The 3 levels of psychiatric treatment: biological, psychosocial, moral

One can consider that psychiatric treatment occurs on three levels: biological, then psychosocial, and then moral-existential. First, if needed, the psychiatrist prescribes medication to rectify biological abnormalities. Second, the therapist facilitates psychotherapy to address psychosocial problems. Third, the therapist uses the clinician-patient relationship to demonstrate that he or she values the patient as a person, moving into the moral-existential dimension of therapy.

This three-level model holds that biological and psychosocial treatments are both valuable, albeit in different ways. To argue that talk therapy is better than drug therapy, or vice versa, is pointless; they serve different functions. As mentioned elsewhere, medication therapy may repair the chain of neurochemicals, but psychotherapy removes the tension on the chain that caused it to break.

Group therapy frequently helps diabetics cope with their illness, yet nobody would suggest that such groups regulate blood sugar; conversely, insulin regulates blood sugar, yet nobody would suggest it helps diabetics cope with their illness. Just as group therapy and insulin help patients with diabetes in different ways, so do psychotherapies and biotherapies help patients with mental disorders. Excellent therapists can have very different interests (e.g., psychoanalysis, medications) but still appreciate that each treatment serves a distinct purpose.

In general, biological therapies eliminate or alleviate symptoms, such as the insomnia of a person with depression, the delusions of a person with schizophrenia, or the spending sprees of a person in a manic state. In contrast, psychosocial therapies usually address issues, such as coping with a job loss, a failed marriage, a medical condition, or a psychiatric disorder. When used properly, biological and psychosocial therapies do not impede but facilitate one another. Repeated evidence has shown that medications do not increase the patient’s passivity, decrease motivation, or diminish involvement in psychotherapy. Correctly medicated patients gain more from psychotherapy. Wildly hallucinating people with schizophrenia feel so bombarded by stimuli that they cannot focus sufficiently to benefit from psychotherapy; once medicated, they can.

Conversely, psychotherapies can accomplish what drugs cannot. They can teach patients about their mental disorders: their symptoms, dangers, causes, and precipitants. Psychotherapies can alert patients to situations that are likely to trigger another episode of illness, help patients understand what their conditions mean to them, and improve patients’ willingness to adhere to the psychiatric treatment plan, such as taking medication. They can also facilitate social adjustment, interpersonal relationships, leisure-time pleasures, or occupational skills, as well as heighten self-esteem, guide ambition, and promote well-being. Finally, psychotherapeutic investigation can reveal how previous experiences affect current difficulties. A patient who cannot figure out why terrible things keep happening to her, why people are rude to her, why men avoid her, why nobody will hire her, can be shown why these events happen, what she can do about them, and how she can regain control over her life.

Evidence-based medicine uses scientific findings (research), clinical experience (judgment, expertise), and patient values and preferences to determine which treatments are most likely to be effective. Efficacy in clinical trials is just one portion of this assessment; it is important for treatments to work effectively in complex real-life settings. A laser focus on efficacy in a medication trial is easier to measure than complex accommodations to a patient’s schemata; however, large-scale changes in meaning are known to create profound behavioral change.

The moral-existential aspects of therapy do not necessarily involve specific treatments or occur during specified periods. Instead, they prevail throughout therapy, pervading both biological and psychosocial treatments. Moral-existential interventions involve the “realm of pure value, where the ultimate aim is integrity of the person … [They entail] moral qualities of trust and gratitude, of loyalty and devotion, and above all, of respect … the therapist becomes firm in the resolve to stand by the patient, even to tolerate a measure of moral failure.” While therapists may not condone their patients’ behaviors and choices, they accept patients for who they are. Once patients grapple with their ambivalence and understand what their choices are, they must make an existential decision. At times, these changes seem to be more like realizations or aha moments than like actual decisions. At times, these changes do not happen, or at least not at this moment. Clinicians learn to accept such decisions and experiences. While supportive therapy provides life skills, and cognitive behavioral therapies are sharply focused on specific behavioral changes or symptom management, moral-existential interventions are aimed at large-scale changes in the patient’s meaning that result in significant global behavioral changes. This sort of shift in meaning is not nebulous and can result in profound practical changes in a person’s life. People’s’ stories infuse their lives and actions with great meaning while de-emphasizing other aspects that are not integral to the preferred story or to its meaning. When they choose to change the stories or their focus, it changes the meaning and vice versa.

These changes can also be deeply experiential epiphanies rather than information-based changes. A single occurrence of even a trivial event can facilitate major change, such as a person escaping addiction after catching a glimpse of himself in a mirror snorting cocaine. This sudden shift in meaning happens when the person seemingly steps outside of self for a moment to observe from a different perspective. The goal in developing motivational interviewing was to create these sorts of changes in a therapy session. The possible decoupling of the medial temporal lobe from high-level cortical regions that seems to occur with the use of psychedelics may cause enough dissociation of self to allow for believable new self-statements to produce extended changes in life values as assisted by the therapist.

Mark D. Kilgus is a clinical professor of neuropsychiatry and behavioral science. Nicolas Badre is a clinical and forensic psychiatrist.