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Biological v. psychosocial treatments: a myth about pharmacotherapy v. psychotherapy

  • Aaron Prosser (a1), Bartosz Helfer (a2) and Stefan Leucht (a3)

Despite evidence for their comparable efficacy, psychotherapy faces a dramatic decline relative to pharmacotherapy in psychiatry. A deep ideological reason for this decline centres on the belief that psychotherapy is a psychosocial treatment whereas pharmacotherapy is a biological treatment. Modern cognitive neuroscience demonstrates that this distinction is a myth.

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Corresponding author
Aaron Prosser, MSc, Complex Mental Illness Program (Forensic Division), Centre for Addiction and Mental Health, 1001 Queen St. W, Toronto, ON, M6J 1H4, Canada. Email:
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Declaration of interest

S.L. has received honoraria for consulting/advisory boards from Alkermes, Bristol-Myers Squibb, Eli Lilly, Janssen, Johnson & Johnson, Lundbeck, Medavante and Roche; lecture honoraria from AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Essex Pharma, Janssen, Johnson & Johnson, Lundbeck, Pfizer and Sanofi-Aventis; and Eli Lilly has provided medication for a trial for which he was the primary investigator.

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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Biological v. psychosocial treatments: a myth about pharmacotherapy v. psychotherapy

  • Aaron Prosser (a1), Bartosz Helfer (a2) and Stefan Leucht (a3)
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Biological v psychotherapeutic: Friston and psychodynamic therapy

jeremy a holmes, Visiting Professor of psychological therapies, University of Exeter, UK
20 April 2016

Prosser et al (1) cogently argue that psychotherapeutic treatment is no less ‘biological’ than pharmacotherapy – a point also made by Bowlby (2) who argued, from an ethological perspective, that behaviour is shaped by evolutionary processes no less than anatomy.

However, in linking Friston’s ‘free energy’ principle with CBT they fall into the trap of ‘brand nominalism’ (e.g. Hoover/vacuum cleaner, Coke/soda, Kellogs/breakfast cereal etc). There is a lot more to psychotherapy than CBT; arguably psychodynamic therapy fits the Friston bill rather better than Beck’s baby.

As I (a non-mathematical psychotherapist) understand it, the essence of the free energy model is the brain’s Baysean shaping of sensory input into experience according to a probabilistic calculus. In healthy psychological functioning discrepancies between prediction and input are resolved by action to reduce uncertainty and update probabilities. Underlying many psychiatric disorders are relational difficulties arising out of outmoded free-energy reducing models. For the psychologically unwell both action and tolerance of uncertainty entailed in updating are inhibited.

Psychodynamic therapy addresses this in a number of ways by : a) creating a trusting attachment relationship, thereby instating an ‘epistemic superhighway’ (3) . This, by ‘borrowing’ therapists’ brains’ free-energy reduction (i.e. their trained Baysean skills) reduces clients’ need to cling to free-energy minimisation at all costs, b) offering an ambiguous stimulus via the neutral transference-promoting stance of the therapist , c) promoting ‘action’, not in the CBT sense of ‘experiments’, but in exploring the resulting fears and fantasies – i.e prior predictions -- that arise in vivo with the therapist, d) tolerating the free energy liberated by abandoning these predictions e) instating more adaptive relational probablisms and f) reinforcing the capacity for action and updating in the living/learning everyday world, whether ‘natural’ or culturally created (e.g. therapeutic Day Hospitals, group therapy etc).

Psychodynamic therapy is thus not, as Freud dubbed it, ‘the impossible profession’, but the ‘improbable profession’, in that it helps its clients revise their predictions and, in collaboration with the trusted secure base, to live with, and put to good use, the ‘surprise’ associated with liberated free energy. These processes are far from exclusively ‘top down’ as Prosser et al suggest, but implicate the amygdala as much as the prefrontal cortex, and need to be seen in the context of the synchronous ‘social brain’ of client and therapist acting in concert.

Prosser, A., Helfer, B. & Leucht, S. Biological v psychosocial treatments: a myth about pharmacotherapy v psychotherapy. B.J.Psychiat (2016) 208 309-311

Holmes, J. John Bowlby & Attachment Theory. 2nd edition (2013). London: Routledge.

Fonagy, P & Allison, E. The role of epistemic trust and mentalising in the therapeutic relationship. Psychotherapy (2014) 51 372–380

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Conflict of interest: None Declared

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Evidence, Not Ideology Should Guide Use of Psychotherapy

Tania M Michaels, Medical Student, Rosalind Franklin University of Medicine and Science, North Chicago
Vivek Datta, Chief Resident, Department of Psychiatry and Behavioral Sciences, University of Washington Medical Center, Seattle
08 April 2016

Prosser and colleagues (1) argue that any distinction between pharmacotherapy and psychotherapy is a fallacy, as both treatment modalities ultimately target underlying disturbances in neural circuitry. However, the justification of psychotherapy on the basis of its ability to deliver neurobiological changes, as the authors argue, is flawed. Specifically, they assume that mental disorders are simply brain diseases and that behavioral aberrations can be accounted for by disordered neurobiological processes. Despite the tremendous resources dedicated to uncovering the biological basis of mental illness, we have yet to identify a reliable biomarker for any mental disorder (2). As such, proposed mechanisms of neurobiological actions of psychotherapy for mental illness are reductionistic at best and highly speculative at worst.

The reformulation of psychotherapy as a neurobiological treatment is yet another example of the creeping trend towards neuroessentialism (3). The evidence for the efficacy of psychotherapies in the treatment of mental disorders stands by itself, and grounding this in speculative theories of its neurobiological action has no added value. Further, the authors seem to equate psychotherapy with cognitive behaviour therapy, although a number of other therapies, including psychoanalytic psychotherapy have demonstrable efficacy (4) with the therapeutic effects best conceptualized as occurring through the therapeutic relationship rather than reductionistic neural mechanisms. Though the authors have the noble aim of championing the role of psychotherapy in the contemporary treatment of mental illness, privileging a biological model of mental disorder may actually reduce clinicians’ empathy for their patients (5). In this way, reducing psychotherapy to simply a biological treatment may undermine its effectiveness. Instead, treatments should be evaluated on the weight of the evidence of their efficacy alone.


1.Prosser A, Helfer B, Leucht S. Biological v. psychosocial treatment: a myth about psychotherapy v. psychotherapy. Br J Psychiatry 2016; 208:309-311

2.Deacon BJ. The biomedical model of mental disorder: a critical analysis of its validity, utility, and effects on psychotherapy research. Clin Psychol Rev 2013; 33:846-861

3.Reiner PB. The Rise of Neuroessentialism. In: The Oxford Handbook of Neuroethics (eds. Iles J, Sahakian B) 161-75. Oxford: Oxford University Press, 2011.

4.Fonagy P, Rost F, Carlyle J, McPherson S, Thomas R, Pasco Fearon RM, Goldberg D, Taylor D. Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: the Tavistock Adult Depression Study (TADS). World Psychiatry 2015; 14:312-321

5.Lebowitz MS, Ahn W. Effects of biological explanations for mental disorders on clinicians’ empathy. Proc Natl Acad Sci U S A 2014; 111:17786-17790

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Conflict of interest: None Declared

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