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Psychiatry for the 21st Century

Posted Feb 08 2008 9:44am
I'm sitting in the cold in Saskatchewan. It's been mild, only -20 this week. Last week one night hit -51 with the wind chill I think. That was miserable. Cars never warm up. I find it hard to make it to work on time in this cold. No one else seems to have that trouble. I've been late several times in the last two weeks. It's too cold. Too much to do to start the car, shovel the snow, etc. Anyway, here's an article that originally appeared in the Herbalist Guild that I wanted to share.


Herbalist Guild article.

Mental Health for the New Millennium

All too common in psychiatry is the reliance upon pharmacology as the primary or only treatment for mental disorders and even strong emotions, themselves. Throughout history, the healing arts have included so much more. Cherokee medicine, for example, included seven major categories of healing, each reflecting a separate level of intervention. These levels included 1) dietary therapies and herbs, 2) water cures (hydrotherapy), movement, and lifestyle, 3) energy medicine (acupuncture with porcupine quills and thorns, crystal healing, hands-above-the-body healing), 4) psychological therapies, 5) body therapies (manipulative medicine), 6) family and community therapies, and 7) spiritual therapies, including ritual and ceremony.

The psychiatry of indigenous cultures used interventions from all of these categories, distinctly different from current academic psychiatry which strives to treat only on the molecular level, with single pure substances. Today, patients appear who are receiving as many as 8 different psychiatric medications, suggesting that the realities of psychiatric and the science of psychopharmacology do not mesh as closely as desired. Herbal medicine can also become lost in chasing symptoms with herbs, rather than exploring the broader meaning and purpose of symptoms.

The Cherokee believed that mild illnesses could be treated with an intervention from any one of the seven levels, that moderate illness required addressing three or four different levels, and that a serious illness required all seven levels delivered simultaneously. Their practice reflected a basic understanding of the concept of synergy, that addressing separate levels simultaneously may produce results beyond the simple sum of the effects of each level taken independently. Synergy is implicit in the understanding that humans are systems and are embedded in larger systems called families and communities. The behavior of systems cannot be predicted from an understanding of the parts. The very definition of a system is a “whole that is greater than the sum of its parts.”

Rather than treat specific diseases, more often, Cherokee medicine treated imbalances. Disease was thought to arise from disturbances in relationships – with food, with plants (herbs), with the animals (breaking hunting taboos, for example), with self, with body, with other family members, with the community, with the tribe, with the land itself, with the soul or energy body, and with the Creator and the spiritual realm. Treatment focused upon the relationships that were most disturbed, regardless of the specifics of the illness. Plant medicine arose from discussions with the spirits of the plants and requests for their help, rather than an allopathic cookbook of specific herbs for specific conditions. The same herb could be used very differently for the same illness, because of the idiosyncrasies of the person being treated and the desires of the spirit of the plant being used.

Integrative psychiatry is the treatment of systems – humans, families, and communities. The molecular level is important, but so are the others. Of equal importance, even on the molecular level, is the need to discover what works and causes the least side effects.

For example, the administration of omega-3 fatty acids improves both schizophrenia and its accompanying membrane abnormalities. [i] Two literature reviews on the use of fish oils found the data to be encouraging. [ii] Important for our principles of integrative psychiatry, omega-3-fatty acids improved both tardive dyskinesia (the abnormal, involuntary movements provoked by the neuroleptic medications given to schizophrenics) as well as also improving the emotional symptoms of schizophrenia. [iii] The patients received 10 gm of Max-EPA daily for 6 weeks.

These kinds of findings stimulate other research, though this work remains far from a conventional psychiatric audience. Thus, a group from Sheffield, UK, [iv] treated schizophrenics who were still symptomatic, despite stable antipsychotic medication, with eicosapentaenoic acid (EPA), docohexaenoic acid (DHA), or placebo for three months. Improvement on EPA was statistically significantly superior to DHA or placebo using changes in symptom score on the Positive and Negative Syndrome Scale (PANSS). Important was the fact that this improvement occurred over and above the maximum improvement that could be obtained with conventional medications alone. EPA was statistically superior to DHA. In a subsequent study, EPA was used as a sole treatment, though the use of antipsychotic drugs was still permitted if clinically imperative. By the end of the study, all 12 patients on placebo were taking antipsychotic drugs, compared to 8 out of 14 taking EPA. The group receiving EPA were significantly better than the control group.

Another group from the University of Stellenbosch (South Africa) [v] treated patients with persistent symptoms after six months of antipsychotic medication. Again the study design permitted us to see that add-on effects of nutritional therapies. The patients received either 3 grams per day of ethyl-EPA or placebo, in addition to their usual treatment over 12 weeks. The EPA group had significant improvement in symptoms along with less abnormal, involuntary movement.

Integrative psychiatry also calls for the study of the process of care. These factors are often called the non-specific factors of the treatment situation, since they are not unique to a particular illness. As such, integrative psychiatry has much to say to the other medical specialties. Our concern is how these non-specific factors affect physical disease and its healing. Does the intent of the doctor affect the action of drugs? And what about the quality of the doctor-patient relationship, the patient’s expectations for results, the culture within which the treatment takes place – and all the more important when different cultures meet in the treatment room, and the role the illness plays in solving family problems?

Future research efforts may need to be re-directed toward discovering what it is that patients and clinicians do when they experience large improvements, comparing these findings to what can be observed about relationships and interventions when small or no improvements occur. Current research methods differ greatly from being able to study what actually happens in clinical practice. Research aims at short studies of single therapies, while practice invokes multiple therapies over periods of years. More prospective, observational studies are needed for us to discover the wisdom of clinicians who help patients and to understand the mysteries of clinical improvement.

Existent studies are meager compared to what is available for medication trials. Many are pilot and descriptive studies. Research funding follows profitability. Many of the therapies we will review cannot be patented or mass produced. Nevertheless, the available studies point to trends and directions that do seem promising, and may yield important future results.

Psychiatry’s Attempts to be Integrative

Psychiatry has long attempted methods beyond the use of just medication. For example, a group from the Institute of Community and Family Psychiatry at McGill University reviewed six high quality studies for major depression, among 883 patients, finding that psychotherapy (from 10 to 34 weeks, median of 16 weeks) achieved similar results as medication, with both active treatments substantially better than placebo. Psychotherapy had the lowest drop-out rate (24%), compared to medication (37%) and placebo (54%).

Other studies in the conventional psychiatric literature have criticized models that fragment care and dilute the doctor-patient relationship. In one representative study, depressed patients receiving split care in which pharmacotherapy was provided by a psychiatrist and psychotherapy by a non-physician psychotherapist did not do as well as patients receiving integrated care, in which both psychotherapy and pharmacotherapy were provided by the same psychiatrist. [vi] Patients receiving integrated treatment used significantly fewer outpatient sessions and had significantly lower treatment costs, on average, than those in split treatment. Integrated treatment was associated with a pattern of utilization characterized by frequent treatment episodes in contrast to that of split treatment, which was characterized by more sessions with fewer breaks of 90 days or more. The authors concluded that the results did not support the prevailing assumption that integrated treatment is more costly than split treatment in a managed care network. This study also suggested a value in a more concentrated relationship than a fragmented relationship.

The prevailing assumptions of managed care and of modern psychiatry have been that medication is more cost-effective than relationship-based therapies. While collaborative care in which patients received both psychotherapy and medication costs more for treating depression, it was also more cost-effective. [vii] Collaborative Care included brief cognitive-behavioral therapy and enhanced patient education. Other studies underscore this, with often savings seen in medical visits.

Conventional psychiatry presents the rest of medicine with an important example of synergistic therapies when it shows that the addition of psychotherapy helps patients who are not responding to antidepressant medications. [viii]

Holism and Inseparability
Key to our understanding of psychiatry is the concepts of systems medicine. A system is a whole that is more than a simple sum of its parts. The behavior of systems cannot be predicted by studying the behavior of each of its component parts. The behavior of a person cannot be predicted by studying the function of each organ. Similarly, the behavior of a family cannot be understood by studying each individual member in isolation from other family members. The family will always surprise us because the interaction of members produces a complexity not contained in the study of each individual member.
Non-separability is another property of whole systems. It means that the state of the whole is not determined by simply adding up the states of its individual parts. Systems theory states that the best way to study the behavior of a complex system is to treat it as a whole, and not merely to analyze the structure and behavior of its component parts. The natures of some wholes or systems are not simply determined by the nature of their parts.
In the practice of psychiatry, this means that the behavior of a person cannot completely be predicted. All of our assessments look at parts of the person, but none can completely grasp the whole. Non-separability means that action at any one level of the person will be taken up and processed by all the other levels and may produce changes that cannot be anticipated. As an example, giving St. John’s Wort is more than just the effects of an herb. The act of giving activates other areas of the person, as does the context of giving, and the patient’s past experiences with treatment. Even simple matters as the appearance of the practitioner or what perfume she might have worn on that day can elicit associations that influence treatment. The concept of an inner healer (Mehl-Madrona, 2003), suggests that people do internalize and work with what they experience to move toward healing in ways that cannot be predicted or anticipated.
Classical science breaks wholes down into parts, believing that the states and properties of those parts completely determine the whole that they comprise. The state of some systems or wholes resists these kinds of reductive analyses. The suffering human being is one such system that is lost when broken into parts. The inner healer is mysterious and not completely predictable.
In physics the quantum state of a system describes the probability that it will take specific actions upon interaction with a measuring device. The human corollary is to think about the likelihood for people to take one action or another when they interact with a healer, an herb, or even a homeopathic remedy. Assessing someone changes them. Pure diagnosis is never possible. Systems theorists call this “perturbing” the system. When we interact with people, the nature of our being interacts with theirs to change the future. We are the measuring device. Our interaction with the patient forever changes the future.
The most complete specification for probability of behavior of a system is called the pure state in physics. Having a pure state means that we can predict all of the possible responses of a system. Even when systems have pure states, some of their components may not. This means that just because we know all the possible choices that the system can make when an interaction with an external system occurs (this is what a measurement is), we do not necessarily know anything about what will happen to the components of a system. For example, we can be certain that a family will go on, though we cannot be certain which members will die and when. Schrödinger describes these components as "entangled". This means, for example, that people who live in families are entangled; they can’t be teased apart and their responses predicted.
The Einstein-Podolsky-Rosen effect helps us to understand this notion of entanglement. In this phenomenon, particles that have been paired (meaning that they have opposite or complementary spins) are separated. When a magnetic field is used to reverse the spin of one particle, the other particle’s spin reverses simultaneously to maintain symmetry even though there is no known mechanism for the physical transfer of information from the reversed particle to the one making the reversal. Additionally, the reversal happens at faster than light speed. This means that information transfer occurs faster than the speed of light.
Remarkable is the lack of “normal world” explanatory mechanism by which the second particle can know that the first particle has changed, and the fact that the change is instantaneous. The two particles are non-separable, despite our ordinary ideas that we have separated them. Non-separable connections are maintained in ways that cannot be explained by everyday physics. In psychiatry, it means that we can know things that we are not supposed to know. Some call this kind of knowledge, paranoia, and, indeed, it can be exaggerated and distorted through pain and intense suffering to the point at which this knowledge seems insane. Others call it intuition. Nevertheless, the notion of inseparability is important, for it offers a way of having information that is outside of our ordinary concepts of space and time.
What this means for mental health is that information flows in ways we cannot anticipate. Information can transcend our usual perceptions of barriers. We can know things that we are not supposed to know and we can act on those things without being crazy. I suspect that schizophrenics are attuned to this reality but without any filtering capacity.
Methodological Holism represents the idea that certain systems are best understood at the level of principles governing the behavior of the whole system, and not at the level of the structure and behavior of the component parts. This is the kind of research and understanding we are trying to promote. Methodological Reductionism represents the way science currently thinks about systems as component parts that can simply be added together. Methodological reductionism guides most current research and treatment. A reductionistic study typically randomly assigns subjects to one of two treatment groups, comparing one very specific, single treatment to a control group. Reductionism assumes that the intent of the researcher will not affect the study. Consistently, researchers find what they expect to find. Even particle physicists find what they postulate. Reductionism ignores the possibility that we are all point-phenomenon in a spacetime field and privy to each others’ information whether we know it or not. Holism would deny the possibility of ever randomizing, since the assignment of a subject to one group (like making a measurement in quantum physics) affects all the other subjects, consistent with the Aharonov-Bohm effect. Symmetry must be maintained, and even of things that we can’t begin to suspect. Additionally, one treatment may only work when part of a suite of related treatments. This is the concept of synergy. Treatment may be non-linear. Any one of three potential treatments (herbs, psychotherapy, acupuncture) may be ineffective alone because each operate in a flat, linear area of the response curve. Taken together and applied simultaneously, they could push the response into the rapidly rising part of the curve. Then a major effect could be seen.

Psychiatric treatment also operates in methodological reductionism. We hear doctors (and even herbalists) counseling patients to do one treatment at a time, so that they will know what works. The systems perspective is that we can never know with certainty what works, because what is done is not independent from the state of the system to which it is done to. That state changes constantly (fluctuates or oscillates) in response to many environmental triggers that we can only guess. Treatment on one day could produce completely opposite results from treatment on other days. Homeopathic research has begun to suggest this. The remedy increases the oscillatory behavior of the system, making the change in energy state more likely (crossing over from illness to wellness), but not actually causing the healing.

In social science, societies are the systems, composed of individuals; while in biology, the systems are organisms, composed of cells, and ultimately of proteins, DNA and other molecules. A methodological individualist maintains that the right way to approach the study of a society is to investigate the behavior of the individual people that compose it. A methodological holist, on the other hand, believes that such an investigation will fail to reveal the nature and development of society as a whole. There is a corresponding debate within physics. Methodological reductionists favor an approach to (say) condensed matter physics which seeks to understand the behavior of a solid or liquid by applying quantum mechanics (say) to its component molecules, atoms, ions or electrons. Methodological holists think this approach is misguided. We need to understand how whole systems operate, which sometimes requires ignoring the parts.
The properties of a system depend upon the relations among its parts as well as upon the properties of the individual parts. But if we are permitted to consider all properties and relations among all parts, then these trivially determine the properties of the whole they compose.
The Aharonov-Bohm effect changed physicists’ conception of reality. Aharonov and Bohm (1959) drew attention to the quantum mechanical prediction that an interference pattern due to a beam of charged particles could be produced or altered by the presence of a constant magnetic field in a region from which the particles were excluded. This effect was then experimentally demonstrated. At first sight, the Aharonov-Bohm effect seems to involve action at a distance. It seems clear that the electro-magnetic field acts on the particles since it affects the interference pattern they produce; and this must be action at a distance since the particles pass through a region from which that field is absent. The same argument has been made for how distant energy healing or prayer works.

But, just as for distance healing, an explanation is possible which portray it rather as a manifestation of nonseparability [Healey (1997)]. There need be no action at a distance if the behavior both of the charged particles and of electromagnetism are nonseparable processes. Such treatment of electromagnetism is increasingly common in physics -- to treat the motion of the charged particles as a nonseparable process.
An interpretation of quantum mechanics that ascribes a nonlocalized position to a charged particle on its way through the apparatus is committed to a violation of spatiotemporal separability , since the particle’s passage constitutes a nonseparable process.
When we open ourselves to the implications of the Einstein-Podolsky-Rosen Effect or the Aharonov-Bohm Effect, we realize that fields may be more important than events, and that points in a field may be privy to all the information possessed by the field. Particles may traverse paths in space-time, interacting with electromagnetism where it is defined.
Quantum theory is interesting because it presents us with examples of physical events that defy our common assumptions about the universe. Perhaps these events are similar to what happens with distant prayer. An action and an effect occur outside of any known physical mechanisms and with not just faster than light speeds, but instantaneously! What this means for psychiatry is that people are connected at deeper and more profound levels than we ever imagined. Consider these examples: A spouse awakens in a cold sweat with chest pain at the exact moment that her husband has a heart attack 3000 miles away. A young woman at college sees her grandmother standing at the foot of her bed at the exact moment of the grandmother’s death. Less striking and more subtle examples happen all the time. The subtle energy shifts that occur during family therapy defy all explanations as post-hoc rationalizations. I see the family of an 84 year old man with prostate cancer. I don’t have a clue what I do for these people. Their family is so chaotic and disorganized as are their sessions. Essentially I sit with them as a witnessing presence. They leave feeling better, appreciating my help, and the man’s behavior dramatically improves for a week or so. When it starts deteriorating again, they call for another session. What do I do for him? Is it all explainable psychologically, or should we evoke quantum effects? Are subtle energy shifts occurring among us that defy rational characterization?
Physics is more about measurements than psychology. Yet what physics has recognized is how measurement changes the system that is being measured. We are less aware of this in psychology. Quantum theory predicts statistical correlations between measurements that are impossible by our ordinary conceptions of reality! Yet careful observation shows that these predictions are correct, despite their violation of ordinary laws of physics. Even the law of time only running forward can be violated. The inevitable conclusion is that spacetime itself and all that it contains represents a system.
The result of all these technical speculations is the simple Native American understanding that everything is connected. Not just people or animals, but every particle, however small. Every rock, molecule of water, packet of sunlight, are all connected to everything else. What this points to is the concept of field. Field is an elusive concept. We can see fields of energy only by their effects. We interpret the presence of a magnetic field by the patterns made by iron filings laid between magnets. What quantum theory suggests is that we are embedded in a very complex field that has the properties we are discovering from quantum theory.
Physicists (Wayne, 1998; Redhead, 1995) speak of field operators that operate at various spacetime points. The field operators produce the properties we are describing: non-separability, holism, instantaneous transformation, symmetry, and synergy. They say that the field is constructed out of products of all of these field operators.
At the turn of the 21st century, string theory (or its descendant, M-theory) has emerged as a speculative candidate for unifying much of fundamental physics, including quantum mechanics and general relativity. String theories operate in one or more dimensions of a space that has 6 or 7 tiny compact dimensions in addition to the three spatial dimensions of ordinary geometry. If these additional dimensions are appropriately considered spatial, then it is natural to extend the concepts of spatial and spatiotemporal separability to encompass them. In that case, processes involving classical strings (or p-branes with p > 0) would count as (spatiotemporally) nonseparable, even though all particles and their properties conform to spatial separability.

The idea is familiar (particularly to Lego enthusiasts!) that if one constructs a physical object by assembling its physical parts, then the physical properties of that object are wholly determined by the properties of the parts and the way it is put together from them. The principle of spatial separability tries to capture that idea.

Classical physics presents no clear examples of nonseparability . The assumption that all physical processes are separable forms the metaphysical background to classical physics. In Newtonian spacetime, the boiling of a kettle of water constitutes an example of separability. It represents the behavior of a system of point particles under the action of finite forces -- a separable physical process depending upon particular values of position and momentum of the particles along their trajectories during the collisions.
The boiling of a kettle of water is an example of a more complex separable physical process. It consists in the increased kinetic energy of its constituent molecules permitting each to overcome the short range attractive forces which otherwise hold it in the liquid. It thus supervenes on the assignment, at each spacetime point on the trajectory of each molecule, of intrinsic physical properties to that molecule (such as its kinetic energy), together with intrinsic physical properties representing the magnitude and direction of the fields that give rise to the attractive force acting on that molecule at that point.
Outcome independence-dependence is another important concept of systems theory. In outcome independence (Howard, 1989, 1992), given two entangled systems, the results of one set of measurements on one of the systems will not affect another set of measurements on the other system. Outcome independence is related to parameter independence, the idea that the relevant variables are unrelated. Quantum theory, however, predicts outcome dependent events, in which measurements made upon one system affect the measurements that will be made on the second system. I think of this as two families “joined” through the marriage of two children. An interview of one family will affect the results of an interview with the second family. Physicists think more in terms of statistical correlations of properties like spin and momentum. 4176
Properties of systems may only exist in the context of well-defined ways of making measurements of the property. This was Bohr’s (1934) view. He thought that the properties arose through interaction of the system being studied with the measurement system. Bohm (1980, 1993) took this further to assert that the system being studied and the measuring system constitute an indivisible whole. Bohm (1952) further developed the concept of the “undivided universe,” or the largest possible whole.
Albert Einstein said, “A human being is part of the whole, called by us ‘universe,’ a part limited in time and space. He experiences his thoughts and feelings as something separate from the rest – a kind of optical delusion of his consciousness. This delusion is a kind of prison for us, restricting us to our personal decisions and to affection for a few persons nearest us. Our task must be to free ourselves from this prison by widening our circle of compassion to embrace all living creatures and the whole of nature in its beauty.” [ix]
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[ix] Einstein A. Quoted in Bloomfield H. Transcendental meditation as an adjunct to therapy. Boorstein S. (ed.). Transpersonal psychotherapy. Palo Alto, CA: Science and Behavior Books, 1980, p. 136.
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