Recent surveys have suggested that increasing numbers of college students are taking neuroenhancing medications—psychostimulant drugs such as Ritalin, Adderall, and Provigil—to sharpen and prolong their focus. These students don't have AD/HD, and, unlike earlier students who periodically tanked up on caffeine and amphetamines to meet deadlines and recover from the effects of too much partying, today's students regularly are taking drugs to improve their baseline academic performance. Estimates of the percentage of undergraduates who use off-label psychostimulants range from 4 to 35 percent. Now the practice has spread to the business world, and younger children may not be far behind. In a poll of 1,400 readers of the journal Nature, taken after the December 11 issue published a commentary calling for destigmatizing the use of neuroenhancers, one-third said they'd feel pressured to give their kids neuroenhancing drugs if other kids were taking them.

In the April 27 New Yorker, journalist Margaret Talbot predicts that we're just at the beginning of this trend of using mind-enhancing drugs. A new generation of medications that will prevent memory loss and boost short-term, verbal, and visual episodic memory are currently undergoing clinical trials. Some workers talk about being pressured by their bosses to boost their productivity so they can match the elevated performance levels of their coworkers already taking neuroenhancers. People trade advice on Internet forums about which combinations and dosages of psychostimulants work best for what purposes. One of the authors of the Nature commentary, neuropsychologist Barbara Sahakian, reports that several of her colleagues use neuroenhancers. Neurologist Anjan Chatterjee believes that "cosmetic neurology" will eventually become as accepted as cosmetic surgery, and that some neurologists will rename themselves "quality of life consultants."

Of course, the trend has economic ramifications, too. NeuroInsights, a company that advises investors about developments in neuroscience, is bullish on neuroenhancers. "Almost every drug in development," says its managing director, Zack Lynch, "will take someone who's working at, say 40 or 50 percent, and take them up to 80." What could be wrong with that?

Very little, according to the Nature commentary. Neuroenhancers give everyone an equal chance to do their best, say the commentators, and when that happens, "cognitive enhancement . . . could lead to substantive improvements in the world."

Not so fast, says Talbot, who questions the assumptions of the neuorenhancers' advocates in her New Yorker article. Do we want to live "in a society where we're even more overworked and driven by technology than we already are, and where we have to take drugs to keep up; a society where we give children academic steroids along with their daily vitamins?"

When Newer Isn't Better

New medications are the lifeblood of pharmaceutical company profits (see Bookmarks, page 59). As older medications go off patent, new meds—typically much more expensive than the old—bring in millions of dollars. Marketing the new medications effectively depends upon convincing people that the're better—not a hard sell in a culture that usually equates newer with better.

The marketing strategy for atypical, or second generation, antipsychotics has been to claim that they have more moderate side effects and are more effective at reducing the symptoms of schizophrenia and other severe disorders than were the old standbys, such as Haldol and Thorazine. Up to now, the case has been so convincingly made by their manufacturers that the SSRI and SSNRI antidepressants are more effective than the MAOI or tricyclic antidepressants at alleviating depression and causing fewer side effects that the newer drugs have virtually pushed the older drugs out of pharmacies and psychiatrists' consciousness.

Recently, however, two metanalyses have found that the atypical antipsychotics and the new SSRI and SSNRI antidepressants aren't necessarily better choices, and suggest that the main wonder of several of the new wonder meds is that they've been so widely prescribed. Unlike clinical trials that used narrow measures of efficacy for their outcomes, the metanalyses looked at a combination of efficacy, side effects, and price—exactly the kind off cost/benefit analysis physicians should make whenever they prescribe drugs.

A metanalysis comparing the new antidepressants with previous antidepressants in the February 28 issue of the British medical journal The Lancet finds that the relatively older sertraline (Zoloft), with its highly favorable balance between efficacy, side effects, and cost, might be the best first choice for adults suffering from moderate to severe depression. The new generation escitalopram (Lexapro) also had a highly favorable rating on efficacy and side effects, but is significantly more expensive. Other newer antidepressants like duloxetine (Cymbalta), fluvoxamine (Luvox), and reboxetine (Vestra), in addition to the older paroxetine (Paxil) and venlafaxine (Effexor), had the highest rates of negative side effects.

A metanalysis of the new generation of atypical antipsychotic meds in the January 3 Lancet, led by German psychiatrist Stefan Leucht, finds that five of the nine atypicals studied were no better than the older antipsychotics in overall efficacy, and one, quetiapine (Seroquel), was less effective. Four—amisulpride (Solian), clozapine (Clozaril), olanzapine (Zyprexa), and risperidone (Risperdal)—were slightly to moderately more effective, but given their significantly higher costs, may not be the best choice for some patients.

What of the claim that the atypicals cause fewer side effects than the older antipsychotics? Although all atypicals seemed to cause less involuntary muscle action, restlessness, and physical rigidity, 95 of the 150 trials that showed this compared the newer drugs to haloperidol, the most potent of the older meds and, therefore, the one most likely to make the side effects of the atypicals seem mild by comparison. An editorial accompanying the metanalysis by Peter Tyrer, professor of community psychiatry at London's Imperial College, suggests that this kind of study design is purposely manipulated to make the side effects of the atypicals seem more benign. When Leucht's metanalysis looked at studies comparing atypicals' side effects to those of less potent older meds, only Clozaril, Zyprexa, and Risperdal fared better. And several of the atypicals, including the most effective, had one side effect the older antipsychotics don't: significant weight gain.

Taken together, the Lancet metanalyses remind us that automatically prescribing new meds can make treatment more expensive and sidetrack the kind of careful decision-making that ought to be based on patients' specific symptoms, tolerance for side effects, and financial situation. That's the difference between practicing good medicine and succumbing to strong marketing.

The APA's Tortured Ethics

A national furor accompanied the release of memos from the Bush administration's Office of Legal Counsel (OLC) that revealed the questionable legal arguments for "enhanced interrogations" put forward by the White House's lawyers, prompting calls for professional legal organizations to discipline or disbar them. However, there was little public attention devoted to what the memos revealed about psychologists' participation in these interrogations and how, like the attorneys, they engaged in activities that many believe violated the spirit, if not the letter, of their profession's code of ethics.

Much of the controversy concerning the psychologists' involvement focused on the ethical stance taken by the American Psychological Association (APA). Post-9/11, the APA revised its ethics code to assert that when ethical responsibilities were in irreconcilable conflict with laws or other forms of state authority, psychologists could adhere to "the requirements of the law, regulations, or other governing legal authority," a position that critics claimed recalled the legal defense of the Nuremberg defendants. In 2005, the APA affirmed that psychologists could "serve in the role of supporting an interrogation" and "as a consultant to an interrogation," insisting that psychologists' presence actually protected prisoners. It was not until 2008 that the APA proscribed psychologists from working in detention centers that violate international law—a position that still remains weaker than that of the American Medical Association, which prohibits physicians from participating directly in any interrogations of detainees.

Except for one previously leaked interrogation log showing that a psychologist advised interrogators on how to increase the suffering of the prisoner during one interrogation session, critics couldn't disprove the APA's contention that the role of psychologists was to insure more humane treatment of detainees. But the OLC memos now make clear that psychologists misrepresented others' research in order to show that "enhanced interrogation" produced no serious psychological damage. Critics insist that such misrepresentation helped provide legal cover for torture.

In approving the interrogation tactics used with Al-Qaeda recruiter Abu Zubaydah, for example, OLC attorney Jay Bybee wrote, "You have consulted with outside psychologists, who reported they were unaware of any long-term problems that have occurred as a result of these techniques." Another OLC memo, from attorney Stephen Bradbury, bases its approval of extreme interrogation tactics partly on a psychologist's citation of a study in which subjects, deprived of sleep for 8 to 11 days, suffered no significant, lasting effects.

These psychologists' opinions on the psychological harmlessness of "enhanced interrogation" failed to consider something so obvious that those justifying extreme techniques could hardly have been unaware of it. As British psychologist James Horne, the outraged author of the sleep-deprivation study mentioned in the OLC memo, points out, his subjects had a strong psychological buffer to the effects of sleep deprivation because they were volunteers participating in a carefully controlled study. Likewise, the expert opinions reported in Bybee's memo were based on evaluations of United States Army personnel who voluntarily participated in a military program that teaches soldiers how to endure extreme interrogation.

There's more evidence of psychologists' questionable involvement in interrogations. A May 10, 2005, memo from Bradbury to a CIA attorney notes, "You have . . . explained that, prior to interrogation, each detainee is evaluated by . . . psychological professionals from the CIA's Office of Medical Services to ensure that he is not likely to suffer any severe . . . mental pain or suffering as a result of interrogation." Psychologists also evaluated prisoners' psychological endurance during each session. Were these psychologists helping the prisoners or assisting their torturers?

Writing in the May 16, 2009, British Medical Journal, psychology ethics researcher Kenneth Pope and psychiatrist Thomas Gutheil, president of the International Academy of Law and Mental Health, call for the APA to change its current ethics code by returning to the standard established at Nuremberg—that individuals can't escape personal ethical responsibility merely by following laws or regulations. Other critics want a full accounting from the APA explaining its ties to military intelligence and how those ties influenced its ethical decision-making process. As psychologist Stephen Soldz, a board member of Psychologists for Social Responsibility, says, "The APA needs a genuine, moral, ethical rethinking about what it stands for."

The Lure of Porn

Between 2000 and 2005, the revenue generated by Internet pornography (IP) jumped from between $8 to $10 billion a year worldwide to $57 billion. In the United States, IP revenue in 2006 exceeded that of ABC, CBS, and NBC combined. Now a survey of 99 marriage and family therapists by therapists Michelle Ayres and Shelley Haddock, reported in January's Sexual Addiction & Compulsivity, finds that about three-quarters of them had clients who brought up the subject within the past year.

The burgeoning revenue figures and increasing mention of IP in couples therapy point only to the frequency with which people view pornography online, not to its addictive power. Nevertheless, psychologist Wendy Maltz, author of The Porn Trap, claims that IP is completely different from earlier kinds of pornography; its psychological and biological effects are more akin to addiction and to an actual affair than to a diversionary recreation. "Orgasms release oxytocin, the attachment hormone," says Maltz, and, unlike with print pornography, the interactive qualities of IP and its multisensory connections give the user a more intense experience and immediate sense of personal connection. While the object of sexual fantasy may not be real, it can be close enough to usurp the relationship with one's real partner. "Users' emotional allegiance shifts; they'll lie to their partner and do whatever it takes to maintain their access to porn," she says. "I've worked with sexuality and counseling for 35 years, and I've never seen anything like this."

With its 24/7 availability, limited cost, and unlimited variety, IP can grab hold of our biology and psyche, creating its own self-perpetuating craving. Our brains crave novelty, information, and sex, Maltz says, and "If we had cocaine drips as available in our homes as Internet pornography, a lot more people would become addicted to cocaine."

The comparison to other addictions suggests some treatment guidelines for couples therapists to consider. Since addictions are often hidden, therapists should ask about IP as part of their normal assessment, even if couples don't bring it up. "Evaluate the extent, nature, and the impact," advises Maltz. If someone is using IP, find out what kind—consensual lovemaking, child pornography, or other permutations. Determine the arc of the use: whether it's progressing from one type to another or there's an increase in frequency. A solid assessment not only helps determine whether there's a serious addiction, but may increase understanding about the couple's emotional and physical-intimacy problems.

If the assessment suggests that IP has gone beyond occasional recreational use, it needs to be addressed directly, as something that can create its own relationship problems, not just as something that's symptomatic of existing emotional issues. Ayres and Haddock found that many MFTs, perhaps because of their discomfort about addressing pornography, typically subsume IP under the rubric of a communication or intimacy problem. They also tend to have little sympathy for the non-using spouse, who is usually the wife. Responding to a vignette of a couple in the survey, only 12 percent of the MFTs indicated that they'd validate the wife's concerns about IP use, while 34 percent made pathologizing statements about the wife and her concerns.

Maltz recommends that treatment focus on IP use as a primary problem, both for the user and for the relationship. "Everyone wants to wake up in the middle of the night and feel respected and loved," she says. IP can put that beyond reach for both partners.

A Petri Dish for Sexual Attraction

For an endeavor that endorses the intense, honest connection between human beings, couples therapy training too often tends to ignore the elephant in the living room of the therapy session: the sexual attraction clients often feel and may indirectly express toward their therapists, says University of Minnesota marriage and family therapist Steven Harris. When disgruntled couples enter therapy, the lack of closeness in their relationship can make the therapist a lightning rod for attraction. All the same factors involved in mate selection—close proximity in an emotionally charged situation, self-disclosure, and shared values and goals—are present in therapy and, according to Harris, make it "a petri dish for developing attraction."

Too many MFTs ignore this dimension of treatment when it surfaces, because it's usually expressed indirectly. A client may invite her partner and the therapist to lunch or comment approvingly on a therapist's new shirt.

Harris believes that ethically utilizing, instead of ignoring, expressions of attraction brings important issues to the surface. When a wife asks a male therapist about going to lunch, for example, what's the husband thinking or fearing? Is this a pattern in their social life? Is she being innocent and oblivious to how he might be viewing such gambits or is she taking a slap at him? The therapist, says Harris, should openly acknowledge what's just happened, saying something like, "It seems as if you'd like this relationship to be something other than what it is. I'm wondering what's going on for both of you at this moment?"

Part of the reason therapists avoid commenting on overtures or undercurrents in treatment may be because newer models of treatment focus on problem-solving and deemphasize the highly charged therapist–client relationship (or neuter it by talking about "alliances"). Another contributing factor may be the increasing emphasis on teaching ethics to students, which, while undeniably important, may have the unintended effect of making therapists shy away from addressing even indirect sexual feelings.

In a study in the May American Journal of Family Therapy, Harris and Texas A&M University graduate student Dinah Harriger surveyed 259 master's students in marriage and family therapy training programs about how they might handle client–therapist sexual feelings. The study finds that, beyond knowing the ethical boundaries, the students are fairly clueless about what to do. About a third of the respondents said they'd be afraid to bring up their own feelings of sexual attraction with a supervisor.

Therapists, says Harris, should never acknowledge their own erotic feelings toward a client with the client; but they should definitely bring it up with colleagues or supervisors. MFTs, he concludes, sorely need training in how to normalize and utilize the sexual attraction that occurs in therapy.

Resources

Cosmetic Neurology: Nature 456, no. 7223 (December 11, 2008): 702-07; New Yorker (April 27, 2009): 32-43. APA & Ethics: British Medical Journal 338, no. 7704 (May 16, 2009): 1178-80. For APA and other responses, see www.bmj.com/cgi/eletters/338/
apr30_2/b1653. Lure of Porn: Sexual Addiction & Compulsivity 16, no. 1 (January 2009): 55-78. Newer Not Better: Lancet 373, no. 9657 (January 3, 2009): 31-41 and 373, no. 9665 (February 28, 2009): 746-58. Sexual Attraction: American Journal of Family Therapy 37, no. 3 (May 2009): 209-216.