Separating the Wheat From the Chaff
This article first appeared in Psychiatric Times on September 14, 2015
Douglas Berger Psychiatrist Tokyo, comments on “Separating the Wheat From the Chaff” by Allan Tasman, MD, September 14, 2015 issue of the Psychiatric Times.
The article Dr. Tasman reports on requires a nuanced examination.
The article reported on:
http://www.nytimes.com/2015/06/28/magazine/tell-it-about-your-mother.html?_r=1 is a long, somewhat flashy and nostalgic, non-scientific description of the attempt to correlate psychoanalysis, specifically only the transference aspect, to some changes in the brain.
Looking further into the article behind it here:
J Am Psychoanal Assoc. 2006; 54(4): 1319–1325.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2367227/ gives the actual details. First note that the study had only 10 subjects, was unblinded to the therapist as well as the subject as to the content of the procedures, and thus there was no blinded control group. This is a significant problem when the psychological mechanisms are hard to operationally define much less tie them into a specific effect or efficacy of psychoanalysis.
The article proposes 2 conditions that has theoretical basis but no validation in any double-blind placebo controlled clinical research:
1. transference, defined as an unconscious aspect of social cognition, is an emerging core concept that can be used to unite theoretical and empirical investigations into normal mental functioning, psychopathology, and psychotherapeutic change.
2. a normal person’s perceptions and affective responses vis-à-vis the self and others are heavily influenced by the activation of significant relationship representations from the past.
Even if we are to assume these conditions are true, translating the operational definition of these concepts into brain changes, and then to some effect of psychoanalysis in this uncontrolled study of 10 subjects, is stretching the limits of valid clinical research.
It is extremely difficult to say with much certainty what is the exact cause of any brain changes found, their specificity, nor their connection to efficacy of psychoanalysis for a specific indication, and both the NY Times article and Dr. Tasman are taking any results of this unblinded and uncontrolled study IN ONLY 10 SUBJECTS far too far. Even if the emotions of transference are correlated to a brain change, that still does not translate to efficacy of psychoanalysis for any specific indication.
The NY Times article at least had the term “Preliminary research” under the image, and the research article itself noted the translation limitation, “It is crucial that the paradigm be designed for optimal reliability and clinical relevance at this stage, before it is applied broadly to questions of development, psychopathology, and psychotherapeutic change.”
Dr. Tasman’s statement that “…positive clinical improvement can be correlated with identifiable changes in brain functioning” is not yet near any kind of confirmation by the data in this preliminary and uncontrolled study.
It should be noted that brain changes can be found in various activities. For example, this study,
http://www.nature.com/neuro/journal/v12/n11/full/nn.2412.html
Nature Neuroscience 12, 1370 – 1371 (2009); 11 October 2009 | doi:10.1038/nn.2412 found and increase in white matter underlying the intraparietal sulcus following training of a complex visuo-motor skill. Note however, this study was unblinded (a training study can not be blinded), and there was no placebo control group.
Mindfulness meditation has also been found to alter regions of the brain associated with memory, awareness of self, and compassion, according to a brain imaging study:
Psychiatry Research: Neuroimaging (Jan. 30, 2011). http://www.health.harvard.edu/mind-and-mood/mindfulness-meditation-practice-changes-the-brain
Mindfulness meditation is the practice of paying attention to moment to moment experience without drifting into thoughts about the past or concerns about the future and without analyzing what is going on around you. It is thus very different from psychoanalysis. The subjects in this study were also unblinded (a meditation study can not be blinded), and there was no placebo control group.
Other studies have found brain changes from running, yoga, etc, This is indicative that the brain is a plastic organ responding to stimuli in some fashion, it would be a jump of wishful-thinking logic at this point to conclude that each type of therapy will provide a differential type of efficacy.
The conclusions here should be:
1. Various actions the brain may undertake may make adjustments to the structure and/or function of the brain.
2. Brain changes as a surrogate end-point are not necessarily indicative of a therapeutic effect of a specific psychotherapy; visual-motor training or meditation may also make brain changes (if we assume the unblinded and uncontrolled studies are valid).
3. To conclude that brain changes seen on imaging is strongly suggestive of an efficacy of a psychotherapy is a jump of logic not born out by a large double-blind or blinded-placebo controlled study.
4. These uncontrolled studies, and especially the study noted by the NY times article with only 10 subjects, do not tie-in a specific psychiatric indication of efficacy of a specific psychotherapy in a confirmatory way.
While different psychotherapies may help persons function better in certain ways, our zeal to validate a specific psychotherapy as a proven method for a specific indication because of brain changes is still based on research with poor methods so that conclusions needs to be tempered or else seem to be deceptive to the intended audience.
Doug Berger, M.D., Ph.D.
US Board Certified Psychiatrist
Tokyo, Japan
Douglas Berger Psychiatrist Tokyo and his staff at the Meguro Counseling Center in the Shibuya-Ebisu area provide mental health care for individuals, couples, and families, in both English and Japanese.
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