Dr. Carlos Sluzki - Articles
Submitted for publication to a refereed journal, 2005
116a. TOWARD AN EVOLVING THEORY OF PRACTICE
Carlos E. Sluzki, MD
After a review of Engel’s biopsychosocial proposal and of Kandel’s “principles for an integration between mind and brain”, the author introduces a set of propositions that aim at integrating neurosciences, genetics, the mind, and the social world into a succinct set of systemic formulations.
In preparation for two plenary presentations delivered at recent congresses on the interaction between genomics and family processes (Sluzki, 2005a, 2005b), I have been re-reading the set of publications that detail the results of the research projects led by Lyman C. Wynne and Pekka Tienari (Tienari, Sorri and Lahti I,1985; Tienari et al 1987; Tienari, Wynne et al.,1994, 2000, 2003, 2004), by David Reiss and his associates (McGuire et al, 1994; O’Connor et al., 1998; Pedersen et al, 1989; Plomin, Chipuer and Neiderhiser, 1994; Reiss et al, 2000; Reiss et al., 2001a and 2001b; Rende et al., 1993), as well as by other researchers exploring the interface between family processes and genetics. Those findings left me quite perturbed — much as a substantive therapy session would. This perturbation translated into perhaps minor but noticeable changes in my practice, clear evidence that some of my basic guiding tenets had been shaken — a sense that the relative weight of some components of the broad systemic guidelines underlying my practices of the field of mental health had been somehow reshuffled. It also led me to re-visit and re-think some core guiding models, as well as to muse on how do we train, or should train, therapists. Allow me to share some of these vicissitudes.
The fact that this Festschrift takes place at the University of Rochester makes only reasonable to start this examination of models with the paradigm proposed in this very University for the first time by George Engel in 1977, that of the bio-psycho-social approach, epitomized by his seminal Science paper (Engel, 1977; cf. also Engel, 1980, Frankel, Quill and McDaniel, 2003, and Rolland and Williams, 2005.) Ultimately, the model consists of a detailed specification of the eco-systemic hierarchy and continuum lodged between the biosphere and the subatomic particles, while its focus, and the many examples that enriched Engel’s publications and countless others in its support, has been centered in the mind-body interface. It was proposed as an alternative approach to the biomedical view or, as Lyman C. Wynne (2003) defined is, as an attack to reductionism as well as a plea for a systemic view of practice.
Engel did not write for the converted, so to speak. In fact, for those professionals already immersed in systemic models at the time of its publication — among them, many family therapists — , Engel’s paradigm contained an already very familiar tune. In fact, Engel acknowledged explicitly the influence that had on his views the flood of systemic principles that was permeating by then as a new wave the so-called soft sciences (making them less soft) and the so-called hard sciences (making less hard). But Engel wrote for the non-converted, he addressed the medical profession in general, and, more specifically, those professional dealing with the interface body-mind and with medical education. For them, and for many others for whom that model was a first exposure to systemic thinking, the impact was extremely substantial, and still is (cf., e.g., Frankel, Quill and McDaniel, 2003.)
Thirty years later, when revisiting Engel’s paradigm, the wisdom of hindsight allows us to comment that, while it shows its multilayered complexity each time he and other authors applies it to clinical examples, the model proper appears linear in its structure — a list of levels of systems, each inclusive of the previous one, Russian dolls-like — as well as non-evolutionary, without an explicit temporal dimension.
Fast forward twenty two years from Engel’s original publication. Many things happened during that lapse, among which the flood of neurosciences research fostered in good part by the strong support of the NIMH, made explicit by its designation of the 1990s as “the decade of the brain.” As part of that trend, the exploration of the genome was being designed. In 1998, perhaps as a reaction to the reductionstic trend of many of those projects and of the prior publications on genetics, Eric Kandel, neurophysiologist, psychiatrist, and recipient of the 2000 Nobel award in Physiology, proposed “five principles for an integration between mind and brain” (Kandel, 1998), a formulation that in turn reached a new generation of psychiatrists and of psychoanalysts. In fact, it was heralded that those principles provided the opportunity to “rewrite metapsychology on a scientific foundation” (Olds, cited by Kandel, 1999.) While apparently not built within nor directly inspired by Engel’s formulation — that author is not listed among Kandel’s references — , and while it focuses in a few of the multiple interfaces of the overinclusive systemic series proposed by Engel’s, Kandel’s model seems to expand the same family of ideas. At the same time, it was more focal, and seems to contain some specific directionality.
Kandel proposed the following set of principles (the parentheses are mine):
- All mental processes, even the most complex psychological processes, derive from operations of the brain (does “derive” mean that mental process are a product of operations of the brain? If affirmative, it subsumes the psyche to the soma!)
- Genes and their protein products are important determinants of the patterns of interconnections between neurons in the brain and the details of their functioning
- Altered genes do not, by themselves, explain the variant of a given major mental illness. Social or developmental factors also contribute very importantly….Learning, including learning that results in dysfunctional behavior, produces alterations in gene expression. Thus all of “nurture” is ultimately expressed as “nature.” (This statement qualifies the previous one. Could it be said, then, that, following the form of the first principle, major mental illness derive, at least in part, from social or developmental patterns?)
- Alterations in gene expression induced by learning give rise to changes in patterns of neuronal connections. These changes not only contribute to the biological basis of individuality but presumably are responsible for initiating and maintaining abnormalities of behavior that are induced by social contingencies. (Is this a qualifier of the second principle?)
- Insofar as psychotherapy or counseling is effective and produces long-term changes in behaviors, it does so through learning by producing changes in gene expression that alter the strength of synaptic connections, and structural changes that alter the anatomical pattern of interconnections between nerve cells of the brain. (He then ties this to a quantitative evaluation of the outcome of psychotherapy. This principle appears to be a benign expansion of the third principle that acknowledges, this time constructively, the influence of social factors and learning.)
These principles could be reduced, in my view, to three basic ones:
- Mind is biologically based
- Genes determine the biological base; and
- Experience — including learning and psychotherapy — structurally alters this genetic expression
As I read them, Kandel’s principles add an evolutionary component (both Darwinian and in the sense of human development), but are skewed toward the gene-body dyad and underplay the reciprocal nature of the influences between the levels he specifies. At the same time, Kandel’s reaching out to psychoanalysis opened an important dialogue with a paradigm that has shown in the past a tendency to lock itself into a closed cosmogony, and attracted the needed attention of many researchers and practitioners that shared that root.
Since Kandel’s formulation, a major scientific event has taken place, the monumental feat of mapping the whole sequence of the human genome, completed in 2003 by an international consortium — only eight years after the first outline for this line of research and only four years after the decoding of genome of the fruit fly. A wealth of research ensued, including large-scale studies of gene-expression — with extraordinary implications for evolutionary biology, as well as specific studies that determine the involvement of sequence in tumor formation, with enormous therapeutic potentials. Further, both the evolutionary rules followed by proteins and cells for an adequate development of the nervous system as well as the psychosocial experiences needed to alter the genetic expression appear to begin to be unveiled (Insel, 2005), among others, through the complex and rich nuances of the interface gene-environment revealed during the past ten years by the already mentioned pioneering research projects led by the Wynne/Tienari team and by David Reiss and his collaborators.
These new insights merit a revisiting of the prior propositions, at least to add these new insights so as to enrich them if not to attempt to explore components of a broader paradigm for our field. Attempting to do this as part of this Festschrift is both reasonable and risky. Reasonable because this gathering to honor Lyman C. Wynne may be the perfect venue for a respectful conversation among friends — a value that permeated and enriched each and all professional and personal interactions with Lyman — , and risky because a gathering of major intellectual forces in our field like this one constitutes a tough public to attempt the acrobatic act of climbing on the shoulder of giants. However… drums, please, maestro!
Allow me to display for your consideration a revised set of conceptual propositions — of guiding formulations — surrounding our main areas of expertise. They are probably just a reordering of the prior ones, visited above, calibrated differently so as to make more explicit the systemic interfaces adjacent to the psychosocial field, perhaps with some added overtones.
The first proposition of this set is, I believe, simply a tight reformulation of the core focus of Engel’s view:
- Mental processes, the neurobiological stratum and the social/relational world operate as a system, and as such reciprocally influence each other
One could question whether they “operate as a system” or they are a system, meaningless one without the other. It should be noted that “the social/relational world” is inclusive of several systemically related layers: the family, the personal social network, the community, the socio-economic environment, the ecological niche, et cetera. And, in turn, “the neurobiological stratum” is inclusive of several subsumed layers, from organism to cellular components, all in turn systemically related.
The second proposition specifies the non-static, evolving nature of that system, making explicit what in Engel’s proposal is implicit:
- Mental processes, the neurobiological stratum and the social/relational world co-evolve
The next three propositions simply specify in a more detailed manner the relationships between levels, while dissociating some of their components and assuring some psychosomatic loops:
- Changes in the social world unavoidably impact both the psychic world (the mental processes) and the somatic stratum, directly through the neuro-endocrine subsystem and indirectly through mental processes
- Changes in the neurobiological system unavoidably affect both the mental processes and the immediate social world
- Changes in the mental processes translate into changes both in the somatic stratum and in the immediate social milieu
The sixth one acknowledges the interface with heredity, building on Kandel’s statements — with a reminder that this is one of the core characteristics of living systems:
- All these processes are affected by, and affect, the genetically programmed proclivities (a characteristic inherent to all biological entities)
And the seventh proposition, a specification of the third one, is discontinuous from the others, a sort of “insiders’ comment” to remind us that we, psychosocial operators, have power, and that this is within our professional purview:
- The set [social milieu ◊ mental processes ◊ neurobiological processes] is sensitive to changes facilitated by psychotherapy (a social practice that perturbates one or more of the set’s interfaces.)
These seven propositions can be reduced, in my view, to four basic tenets:
- Mental processes, the neurobiological stratum and the social/relational milieu operate as a system or set, and as such reciprocally influence each other
- This set co-evolves
- This set processes are affected by, and affect, the genetic proclivities of individuals
- This set is sensitive to changes facilitated by psychotherapy
We social scientists have, understandably, a social-sciences bias or, at least, a privileged focus for speculation and for action: we intervene at the level of the psychosocial world of people. Further, from the perspective of these formulations, human problems are problems of calibration of processes within the biopsychosocial realm or of calibration of fit between levels of processes. In the latter case, our area of action can be defined as located at the interface between systemic levels, and changes we foster are changes toward perturbing, calibrating, or fitting interfaces.
If we accept that the focus of therapist is the vast territory of those sub-systemic interstices, then therapists should not only be learned about these subsystems and the process of fit and misfit between them but, equally important, keep these interfaces as a central locus of their practices. In fact, training of future therapists should include, if not be located, at those interfaces.
In the specific case of the interface between genetic and the psychosocial world, one of the many clinical corollaries of Lyman’s as well as David’s research is that the genetic program is a proclivity, not a destiny. Acknowledging both the presence and the malleability of the genetic potentials empowers families toward tolerating differences and calibrating their own style so as to maximize the positive components of interactions and interfaces and to minimize the negative ones: while therapeutic narratives based on “origin” or “cause” instill hopelessness, narratives based on “fit” are empowering.
And, I ask, does this broad view of interfaces permeate the way we actually do therapy, do they reflect in our theories of practice or theories in action, as Argyris and Schön (1974, 1978; cf. also Schön 1983) named those assumptions that guide our daily practices? Further, while we may believe the tenets proposed above — and even react with an “Of course!” when reading them — , are they reflected in the curricula with which we train the psychotherapists of the future? And, do they translate into our research designs?
I contribute this set of propositions as homage to the pioneering work and the humanistic spirit of the dear colleague whose life and work we are celebrating in this meeting. Lyman C. Wynne models for us the need to push the boundaries of our traditional models in the constant search toward a post-Cartesian, integrated vision of humans as simultaneously (and indivisibly) biologic, psychological and social beings.
- AAvv. (2003): Beyond Therapy: Biotechnology and the Pursuit of Happiness (A Report of the President’s Council on Bioethics). New York and Washington, Dana Press
- Argyris C. and Schön D. (1974) Theory in practice: Increasing professional effectiveness, San Francisco: Jossey-Bass.
- Argyris C., & Schön D. (1978) Organizational learning: A theory of action perspective, Reading, Mass: Addison Wesley.
- Ashby WR (1954): Design for a Brain. New York and London, Chapman & Hall.
- Bateson G (1972): Steps to an Ecology of Mind. New York, Ballantine.
- Bertalanffy Lv (1950): The theory of open systems in physics and biology. Science, 111:23-29.
- Bertalanffy Lv (1968): General Systems Theory. New York, Braziller.
- Buckley W (1968): Modern Systems Research for the Behavioral Scientist: A Sourcebook. Chicago, Aldine.
- Caspi A, MClay J, Moffit, TE, Mill J (2002): Role of genotype in the cycle of violence in maltreated children. Science, 297(5582):851-55
- Engel GI (1977): The need for a new medical model: a challenge to biomedicine. Science, 196:129-136.
- Engel GI (1980): The clinical application if the biopsychosocial model. Am J Psychiat, 137:535-44
- Frankel RM, Quill TE, y McDaniel SH, Comps. (2003): The Biopsychosocial Approach: Past, Present, Future. Rochester NY, University of Rochester Press.
- Ginker RR, Ed. (1956): Toward a Unified Theory of Human Behavior: An Introduction to General Systems Theory. New York, Basic Books (2nd. Edition: 1967.)
- Insel TR (2005): Commentary. In Kandel, ER (2005): Psychiatry, Psychoanalysis and the New Biology of Mind. Washington DC, American Psychiatric Publishing pp.27-31.
- Kandel ER (1998): A new intellectual frame for psychiatry. Am.J.Psychiatry, 155:457-469.
- Kande, ER (1999): Biology and the future of psychoanalysis: A new intellectual frame for psychiatry revisited. Am.J.Psychiatry, 155:457-469.
- McGuire S, Neiderhiser JM, Reiss D, Hetherington EM and Plomin R (1994). Genetic and environmental influences on perception of self worth and competence in adolescence: A study of twins, full siblings and step siblings. Child Development, 65(3):785-799.
- Morrison PJ (2005): “Insurance, unfair discrimination, and genetic testing.” (Commentary) The Lancet, 366, 877-880.
- O’Connor TG, Neiderhiser JM, Reiss D, Hetherington EM and Pomlin R. (1998): Genetic contributions to continuity, change and co-occurrence of antisocial and depressive symptoms in adolescence. J Child Psychol Psychiat and Allied Disciplines, 30:323-336.
- Pedersen NJ, Lichtenstein P, Plomin R, DeDaire U, McClearn GE & Mathhews KA (1989). Genetic and environmental influences for Type A-like measures and related traits: A study of twins reared apart and twins reared together. Psychosom. Med. 51:428-440.
- Plomin R, Chipuer HH, and Neiderhiser D (1994). Behavioral genetic evidence for the importance of the nonshared environment. In Hetherington, E.M., Reiss, D., and Plomin, R Eds.: Separate Social Worlds of Siblings: Impact of the Nonshared Environment on Development. Hillsdale: Lawrence Erlbaum.
- Reiss D, with Neiderhiser JM, Hetherington EM and Plomin R (2000): The Relationship Code: Deciphering Genetic and Social Influences on Adolescent Development. Cambridge, Harvard University Press.
- Reiss D, Pedersen NL, Cederblad M, Lichtenstein P, Hansson K, Neiderhiser JM and Ethammar O (2001a): Genetic probes of three theories of maternal adjustment: I Recent evidence and a model. Fam Proc 40:247-259.
- Reiss D, Cederblad M, Pedersen NL, Lichtenstein P, Elthammar O, Neiderhiser JM & Hansson K (2001b) Genetic probes of three theories of maternal adjustment: Genetic and environmental influences. Fam Proc 40, 261-272.
- Rende R, Plomin R, Reiss D and Hetherington EM (1993). Genetic and environmental influences on depressive symptomatology in adolescence: Individual differences and extreme scores. J Child Psychiat Psychol, 34(8): 1387-1398.
- Rolland JS and Williams JK (2005): Toward a biopsychosocial model for 21st Century genetics. Family Process, 44(1):3-24.
- Schön D (19983): The Reflective Practitioner. New York: Basic Books.
- Sluzki CE (2005a): “The interface between genomics and the family field.” Plenary presentation at the AFTA-IFTA 2005 International Conference on Family Therapy “Politics, Community and Clinical Practice.” Washington DC. J Family Psychotherapy (accepted for publication.)
- Sluzki CE (2005b): “The social nature of biological processes.” Keynote presentation at the IV World Congress of Psychotherapy, Buenos Aires, August 30, 2005.
- Tienari P, Sorri A, and Lahti I (1985). Interaction of genetic and psychosocial factors in schizophrenia. Acta Psychiat Scandinavica, 71:19-30.
- Tienari P, Lahti I, Sorri A, Naarla M, Moring J, Wahlberg K-E and Wynne LC (1987): The Finnish Adoptive Family Study of Schizophrenia. J Psychiat Research, 21(4)437-445.
- Tienari P, Wynne LC, Moring J, Lahti I, Maarala M, Sorri A, Wahlberg K-E, Saarento O, Seitamaa M, Kaleva M and Laksy K. (1994). The Finnish Adoptive Family Study of Schizophrenia: Implications for family research. British J Psychiat, 164:20-26.
- Tienari P, Wynne LC, Moring J, Läksy K, Nieminen P, Sorri A, Lahti I, Wahlberg K-E, Naarala M, Kurki-Suonio K, Saarento O, Koistinen P, Hakko H & Miettunen J (2000). Finnish adoptive study: Sample selection and adoptee DSM-III-R diagnoses. Acta Psychiatrica Scandinavica 101, 433-443.
- Tienari P, Wynne LC, Läksy K, Moring J, Nieminen P, Sorri A, Lahti I & Wahlberg K-E (2003). Genetic boundaries of the schizophrenia spectrum: Evidence from the Finnish Adoptive Family Study. Am J Psychiat 160, 1587 - 1594.
- Tienari P, Wynne LC, Sorri A, Lahti I, Läksy K, Moring J, Naarala M, Nieminen P & Wahlberg K-E (2004). Genotype-environment interaction in schizophrenia-spectrum disorder. Long-term follow-up study of Finnish adoptees. British J Psychiat 184, 215-222.
- Wiener N (1948): Cybernetics. Cambridge, MA, MIT Press (reprinted 1961).
- Paper presented in occasion of the Festschrift Conference in honor of Lyman C. Wynne MD PhD, University of Rochester School of Medicine and Dentistry, Rochester NY, September 9-10, 2005. It is loosely based on a keynote presentation delivered by the author at the IV World Congress of Psychotherapy, Buenos Aires, August 30, 2005.
- Research Professor, CHSHS, ICAR and KI, George Mason University, Arlington/Fairfax, VA; Clinical Professor of Psychiatry, George Washington University Medical School ( HYPERLINK “mailto:firstname.lastname@example.org” email@example.com)
- Bertalanffy’s writings (eg, 1950, 1958, 1968), the legendary Macy conferences starting in 1946, Wiener’s own pioneering synthesis (1948), et cetera, had already produced by then a major impact on the behavioral sciences (e.g., Grinker, 1956, Buckley, 1968, for some early echoes) and had spearheaded the development of family therapy, directly through Bateson and his co-workers (cf. e.g., Bateson’s 1972 collection of articles), and indirectly through the influence of the systemic paradigm in most of the pioneers and subsequent generations in the field.
- The following is an example of this reciprocity: Why some children who are maltreated grow up to develop antisocial behaviors, whereas others do not? Caspi et al. (2002) traced back a genetic susceptibility moderated by the functional polymorphism in the gene encoding the (neurotransmitter-metabolizing enzyme) monoamine oxidase A: maltreated children with a genotype that facilitates high levels of MAOA were less likely to develop antisocial problems.
- Genomics has also become a field filled with economic potentials — and hence mined by the private industry in developments parallel to pharmacology: attempts at exploiting advances for economic reasons, patent wars and promises of panaceas. To that should be added the ethical quagmires entailed in the potential utilization of genetic markers for differential selection criteria by managed care, health insurance, mortgage-related insurance (being considered with considerable controversy in the UK specifically for Huntington’s disease to prevent defrauding of insurance companies, Morrison 2005), and the distortion of genetic findings at the service of racist politics. This presentation does not explore these perils — there is an increasingly rich and eloquent literature on the subject — but only highlights the constructive potentials of the interface between genomics and the psychosocial world. For a discussion on bioethics with specific reference to neuroscience and genetics, cf., e.g., AAvv, 2003, the special 2004 issue on “Neuroethics” of the journal Cerebrum,