by Yong Lee, M.D.
[September 1995; Vol. 22 No. 4]
[Dr. Lee is presently a resident in Psychiatry at Johns Hopkins Hospital and is the winner in the 1995 Residents’ Essay Contest sponsored by the MPS Residents and Fellows Committee. The judges, who were blind to the contestants and their institutions, included Drs. Thomas Koenig and Anne Stoline. The MPS Residents and Fellows Committee was chaired by Dr. Joseph Schwartz and the contest was coordinated by Dr. Michael Hooten.]
“…[T]he occupational hazard of being a psychotherapist is the God complex. The psychiatrist knows he is God; the psychologist wants to be God. The psychiatrist and the psychologist are in titanic conflict as to who will be God on the mental health Olympus. Only the social worker abstains from overt engagement in the battle before the totem feast. She does not enter into the struggle as to who will be God-the-Father. She is content to be the Mother of God.” (Shwartz, 1958, pp.449-450)
Dr. Jerome D. Frank (1992), professor emeritus of psychiatry at the Johns Hopkins School of Medicine, recognized the tension that arose between physician and non-physician therapists when he assumed responsibility of the psychiatric outpatient department at Hopkins in the early 1950s. During that time, nonmedical professionals were “distinctly second-class citizens” in relation to physicians. Dr. Frank believed that perhaps several of the staff psychologists left Johns Hopkins to work in more hospitable environments. He writes: “As both a psychologist and psychiatrist, I could empathize with their frustration.” (p.394)
Part of this tension might have risen from the questions of boundaries. Prior to coming to Hopkins, Dr. Frank worked at the V.A. in Washington, DC, since 1947, where “[i]n those far-off days, the division of labor was unquestioned (p.392).” That is, the social workers did the initial interview; psychologists assessed intelligence and personality; and the psychiatrists did psychotherapy. These divisions were not as distinct when Dr. Frank came to Hopkins. They are even less so today. This discussion will attempt to address the role of psychiatrists in relation to nonphysician therapists, as well as to suggest what is it about psychiatric training that qualifies psychiatrists to have the ultimate responsibility of treating the mentally ill.
Dr. Frank noted wistfully that past projects he led that took a multi-disciplinary approach, such as one determining the relative effectiveness and common features of various therapies, would be much more difficult—if not impossible—to carry out today. Public support for psychotherapeutic research headed by psychiatrists has largely “evaporated.” He suggests:
At least two developments have contributed to its demise. One was a growing shift in the providers of psychotherapy. Initially almost exclusively the province of psychiatrists, psychotherapeutic practice is now mainly in the hands of psychologists, social workers, mental health counselors, and pastoral counselors. Furthermore, advances in psychopharmacology, neurophysiology, and micromolecular genetics have increasingly lured psychiatrists away from psychotherapy into these fields, for which their medical knowledge especially qualifies them. (p.395)
Some psychiatrists would counter that not only is this development inevitable, it is desirable. Perhaps new lines need to be drawn regarding the relationship of psychiatrists with non-physician therapists. Perhaps psychiatrists should forfeit psychotherapy to non-M.D.’s thus freeing themselves to become experts in the neurobiochemical physiology of organic brain disease, just as Emil Kraeplin strove to do at the latter half of the nineteenth century. As for psychotherapy, perhaps they can be referred elsewhere to nonphysicians.
Other psychiatrists warn against taking an all-or-nothing attitude toward psychotherapy. Psychiatry is not a science, they would say; rather, it is, in Dr. Jarl Dryud’s (1980) words, “a branch of medicine that cares for that subset of human misery that cannot be alleviated by the knife or a pill.” Dr. Dryud warned against disenfranchising psychiatry from the social sciences, from closing psychiatry off from the importance of understanding the role that human experience plays in mental disorders. He acknowledged the temptation to seek closure when faced with ambiguity, but he warned his colleagues against narrowing the field to the point of excluding potentially beneficial treatment modalities—be they pharmacological, psychotherapeutic, or behaviorally oriented.
I believe physicians are not in any way more qualified to be psychotherapists as compared to nonphysicians. After all, a medical education is not intended as preparation for training in psychotherapy; rather, the goal is to inculcate students to think firmly in the medical model, to accept responsibility for patients, to evaluate them competently and thoroughly, to recognize pathology—health from disease—to come up with a differential diagnosis, to decide upon a rational treatment plan, to implement it, to follow the patient diligently, and to decide when the patient has recovered. A medical education, on the other hand, does ground the psychiatrist-in-training in treating illnesses—in this case, abnormalities in the realm of mentation, affect, and behavior.
Dr. Martin Orne (1980) points out that psychiatrists are seen as the members of the medical profession that are called upon to determine who was “mentally healthy or sick.” This responsibility assumes that there is such an entity as mental illness, that those who are diagnosed as mentally ill suffer from a disease, a pathological entity that differs qualitatively from health. Physicians regard disease as the “enemy”, something to be ferreted out and eliminated. Psychiatrists, having been trained in medicine, traditionally regard mental illnesses—such as schizophrenia, major depression, bipolar affective disorder—as disease entities that have etiologies, a definable course, and a final outcome; one can, therefore, make a diagnosis based on signs and symptoms, offer a prognosis, and initiate rational treatment grounded in scientific principles.
Certainly, there are those who suffer from, as E. Fuller Torrey (1974) puts it, “dis-ease”—that is, problems in living. These individuals might suffer from personality vulnerabilities that have gotten them in trouble. They might be suffering from a bad marriage, an unfullfilling career, a sense of emptiness. Something is wrong with their lives. They want help. These individuals do not suffer from mental illness; they do not need treatment from a physician. They, however, can benefit from psychotherapy, primarily as an educational, supportive, self-actualizing experience. They can go to a psychiatrist for psychotherapy, but they do not necessarily need to do so.
Being a physician—or, for that matter, a psychiatrist—does not qualify one to be a psychotherapist. Sigmund Freud, the physician who “discovered” psychoanalysis, did not believe that a medical education should be a prerequisite for training in psychoanalysis. Freud trained a number of non-physicians notably Otto Rank, Theodore Reik, and his daughter, Anna Freud—in his techniques. (When Reik was charged with practicing medicine without a license, Freud wrote what would later be published as The Question of Lay Analysis in his defense).
On the other hand, it is important to distinguish those who suffer from disease from those that suffer from dis-ease. Those who suffer from disease need treatment; those that suffer from dis-ease might benefit from reeducation. In this regard, nonphysician therapists are at a distinct disadvantage in making this distinction as compared to their medical colleagues. Dr. Lawrence Kubie (1950), a physician-psychoanalyst sympathetic to the role of lay (nonphysician) psychoanalytic psychotherapists, gave careful consideration to their critics:
[T]hese critics point to certain deficiencies which the laymen not infrequently brings to therapeutic procedures. There is the danger that in his eager search for psychological causes…the lay analysts may overlook early warning symptoms of physical disease…The critics of lay analysis are afraid also of the layman’s naive enthusiasm for therapy, an enthusiasm which centuries of lessons learned painfully at the autopsy table have taught physicians to curb with rigid skepticism and self-criticism. They are afraid of the layman’s lack of a fully developed sense of therapeutic responsibility and of his lack of that basic scientific training which is needed if the therapist is to use sound critique in evaluating his results. The further argument is advanced that especially in psychotherapy the interplay of physical and psychological factors must be watched at all times. Physical disturbances can be superimposed on psychological illnesses and vice versa, and sometimes it is far from easy to demarcate the boundary from the two. (pp.215-216)
This said, it should be remembered that there are far fewer psychiatric “patients” suffering from disease than dis-ease. Having made the initial evaluation and diagnostic workup, the psychiatrist should tell the patient his or her diagnosis. If, indeed, the patient is suffering from a psychiatric illness, he or she should be followed closely by a psychiatrist who accepts medical responsibility for the patient and practices good standard of care, which presently includes both psychobiological interventions and psychotherapy. Alternatively, the psychiatrist could relegate much of psychotherapeutic interventions to a qualified nonmedical colleague, although assuming final responsibility of the patient’s overall care.
But, on the other hand, if the patient is not suffering from a psychiatric illness, the psychiatrist should offer the option of psychotherapy with a nonphysician therapist; besides being typically less expensive, the nonphysician psychotherapist is often better trained in psychotherapy and might have real-life experiences that could prove helpful to this individual. I would suggest that at this point the person ceases to a “patient” and becomes, in the parlance of psychologist, Dr. Carl Rogers, a “client”. Clients can choose to follow-up with a psychotherapist (either medically-trained or not), pastoral counselor, or best friend. Because clients are not ill, they can choose to come and go as they please; because they are not patients, they need not submit themselves under a physician’s care. The responsibility for overcoming their problems in living lies entirely on their shoulders. (Carl Rogers was adamant about his nondirective stance; he felt that encouraging the patient role took away too much responsibility away from the client. Even if the client were to threaten to commit suicide, the therapist, he would say, had no responsibility—or even the right—to advise otherwise.)
Physicians have a different responsibility toward their patients. When they assume the care of a patient, they are under an obligation—legal, professional, moral—to assure that this patient does not suffer from undue morbidity and mortality. We are in the business of preserving life, health, and dignity. We would not let a patient commit suicide; we would do anything in our power to stop it. We do this because this is part of our identity as physicians.
As psychiatrists much of our authority derives by the mere fact that we are physicians. We have deferred any short-term goals to complete our medical training. We have all diagnosed myocardial infarction, gastrointestinal bleeding, and diabetic ketoacidosis. I remember putting in my first central line, delivering my first baby, assisting in my first hemi-colectomy. Although I may never perform these procedures again, they are very much a part of my professional identity. As a physician, I am comfortable with the idea of assuming responsibility for human life because I have been trained to do so; this, too, is part of my identity. Currently, there is no better way to prepare for this leadership role outside of medical training.
As physicians, psychiatrists must recognize their privileged position in the multi-disciplinary mental health team. Oftentimes, patients will not be satisfied that their questions have been adequately answered unless they talk to their doctors. Sometimes they will give our directives greater credence because these statements are coming from a physician. Understandably, this causes frustrations in the other members of the team. We should recognize this, and steadfastly maintain a team approach with clear emphasis on the many contributions of all team members. We should willingly refer individuals who suffer from problems in living to nonphysician therapists who might have greater expertise in dealing with these problems; in turn, we should maintain a collegial relationship with these professionals so that they would feel comfortable referring patients to us for initial consultations and reevaluations.
I still feel that a psychiatrist must do psychotherapy even if the bulk of ongoing psychotherapy has been delegated to others. I think we are fooling ourselves as a profession to think that we have many of the answers in treating mental illness sewn up from a psychobiological perspective. Far from it. As Dr. Lewis Thomas pointed out, in general medicine, it has only been in this past century that medical intervention has been of any demonstrable benefit at all. Before Pasteur’s germ theory, before the age of vaccines and antibiotics, doctors could do little but make diagnoses and prognoses. Mostly, they were there to explain things to the family and comfort the sick, to take responsibility for the patient. As psychiatrists look to the future, they need to reflect on medicine's past caring for the afflicted; educating; leading; taking responsibility. This, too, is our tradition.
Dyrud, J.E. (1980). Is Behavior Therapy a Fad or a New Direction for Psychiatry?. In J.P. Brady and H.K.H. Brodie (Eds.), Psychiatry at the Crossroads (pp.33-48). Philadelphia: The Saunders Press.
Frank, J.D. (1992). The Johns Hopkins Psychotherapy Research Project. In D.K. Freedheim (Ed.) & H.J. Freudenberger et al. (Assoc. Eds.) History of Psychotherapy: A Century of Change (pp.392-396). Washington DC: American Psychological Association.
Kubie, L.D. (1950). Practical and Theoretical Aspects of Psychoanalysis. New York: International University Press, Inc.
Orne, M.T. (1980). Should Psychiatrists Be Medically Trained? In J.P. Brady and H.K.H. Brodie (Eds.), Psychiatry at the Crossroads (pp. 201-239). Philadelphia: The Saunders Press.
Schwartz, E.K. (Ed.) (1958). A psychoanalytic approach to the mental health team. American Imago, 15, 437-451.
Torrey, E.F. (1974). The Death of Psychiatry. Radnor, PA: Chilton Book Company.