How Much Progress Have Psychology and Psychiatry Really Made? A Freakonomics Quorum
We invited some people who think a lot about such issues — David B. Baker, John Medina, Dan Ariely, Satoshi Kanazawa, Peter D. Kramer, and Laurie Schwartz — and asked them the following:
How much progress have psychology and psychiatry really made in the last century? Do we know enough about the human psyche to prescribe the medication that we do?
Here are their answers. Thanks much for their participation and insights.
John Medina, a developmental molecular biologist, author of Brain Rules, an affiliate professor of bioengineering at the University of Washington School of Medicine, and columnist for the Psychiatric Times.
“I certainly applaud the point of view of explaining psychological processes in biological terms … I am also the first to admit, however, that the view we get can be very disturbing.”
How much progress has psychology really made in the last century? A lot, though the journey has been depressingly uneven.
Psychology is a truly original scientific product of the 20th century — the first real attempt to take the interior mental life of people seriously. Before that, we were drilling holes into the heads of mentally ill patients to drive out hallucinogenic spirits, or saying mental health was the interactive balance between a person’s bile and their phlegm.
My personal hero in the exodus away from mental superstition is a large bolus of ego named Emil Kraepelin (1856 to 1926). He had the audacity to assume everything that was psychological was simultaneously biological. Emil posited that by using the investigative tools of natural philosophy to study the brain, one could eventually ferret out the secrets of the mind. To show how truly radical this idea was, astronomers in his day were actively debating whether or not the dark places on the moon were caused by enormous swarms of migrating insects.
Though prescient, Emil’s perspective did not stop psychology from taking detours.
Kraepelin’s point of view was lost for many years, obscured in the more American-favored, Victorian-drenched, nightmarish world of Freud, feces, and sex-with-your-parents.
Much has changed, fortunately. With the advent of modern neuroscience, the contributions neurochemistry makes to older psychological observations in human behavior are becoming clearer and Kraepelin’s point of view has returned with a vengeance. By the end of the 20th century, the emerging science of cognitive neurobiology was born and growing. It is a very exciting time to be a neuroscientist.
Do we know enough about the human psyche to prescribe the medications that we do? No. But we have had to do something, because people all over the world regularly try to kill themselves, and drilling holes in their heads or measuring their bile or even giving them a good pep-talk often doesn’t save their lives.
When you give such people proper therapy, which can include medications thoughtfully prescribed under the care of a well-trained therapist, they often stop killing themselves. They often report becoming — in their words — not “better,” but “normal.”
I certainly applaud the point of view of explaining psychological processes in biological terms — I’m a molecular biologist, for heaven’s sake — and enjoy exploring the chemical contributions to human behaviors. I am also the first to admit, however, that the view we get can be very disturbing.
There is an old neuroleptic drug called phenothiazine. It works by binding to certain receptors in the brain, and if you give it to schizophrenics, many of them stop their otherwise full-blown hallucinations. In the bioengineering lab, we can quite easily lop an interior atom off such a drug. If I do that with just one well-placed carbon in phenothiazine, the medication no longer binds to the receptor. When that happens — and you give the modified drug to treatable patients — their hallucinations return.
Does that mean I can turn off such complex human behaviors as full-blown hallucinations with the presence or the absence of one single, lousy carbon atom? It most certainly does. You could be forgiven if that makes you queasy — or angry. Seems like Kraepelin’s perspectives, old as they are, still have the power to shake people up — even scientists who do it for a living.
We certainly don’t know enough about the human psyche to prescribe everything. But we are learning more and more each day. Someday we will understand the chemical relationships to human behaviors very well. God help us to use the information responsibly when we do.
Peter D. Kramer, clinical professor of psychiatry and human behavior at Brown University, the author of Listening to Prozac, Against Depression, and Freud: Inventor of the Modern Mind, and his own blog, In Practice.
“Psychoanalysis may have created a misleading paradigm.”
One century ago, in the year before Freud and Jung’s famous visit here, American psychiatry was in crisis. There had been hope for treatments like hydrotherapy and electric stimulation, along with asylum care, but cure rates had proved disappointing. Meanwhile, psychologists had a sense that social pressures, including a trend toward late marriage, were causing illness rates to rise. That’s why there was growing enthusiasm for psychotherapies, especially those involving the revelation of repressed sexual drives.
This cutting-edge treatment — medical, as opposed to already popular religion-based psychotherapies — was not well-developed or widely available, but its principles were understood at the leading centers.
For fifty years, psychiatry moved on this track — the elaboration of Freudian principles. If we accept the premise that the active elements in therapy are “general” ones, like the rapport between patient and doctor, then there is little reason to believe that what we offer today is more effective than what patients received in the first half of the last century. (For a convincing statistical elaboration of this sort of argument, I recommend The Great Psychotherapy Debate, by Bruce Wampold. No particular approach, Wampold demonstrates, has proved its superiority. In particular, he debunks many of the special claims of cognitive therapy.)
Psychoanalysis, in imitation of its founder, became rigid and authoritarian. In response, variant treatments flourished, including ones that found room for empathy from the therapist, rather than emotional withholding. By the 1970’s, researchers counted hundreds of distinct schools of psychotherapy. I loved those middle years — loved to collect odd therapies and stitch their methods into my work.
Lately, therapy has been on a diet. A handful of manualized varieties — “cognitive-behavioral,” “interpersonal” — get all the press and research funding. Meanwhile, there is the problem of insurance companies, which limit expenditures. By my scorecard, I would say that we have made strides in psychotherapy over the century, but it is also possible that today we are “past peak,” and that the glory days are behind (and, we can hope, ahead of) us.
Meanwhile, in 1908, Paul Erlich‘s laboratory developed Salvarsan. “Dr. Ehrlich’s Magic Bullet” — the nickname is also the title of a charming Edward G. Robinson biopic — was an arsenic-containing compound that is considered the first antibiotic. Salvarsan was a specific against syphilis, which as it progressed might become “generalized paresis of the insane,” one of the most serious and common mental afflictions of the era.
In this arena — the overlap of psychiatry and general medicine — change has been stunning.
The hormonal, nutritional, vascular, and infectious diseases that cause mental illness are vastly more preventable and treatable than they were a century back — think of blood tests that allow us to diagnose subtle thyroid deficiencies or scans that reveal lesions in the brain.
One offshoot of that progress was the birth at mid-century of modern psychopharmacology, via the development-from antihistamines, antitubercular drugs, and later, antiepileptics — of medications to treat schizophrenia, depression, and bipolar disorder.
A separate development, the discovery of the mood stabilizing properties of lithium salts, may be the single most important development in the history of psychiatry. It might be argued that (parallel to the case for psychotherapy) by the 1970’s, psychotherapeutic drugs were available that were as effective as any we have seen since.
But the newer medications for all the major diseases are better tolerated, and doctors have gotten more skilled at combining treatments. While giving a nod in the direction of the many arguments about the inaccuracy of diagnosis (see my comments here and here), mis-prescribing and over-prescribing (here), and the deceptiveness of Big Pharma (here and here), I would say that, because of pharmacotherapy, we are much better today at treating mental illness than ever in the past.
Looking at the broader picture, including both drugs and talk therapies, it might be fair to argue that more progress was made in the past century in the treatment of mental illness than in the entire prior history of medicine.
Do we know enough psychology to back our pharmacotherapy?
Always, we would wish to know more. The key issue is the nature of the relevant wisdom.
Psychoanalysis may have created a misleading paradigm. I don’t know that further information about unconscious conflict will inform prescribing. (Often now, as in standard cognitive approaches, it does not inform psychotherapy.) It may be that medicating simply is the sort of task where what would guide us better is more refined knowledge about diagnosis, drug mechanism of action, side effects, brain pathways, genetics, biological resilience, and the like — along with the usual doctor-ly expertise about the patient’s personality and life circumstances. I say that this gross sort of understanding might suffice because the medicines we have at hand are reasonably coarse in their effects. If we had subtler drugs, we would need subtler knowledge.
Let me end with a clinical vignette:
Not long ago, I was treating a young mother after the birth of her second child. We were doing psychotherapy, discussing her response to the constraints that a larger family put on her life. When her milk supply stopped, this woman developed a rapid-onset, dangerous post-partum depression.
This condition can be hard to treat, but we were lucky, and a simple combination of medications ended the episode. Then, within weeks, my patient suffered a grievous loss and slipped back into depression. This stressor was straightforward — but how ought we to respond? More frequent therapy sessions? Riskier medications?
At this juncture of biology and meaning, we simply do not have enough to guide us. We tend to up the ante in both spheres, and often we are lucky again. But it would be better to know more. At the same time, this case illustrates the level of our progress. At any other point in human history — in 1908 — the outcome of this sort of story would have much more likely been disastrous.
Laurie Schwartz, a wife of 30 years, mother for 28, and a library assistant.
“Four years ago I lost a beloved son to suicide due to bipolar disorder. As devastating as this is, I do believe that the treatment he received increased his quality of life and chances for survival.”
I believe that the field of psychology has made great strides forward in studying, understanding and treating mental illnesses. When I was growing up in the late sixties and early seventies, we lived near an institution called “Eloise,” which is where the “crazy people” lived. The stigma was strong, and to be called “crazy” was threatening to me as a child because the association was obvious.
For most people suffering from a mental illness to be able to live and function in mainstream society today is a big step forward, and that progress is the direct result of better understanding and treatment of mental disorders.
Four years ago I lost a beloved son to suicide due to bipolar disorder. As devastating as this is, I do believe that the treatment he received increased his quality of life and chances for survival. His doctors and therapists were compassionate and concerned, working very hard to assess and adjust his treatments, and I came to respect the complexity of his condition and what they were trying to do on his behalf.
Is it possible he was in some ways a guinea pig in terms of the various medications he took? Perhaps, but I believe they were our only hope of giving him a chance in light of the seriousness of his condition and his previous suicide attempt. When he did complete suicide, we discovered that he had stopped taking his medications, so I don’t blame the medications, but the lack of them.
When Matt was diagnosed as a teen in the mid-1990’s, there were very few resources available to us, especially about early onset/childhood bipolar diagnoses. Since then, much progress has been made to study and understand this particularly devastating type. Several months after Matt died, a wonderful magazine was first published, called bp Magazine that I continue to subscribe to. It is written for, by, and about people with bipolar disorder, and has really helped me to understand the complexity of this illness in laypersons’ terms.
I currently work at a public library, where I have been surprised and encouraged to see people checking out many books about every aspect of bipolar disorder; these weren’t available when I needed them, but they are now.
I regularly read newspaper articles about new discoveries and insights into the genetics of mental illnesses, and am encouraged by the outpouring of support for mental health parity in medical insurance coverage. I have been asked to tell Matt’s story for the benefit of a book being written by a psychiatrist to help school counselors, teachers, and coaches look for warning signs in high-school students to prevent possible suicide attempts. And I participate in Survivors of Suicide, a national network of survivor support groups that try to help the surviving victims and increase social awareness of diagnosing and treating mental illnesses and suicide prevention.
I really believe that much is being done to grow in knowledge and understanding of the true suffering experienced by people with mental illnesses, and that the majority of researchers and practitioners are doing their best for the good of humanity.
There are serious risks inherent in the search for knowledge and treatment, especially in the use of medications, but we can’t ignore what the lack of knowledge and treatment can lead to. I am grateful for all that was done for Matt, and hope and pray for a better future for others.
Dan Ariely, Alfred P. Sloan Professor of Behavioral Economics at the M.I.T. Sloan School of Management, principal investigator of the MIT Media Lab’s eRationality group, and author of Predictably Irrational: The Hidden Forces that Shape Our Decisions.
“This, in my mind, is another important lesson that psychologists have learned — that our intuitions about what drives our behavior are not always correct.”
When I was a psychology student, whenever I met people and told them what I was studying they immediately assumed that I was a clinical psychologist (a Freudian psychologist in most cases) and the discussion progressed in interesting ways from there.
The reality is that clinical psychology is just one of many different branches of psychology. A few others include developmental psychology (largely dealing with how we change over time), learning (mostly looking at how animals and humans learn), animal models for different diseases (such as depression and Alzheimer’s), perception (how we see, hear, etc.), psychometrics (how we should construct tests), and human factors (how to build computer interfaces and products that fit our ability).
While each of these sub-fields has developed substantially in recent years, I will focus here on two other sub-fields of psychology: social psychology and the psychology of judgment and decision making (also known as J.D.M.) because they are the most relevant to economics and because I know more about them.
In my mind, we have learned three main lessons in these two sub-fields: 1) that the environment has a large, yet unrecognized, effect on our behavior; 2) that our intuitions about what drives our behaviors are flawed; and 3) that emotions play a large role in our decision making. Let me give some examples.
The environment has a large, yet unrecognized, effect on our behavior.
One of my favorite graphs in all of social science is the following plot from an inspiring paper by Eric Johnson and Daniel Goldstein. This graph shows the percentage of people, across different European countries, who are willing to donate their organs after they pass away. When people see this plot and try to speculate about the cause for the differences between the countries that donate a lot (in blue) and the countries that donate little (in orange) they usually come up with “big” reasons such as religion, culture, etc.
But you will notice that pairs of similar countries have very different levels of organ donations.
For example, take the following pairs of countries: Denmark and Sweden; the Netherlands and Belgium; Austria and Germany; and (depending on your individual perspective) France and the U.K. These are countries that we usually think of as rather similar in terms of culture, religion, etc., yet their levels of organ donations are very different.
So, what could explain these differences? It turns out that it is the design of the form at the D.M.V. In countries where the form is set as “opt-in” (check this box if you want to participate in the organ donation program) people do not check the box and as a consequence they do not become a part of the program. In countries where the form is set as “opt-out” (check this box if you don’t want to participate in the organ donation program) people also do not check the box and are automatically enrolled in the program. In both cases large proportions of people simply adopt the default option.
You might think that people do this because they don’t care — that the decision about donating their organs is so trivial that they can’t be bothered to lift up the pencil and check the box. But in fact the opposite is true.
This is a hard emotional decision about what will happen to our bodies after we die and what effect it will have on those close to us. It is because of the difficulty and the emotionality of these decisions that they just don’t know what to do, so they adopt the default option (by the way this also happens to physicians making medical decisions, and also to people making investment and retirement decisions).
The organ donation issue is just one example of the influence of rather “small” changes in the environment (opt-in vs. opt-out) on our decisions.
The more general point is that the environment has a large effect on our behavior — suggesting that if we want to have a validly descriptive model of human behavior we must incorporate the environmental variables into our models.
Our intuitions about what drives our behaviors are flawed.
Using the organ donation example again, think for a minute about whether you are willing to accept the idea that you yourself would be influenced by the opt-in or opt-out framing of the form at the D.M.V. It is easy to accept that those funny Europeans would be influenced by such small things, but it is incredibly difficult to accept that we ourselves would behave differently in these two scenarios.
This, in my mind, is another important lesson that psychologists have learned — that our intuitions about what drives our behavior are not always correct. This understanding is important for the way we think about economics (which is based on intuitively appealing psychology) and for the role of experiments in psychology.
The moment you realize that your intuition about your own behavior might be wrong it is clear that you need another, more objective input.
This is what experiments are all about. We could have never intuited the opt-in, opt-out effect, nor could we have intuited the magnitude of this effect, and this is why empiricism is so important.
This lesson is also important for policy. If our intuitions are fallible, and the only way to know things for sure is to try them out in an experiment, shouldn’t we ask the government to first test its ideas before it invests billions of dollars of our tax money into particular programs (for example the most recent $153 billion stimulus package)?
Emotions play a large role in our decision making.
A third important lesson we continue to learn about psychology concerns the role of emotions in our decisions. We used to think about decisions as old, calculated, detached, computations that examine the costs and benefits — but recently we have gained a higher appreciation for the role of emotions in our decisions and for the fundamental ways in which they change us.
One example of this is a fantastic paper by Paul Slovic in which he asks the question of why we care about baby Jessica (Remember her? The cute kid that got stuck in a well 20 years ago … ) but don’t seem to care as much about genocides such as the one in Darfur (where 800,000 people were murdered in about 100 days, while the world watched and did nothing).
Of course there could be many reasons for the difference but it is rather amazing to realize that baby Jessica got more C.N.N. coverage than Darfur. Why? One of the emerging reasons for this seems to be that we are called into action by emotions — we see a cute toddler in trouble, and our hearts go out to her, but numbers and statistics numb our emotions and reduce our motivation to act.
Joseph Stalin expressed this sentiment when he claimed that “One man’s death is a tragedy. A thousand deaths is a statistic.”
Nobel Prize winning physiologist, Albert Szent-Gyorgi had a related observation: “I am deeply moved if I see one man suffering and would risk my life for him. Then I talk impersonally about the possible pulverization of our big cities, with a hundred million dead. I am unable to multiply one man’s suffering by a hundred million.”
It turns out that we are numbed by numbers much quicker than Stalin and Gyorgi suggested.
For example, it turns out that describing one starving child in Africa creates higher emotional responses than describing two starving children using an equivalent amount of information. The single child creates a higher emotional response and, as a consequence, people donate more money to the one child compared with the two. It also turns out that describing one starving child creates more emotional reactions (and donations) relative to a situation where the same child is described but this time with additional information concerning the magnitude of the hunger problem (3 million kids in Malawi are facing hunger).
Emotions are an integral part of who we are, a part that represents our evolutionary history, a part that is a basic and necessary component of our behavior. We are learning more and more about emotions and their effects on us all the time, but it is also clear that we need a greater understanding of emotions if we want to understand and predict human behavior.
Do we know enough about the human psyche to prescribe the medication we do?
I think that there is a larger economic-related issue here, and this is the question regarding the optimality of the medicine market. Let’s look at some general facts about this market:
We spend about 19 percent of G.D.P. on health; there are many people involved; many of the people who work in this market are experts; and there are many natural opportunities for learning (journals, patients, and treatment opportunities are only a few examples). All of these would suggest that the medicine-market would be a market where we would have achieved an optimal outcome (large financial motivation and many opportunities to learn).
But any serious observation into the reality of this market makes it crystal clear just how much we don’t know. And this lack of knowledge is evident for old treatments, not just for new treatments. For example, after about 30 years of giving young kids cough syrup for cold symptoms, we recently realized that this is a bad idea and the F.D.A. announced that we should stop.
How can it be that with all this energy, time, and money the medicine market remains so primitive in terms of its ability to learn about the optimal outcome? I suspect that the answer is that learning, and natural learning in particular, is much harder than we imagine and, as a consequence, we end up with intuitions about what should work but not with real knowledge.
I also think that it is time to try and fix this situation. If we accept the notion that we are inefficient in naturally learning about what works and what doesn’t work, we should also try to create better mechanisms that would force us to carry out controlled studies and force ourselves to learn more over time. Is an F.D.A.-on-steroids type of institution in our future? I sure hope so.
David B. Baker, professor of psychology, the Margaret Clark Morgan Director of the Archives of the History of American Psychology, University of Akron, and co-author of the book From Séance to Science: A History of the Profession of Psychology in America.
“Humans are a complex and messy species and as such continue to offer psychology plenty of material to work with.”
A nuanced answer is that “progress” can be measured using many yardsticks. A quick and simple answer is that psychology has made abundant progress.
A century ago one could be labeled “feeble-minded,” committed to an institution, subjected to sterilization, and be powerless to do anything about it. In the span of 100 years, psychological science and practice have made significant gains in assessing and treating the human condition.
Psychological research played a key role in the 1954 Supreme Court ruling that found school segregation to be unconstitutional. In 1957, psychologist Evelyn Hooker examined the personalities of homosexual and heterosexual men and found no differences. Her work helped to end the labeling of homosexuality as a mental illness. Stanley Milgram‘s seismic studies of obedience and conformity in the early 1960’s offered a view of human nature that continues to inspire debate and discussion.
Every aspect of modern life is touched by psychology. When you fly in an airplane your safety has been enhanced by the work of psychologists who help make cockpits more manageable. If you question your child’s readiness for school, a psychological assessment can provide useful data to help your decision making. If a loved one is battling depression, proven psychological treatments are available. Psychological science and practice not only point to what is helpful, they also alert the public to questionable practices. Facilitative communication is an unfortunate example.
Suggestibility was a topic of interest to psychology a century ago. Today, studies of ways in which the mind can deceive have matured and the results are instructive. There is a substantial body of research that shows memory is a fragile faculty capable of being easily distorted and manipulated.
In the 1980’s the McMartin Preschool abuse scandal brought significant attention to the issue and more recently, Hillary Clinton found out just how dangerous a false memory can be.
Psychological science continues to show that our thinking is prone to a host of errors. Consider the phenomenon of illusory correlation. Illusory correlation is seeing a relationship between two events where none exists. The debates over Iraq offer plenty of examples. Not that long ago many Americans believed that Iraq played a role in the attacks of 9/11, a relationship that George Bush denied. Understanding and counteracting distortions of our thinking and reasoning can provide a powerful antidote to many of the ills that beset us.
Psychology has offered a better understanding of our behavior and its relationship to our well-being. The leading causes of death in America, heart disease, and cancer, have strong behavioral components. Encouraging healthy behaviors (diet, exercise) and eliminating unhealthy ones (smoking) are activities that psychologists are well suited to address.
The same is true for the leading causes of death among young people (accidents, homicides, and suicide). Psychology has come a long way in a 100 years but much remains to be done. Poverty, violence, and injustice are reminders. Humans are a complex and messy species and as such continue to offer psychology plenty of material to work with.
“I think the field of psychology began making important and cumulative progress when it ceased to be a social science, and became a natural science.”
In my opinion, the progress in psychology in the last century (say, 1908 to 2008) has not been constant or steady. For the first three-quarters of a century or so, there was very little cumulative progress, as the field underwent one fashionable fad after another (Freudian psychoanalysis, behaviorism, “cognitive revolution,” etc.).
I think all of this changed about 25 years ago, with the emergence and success of three subfields: evolutionary psychology, behavior genetics, and cognitive neuroscience. There has been steady accumulation of scientific knowledge about human behavior and cognition since the emergence of these fields.
To put it another way, I think the field of psychology began making important and cumulative progress when it ceased to be a social science, and became a natural science. Psychology is really a branch of biology or zoology. The success of evolutionary psychology, behavior genetics, and cognitive neuroscience also underscores the importance of reductionism in science — as all good science is reductionist. These fields reduce psychology to (more fundamental) biology and biochemistry.
Do we know enough about the human psyche to prescribe the medication that we do? This is a very interesting question, but I regard it as lying outside the realm of science. As I have said elsewhere, the only purpose of basic science is to explain nature; the only purpose of psychology as a basic science is to explain human cognition and behavior.
Helping people is not part of basic science; medicine and psychiatry are applied sciences or engineering, not basic sciences. So anything that involves medication in the hope of helping people, alleviating pain, or curing diseases is not part of science.
If I may venture a guess as an outsider (as a basic scientist unconcerned with and uninterested in helping people), we may now know enough to treat some symptoms with proper medication, but not the ultimate causes. We may know how to alleviate symptoms, but not why diseases occur in the first place (especially in the area of mental health). One important lesson from the field of Darwinian medicine is that sometimes alleviating the symptoms prolongs the disease itself, and it is often better not to treat them (as when taking aspirin to reduce the fever prolongs the flu by not allowing the body to kill the flu virus in the body).