Kandel’s Challenge to Psychoanalysts

To the Editor: Eric R. Kandel, M.D., advocates adopting a new intellectual framework for the purpose of training future psychiatrists. Despite an admirable review of recent advances in neuroscience, Dr. Kandel’s article leaves two disturbing questions unanswered. First, to what precisely is he objecting, and second, might there be overlooked, undesirable consequences in adopting his framework?

Dr. Kandel asserts that medical students are not attracted to psychiatry because they sense that psychiatric training “is often based primarily on doing psychotherapy.” I would venture to say that most psychiatry training directors would disagree with this unsubstantiated assertion, claiming instead that their programs provide more than “just a nodding familiarity with the biology of the brain.” Even if Dr. Kandel’s assertion were true, it does not follow that psychiatric training is necessarily rooted in the particular brand of psychotherapy that he seemingly chiefly decries—psychoanalysis.

While Dr. Kandel is careful to make note of the importance of learning as well as social and developmental factors in accounting for the efficacy of psychotherapy and “the variance of a given major mental illness,” respectively, his framework is clearly intended to place “greater emphasis on biology.” I fear that the adoption of more overtly biological paradigms will result in psychiatry’s losing its already somewhat tenuous clinical credibility. My credibility with the department of family practice in which I work and teach, for example, is not based on my superior knowledge of neuroscience, my “facility with validated and objective criteria,” nor even my knowledge of psychopharmacology. Rather, it is primarily based on my ability to calm agitated patients, elicit the hopes and fears of those who are ill, and earn the trust of the mistrustful—skills that have been developed through painstaking training and practice. Dr. Kandel’s framework does not necessarily preclude the teaching and acquisition of these skills, but I fear that as psychiatry becomes more deeply embedded in overtly biological models, the result will be the further erosion of those assessment and therapy skills that are less than well understood from the biological perspective.

Some would argue that psychiatry’s rush to gain credibility in medical circles has already had unfortunate unanticipated consequences. Gary Tucker (1), for example, has recently argued that the adoption of DSM paradigms has resulted in just such consequences, robbing the profession of its distinctive richness and clinical validity.

One of Dr. Kandel’s chief aims is to transform psychiatry into a profession that “will take its commitment to the training of biological scientists more seriously.” In changing the conceptual framework of psychiatry with this aim in mind, let us not forget the careful training needed to acquire those clinical skills essential to the establishment of personal, human connections with patients. If we lose those skills, we lose the patients and the opportunity to use our large and growing knowledge of neuroscience to help them.