, and is at one with this core paradigm.         

Yes, I understand the historical problems with psychotherapy. There have been charlatans. There have been incompetent practitioners. There have been byzantine and frankly incomprehensible theories which are off base. I understand that it takes a long time and is very expensive. Nonetheless, this does not change the basic truth of its value. I’m not an expert in proving its efficacy but I know that "evidence-based" is "evidence" in name only, not substance. We need to embrace a paradigm that encompasses human nature and the recovery from damage.

Robert A. Berezin, MD is the author of “Psychotherapy of Character, the Play of Consciousness in the Theater of the Brain”

robertberezin.com

Robert Berezin, M.D., is the author of Psychotherapy of Character. He taught psychiatry at Cambridge Hospital, Harvard Medical School for thirty years.

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