Orne, M.T. Should psychotherapists be medically trained? Let’s consider the alternatives in light of what the psychiatrist does. In J.P. Brady & K.H. Brodie (Eds.), Controversy in psychiatry. Pp. 43-81. Copyright 1978 Elsevier Inc. (originally published by W.B. Saunders)

Should Psychotherapists be Medically Trained? Let's Consider the Alternatives in Light of What the Psychiatrist Does*


The Institute of Pennsylvania Hospital and University of Pennsylvania

The generally accepted definition of psychiatry is exemplified by that offered in the abridged Oxford dictionary: that branch of medicine dealing with mental, emotional, or behavioral disorders. On the face of it, it seems strange indeed for anyone to question the necessity of medical training for the practice of medicine. Certainly no such question was raised until the early 1950s. In this discussion we will try to understand how this question arose, the implications it raises for various views of psychiatric practice, the consequences it has had for the status of psychiatry in American medicine and among the public at large--consequences which are only now becoming obvious--and, finally, what we might learn from such a discussion about the future of our field.

The development of psychiatry as a discipline

The role of the psychiatrist as a physician who dealt with psychoses, severe neuroses, and functional somatic symptoms evolved during the early part of the century until, by the end of World War II, these three functions were accepted as an integral part of psychiatric practice. By that time psychiatry had established itself as a separate discipline distinct front neurology. While there were several different patterns of psychiatric practice, the main division was between two groups:

*The substantive research upon which the theoretical outlook presented in this paper is based was supported in part by grant #M 19156 from the National Institute of Mental Health and by a grant from the Institute for Experimental Psychiatry.

I am indebted to A. Gordon Hammer for his many conceptual contributions, and to William M. Waid for his substantive comments in the preparation of this paper.




1. Those psychiatrists committed to the view that the major psychoses would ultimately be identified as organic and/or genetic in origin, who, while using a variety of psychotherapeutic approaches, nonetheless saw biologically oriented procedures as the real treatment. This group, which included many neuropsychiatrists, eclectic psychiatrists, and traditional mental-hospital-based psychiatrists, identified themselves with biological psychiatry and, until the mid 1940s, represented psychiatric orthodoxy.

2. Other psychiatrists who viewed the psychodynamic approach as central to psychiatry. The etiological factors that mattered were seen as developmental and psychodynamic in nature. Explanatory mechanisms for psychiatric symptoms were sought in the life experiences of the individual. Though differences between neuroses and psychoses were clearly recognized, the latter were generally interpreted as involving psychological traumas, particularly loss and other interactive deficits, at a very early period, while the neuroses involved similar psychological stresses at a later time in an individual's development. Even psychosomatic illnesses were seen as yet another type of consequence which followed from specific psychodynamic etiologies. Obviously, if the etiology of all psychiatric conditions involves psychological trauma, it is hardly surprising that the only appropriate treatment becomes psychodynamically oriented psychotherapy.

Though one might expect that the basic division within psychiatry might lead to different attitudes toward medical training, orthodox psychoanalysis as well as most of the derivative psychodynamic schools shared the commitment to medical training with their colleagues in biological psychiatry.

The therapeutic process (psychoanalysis or dynamic psychotherapy) was seen as a delicate medical treatment requiring extensive special training, acquired like other medical skills by both formal training and extensive apprenticeship, for its proper execution.


As long as psychiatry was seen as a narrow specialty dealing with the diagnosis and treatment of deranged individuals, the field had little impact on medicine in general. Medical students had only a few hours of training in this specialty. However, in its development psychoanalysis had captured the interest of artists and writers, and a good many novels, plays, and movies were greatly influenced by its theories. The concept of psychological causation was all but taken for granted by modern writers, and psychiatry successfully redefined its role, not merely as treating deranged individuals but, even more important, as helping the relatively mildly neurotic individual to lead a more effective, more satisfying, more successful life.

One of the crucial decisions that was made by the American Psychoanalytic Association was to limit its membership to psychiatrists. Thus, psychoanalysis by definition became a medical treatment and a medical science, a point of view, that was eminently congruent with the conceptual.



model upon which it was built. This decision helped provide the basis for its later wholehearted acceptance by academic medicine.

Probably the single most important factor in this acceptance was the success with which psychodynamic psychiatry asserted its claim that it represented a rational scientific approach based on well-established theories in contrast to the crude eclecticism which characterized much of the contemporary psychiatry of the day. Psychoanalysis seemed to provide a rational diagnosis of psychiatric disorders, somewhat analogous to medical diagnoses based on a sound knowledge of physiology, and seemed to provide a treatment based on that diagnosis.*

During the decade following World War II, psychodynamic treatment became equated with psychiatry. Although there were some active biological psychiatrists, they were all but eclipsed within much of academic medicine. Textbooks of general medicine included discussions of psychoanalytic views, and even the Merck manual--the intern's bible--carried extensive sections on psychodiagnosis and treatment. During this period psychiatry became a very popular medical specialty and psychosomatic medicine came to be accepted as an integral part of the modern medical center. Psychiatric consultation became accepted by other medical specialties as a necessary medical service, and the number of individuals in psychiatric training rapidly increased to meet the growing demands for psychiatric services--demands generated by the growing awareness of functional disorders and neuroses by physicians in other specialties.

This recognition was coupled with a new-found respect for the specialty of psychiatry and the realization that a considerable group of patients could be helped by psychiatrists. Equally important, however, was the increased visibility of psychiatry among large segments of the public who sought psychiatric help directly because of a self-perceived need for help of this type. During this period the demand for psychiatric services continued to exceed the availability of trained individuals. Further, psychiatrists themselves saw their training as relevant to an increasing number of problems which went far beyond those of treating individual patients.


Though psychodynamically oriented psychiatrists in the early 1950s tended to reject the significance of hereditary factors for the etiology of psychoses, were reluctant to utilize psychotropic agents or other biological treatments, and carefully avoided becoming involved in the patient's physi-

*It should he kept in mind that medicine has appropriately been concerned not only that its treatments be effective but that they also be rational and based on valid scientific principles. There have been many instances in the history of medicine where individuals providing irrational therapies based on unacceptable premises seemed for it time to be more successful, e.g., homeopathy. In the long run, however, acceptance by established medicine depended upon an acceptable theory as well as evidence of success. For example, Christian Science, while often effective in providing relief of functional symptoms, has obviously not become acceptable medical treatment.



cal difficulties, they nonetheless shared basic assumptions with those psychiatrists who were more clearly biologically oriented.

All psychiatrists emphasized the rational scientific basis upon which their procedures rested. Though there was considerable disagreement within the field about etiology, diagnosis, and appropriate treatment, there was a clear consensus that it was necessary to have an understanding of etiology; it was essential to diagnose the patient's disorder and to base a rational treatment upon this diagnosis.

To summarize the basic points relevant to the medical view of psychological illness:

1. Psychiatrists, regardless of their persuasion, perceived themselves as physicians treating patients suffering from some form of disorder. The diagnostic manual was seen as providing useful categories which would allow classification of any difficulty afflicting an individual who might be seen by a psychiatrist. In developing the manual, care was taken to provide for the various orientations that characterized contemporary psychiatry.

2. In all matters of health, the medical profession had, by common consent, defined what constituted illness and health. The extent of the physician's definitional role is seen if one considers that under most circumstances an individual is not considered dead until pronounced so by a physician. Similarly, psychiatrists were seen as those members of the medical profession who defined whether an individual was mentally healthy or sick, a matter which determined whether the individual was capable of making a will, managing his own affairs, or even being allowed to come and go as he pleased. The courts generally sought and accepted psychiatric opinion on such matters, and in a real sense the psychiatrist determined who was psychotic, who was neurotic, and who was within the normal limits of mental health. In an analogous way, the psychiatrist was the one who determined when a patient needed treatment and what treatment was required. He then usually became the therapist and ultimately the judge of when the patient was well. Though the nature of the diagnosis and treatment might vary with psychiatrists of different orientations, the exercise of these functions was considered by essentially all psychiatrists not so much as their prerogative but rather as the necessary and appropriate exercise of their professional responsibilities.

3. As in all medical treatment where the physician takes on specific moral and legal responsibilities when he agrees to minister to a patient, in the same way psychiatrists took medical responsibility for the treatment of their mentally ill patients. Clearly, if a patient became overtly suicidal, the psychiatrist viewed it as his obligation to prevent the patient from committing suicide. Not to do so in the face of a high likelihood of such an event was seen as a clear dereliction of duty. Just as the physically ill patient who becomes delirious may need to be restrained temporarily to prevent him from doing damage to himself, so would the depressed patient require analogous help lest he do something in his morbid state of mind which would certainly have been against his wishes once he had recovered from this depression. The issue of medical responsibility is at the very core of



the physician's role in society. While such responsibility was accepted by both dynamically and biologically oriented psychiatrists, there were important contradictions between some tenets of psychoanalytically oriented treatment and the view that the psychiatrist was ultimately responsible for the patient's welfare. This troubling paradox was dealt with in different ways by a number of authors, but in general it was deemed appropriate that psychiatrists should avoid becoming responsible for the neurotic patient but could not avoid an obligation to protect both the individual and society in the case of psychotic patients. Szasz (1961) was the first to articulate clearly the inherent contradictions in such a position and used it as the basis for a concerted challenge to current psychiatric practice.*

4. The medical model conceives of signs and symptoms as superficial manifestations of underlying pathological processes. An excruciatingly painful big toe which brings the patient to his physician is recognized as reflecting the systemic disorder of gout, which in turn is treated biochemically, effectively bringing relief. This conceptual model was carried over into psychiatry. Consequently, both subjective symptoms and behavioral signs were taken as evidence of an underlying pathology which needed to be treated. Specific symptomatic relief was generally considered an inappropriate goal, much as the application of local anesthetic to relieve the gouty toe would hardly be considered an appropriate treatment. Though the concept of symptoms reflecting underlying disorders was almost totally accepted by psychiatrists until very recently, there was of course considerable disagreement about the nature of the underlying processes, with some psychiatrists focusing upon genetic and biochemical etiologies, others emphasizing psychobiological consequences of specific stressors, and psychodynamically oriented psychiatrists tending to look to developmental and interpersonal etiologies. While the psychodynamic psychiatrists accepted the model of illness, the basic sciences which would contribute to their elucidation were seen to be more closely related to psychology, sociology, cultural anthropology--all disciplines which concerned themselves with the study of mechanisms which were postulated to be basic to the patient's clinical problems.+

5. One corollary to the medical point of view seems particularly important in terms of more recent developments. Illness has always been viewed

*While Szasz's position is in many regards logically consistent and points to areas where there have been instances of serious abuse, he merely pushes upon the courts the responsibility for deciding the difficult questions of the degree to which an individual has the right to harm himself, the extent to which the psychiatrist has an obligation to protect his patient from harming not only himself, but others, and a variety of related questions for which the courts had sought advice from psychiatry.

+It was this realization that led to one of the early challenges to the appropriateness of' medical training for psychiatrists. Dr. Lawrence Kubie (1950) proposed that a new kind of degree in the healing arts, a doctorate in medical psychology, be established, which, like dentistry, would teach the basic sciences and allow the graduate to obtain a license to use those drugs appropriate to his discipline, but in addition to general medicine the training would include much psychology, sociology, and anthropology and thus be specifically tailored to provide the background which was relevant from the point of view of psychodynamic psychiatry.



as the enemy by the medical profession. Thus, it is hardly surprising that psychiatrists saw themselves as opposed to mental illness in all of its manifestations.

While a number of psychiatrists had recognized that the creative urge was uncomfortably closely related to some aspects of psychopathology (see Hartmann, 1964; Kretschmer, 1948; Kris, 1952), the experience of a psychotic episode was never seen as desirable or productive.

The physician's role in society and the medical model in psychiatry. One can hardly leave a discussion of the medical model in psychiatry without recognizing the tremendous social importance which medicine has in modern society. Physical illness is the one event which can excuse just about every kind of behavior in modern society. There is little or no blame attached to the soldier who falters in battle because he is physically ill; there is no social obligation from which one is not excused because of physical illness. Some courts accept illness as an appropriate reason to delay any form of trial, and medical excuses are even accepted by the IRS!

Modern society is justly proud of its enlightened humanitarianism. While anthropologists point out that other societies such as the Hopi lack the concept of physical illness, ascribing all illness to either witchcraft or bad thoughts, we are quick to dismiss such a naive view with a smile and some self-satisfied thoughts about the irrationality of such a position. It might be well to consider, however, that modern society's enlightened view of illness is by no means necessarily totally rational. Ample research has shown that motivated individuals with very high fevers can carry out a wide range of performance tasks with little or no perceptible decrement (Alluisi et al., 1971). In practice, what excuses an individual rarely involves proof that he is incapacitated by an actual test, but rather it is sufficient to be seriously ill and have a physician attest to the fact that undertaking a certain activity might have untoward consequences for the individual's health. Whether or not the illness is sufficiently incapacitating to justify being excused from whatever would otherwise be required is a decision made by physicians according to appropriately conservative criteria--in the sense of protecting the patient more than worrying about his obligations. In most instances, the word of even a single reputable practitioner is rarely challenged.

As one considers the medical model in psychiatry, one cannot ignore the social significance illness has in our society and the high degree of acceptance of medical statements by a broad range of institutions. Thus, the psychiatrist gains considerable credibility within our society by the simple fact that he is a physician. Though physicians as a group do not now enjoy the unambivalent admiration of most Americans that was common some 30 years ago, their statements continue to have a high degree of credibility. (Ironically, the high incidence of malpractice suits is partly at least related to the high degree of belief in the physician's inherent ability to be correct and assure good therapeutic outcomes.)




During the period following World War II, psychiatry had come of age as a specialty. It was suddenly accepted not only by academic medicine but also by other academic disciplines. Psychiatrists were eagerly sought after and listened to in departments of psychology, anthropology, sociology, literature, industrial management, and political science. It is hardly surprising that they saw their training as relevant to an increasing number of problems which went far beyond those of treating individual patients and began to encompass most of the social ills man was heir to--war, prejudice, aggression, crime, as well as other forms of social deviance.

While a significant segment of psychiatrists were re-evaluating their role and saw themselves as more closely allied with humanism and the social sciences, a number of other factors also combined to encourage a split of psychiatry from the rest of medicine. It will not be possible here to trace each of these developments and the complex interrelationships; rather, we will only touch upon some of the trends. There were three main thrusts involved: (1) the intellectual challenge to the medical model stemming from psychology and the development of psychological therapies; (2) the development of social psychiatry, ultimately leading to the community mental health center where psychiatric services were provided by mental health aides or counselors with little formal training or education; (3) the challenge to the concept of mental illness from. within some segments of psychiatry, which in the service of a new humanism sought to redefine the subject matter of psychiatry as helping people deal with problems of living.

The intellectual challenge. From the very beginning psychoanalysis sought to develop a psychological science. Though Freud appropriately felt that nineteenth century psychology had little to offer the psychotherapist, he also recognized the importance of developing a psychology which could form the scientific basis for psychotherapy. While much of psychoanalysis developed outside the academic context, it rapidly began to have an impact on the developing science of psychology. Thus, Freud's lectures in 1911 at Clark University were given under the auspices of the department of psychology, and there was some continuing interest in psychodynamic aspects by the psychologists of that period. Other outstanding medical therapists at the turn of the century emphasized that they were practicing medical psychology. Pierre Janet in France and Morton Prince in the United States are particularly clear examples. Thus, Morton Prince, a medical therapist, founded the Journal of Abnormal Psychology, which ultimately was given to the American Psychological Association. In those early years, Freud, Jung, Adler, and other medical psychotherapists thought it appropriate to train nonmedical therapists, and a small number of psychologists chose psychoanalysis or psychotherapy as a career. These individuals were trained in traditional psychopathology and tended to think in terms of the medical model. They were few in number and were not



perceived as a threat to those relatively few psychiatrists who were interested in the psychotherapeutic treatment of troubled individuals.

The first real challenge came from a different tradition of psychological therapy. Carl Rogers, a psychologist trained in the child guidance movement--an interdisciplinary treatment approach which originated in the 1920s--eventually accepted an academic appointment in clinical psychology with responsibility for a counseling center. It was within the tradition of counseling psychology that Carl Rogers (1942) wrote his remarkably successful book on nondirective therapy.

Rogers put forth a number of ideas which dramatically challenged the medical model in treatment. He argued that it was not necessary to diagnose the patient's difficulties. Instead, it was sufficient to provide an atmosphere of unqualified positive regard for the client (emphatically not the patient) and in such a context the individual would resolve his own difficulties. He provided an upbeat view of man where the individual was seen as basically healthy and his difficulties relatively easily resolved--provided he had the opportunity to reflect upon them in an appropriate setting. In particular, he felt that the client would need to understand his feelings, and to facilitate this process the therapist should sedulously strive to reflect the patient's feelings without making any interpretations or comments. Not only did Rogers propose that such a process would be therapeutic, but he also insisted that as long as the therapist provided the appropriate positive emotional setting the mere act of reflecting feelings would allow the patient somehow to get to understand his problems and work through a constructive solution for them. In contrast to the medical model, Rogers argued that the therapist does not know best, nor should he attempt to second guess what the patient ought to do. He genuinely felt that the patient could and would learn the unique solution to his problems by having his creative capacities liberated by working with someone who truly respected him as an individual and sought truly to understand his feelings.

Not only did Rogers provide the first important novel psychotherapeutic approach not based on a medical model, but he also initiated the first major research effort to explore the factors affecting success in psychotherapy. In a series of pioneering studies he and his colleagues (1954) demonstrated that the appropriate emotional tone was crucial to therapeutic progress, that therapists who talked less were more effective than those who talked more, and so on (see Truax and Mitchell, 1971). Thus, Rogers not only provided a technique of psychotherapy developed by a psychologist, but also offered systematic evidence concerning the factors affecting therapeutic effectiveness. It is hardly surprising that his work attracted wide attention within the psychological academic community, and, though it was virtually ignored by psychiatrists, rogerian therapists established themselves in counseling services of a large number of institutions and some became private practitioners. Rogerian therapists did not generally agree to see psychotic individuals, nor did they view themselves as trying to help



severely incapacitated individuals. In restricting their activities to individuals not defined as sick, they distinguished what they were doing from medical treatment and obviated the need for what they viewed as pigeonholing individuals in some diagnostic category.

In time rogerian therapists inevitably sought to treat an increasingly wide range of troubled individuals. They did not, however, ever come to feel the need to concern themselves with diagnostic categories. Probably because rogerians addressed themselves mostly to their academic colleagues and published largely in the context of counseling psychology, the profoundness of their challenge to the medical model in psychotherapy did not come to the attention of psychiatrists until recently, when rogerian thinking, as one of the important roots of humanistic psychology and, in particular, as the basis of T-groups, helped usher in some of the more recent popular developments of quasitherapies. It seems all the more relevant in view of this recent development to consider Rogers' historical position about psychotherapy, a position which has undergone remarkably little change through the years, though it is perhaps difficult for the observer to identify the eminently proper, establishment-oriented counseling psychologists (who often held important administrative roles in universities) and the hip, counterculture-oriented T-group leader as sharing the same intellectual heritage.

In structuring the therapeutic relationships Rogers carefully eschewed taking any responsibility for the patient's well-being, insisting that it was his role merely to help the patient comprehend his feelings and to provide the setting where he would be able to carry out his difficult work of reappraisal. Rogers never claimed expertise in the sense of knowing what was wrong with his clients. On the contrary, he exuded a sublime belief in the patient's ability to heal himself and was firmly convinced that in the context of the therapist's unswerving respect for his feelings, the client would come up with the solutions best adapted to his needs. In direct contrast to the medical model, there was no diagnosis and no concept of medical responsibility. Even when a client threatened to commit suicide, Rogers would not deviate from this position. In no case did he feel entitled to take responsibility for the patient; rather, he would steadfastly act in accordance with his conviction that the patient would resolve his own problems and the expectation that he would see him at the next appointment.*

*Considerable controversy followed his playing a tape of a course of therapy with a client who indeed sounded extremely suicidal, where many colleagues felt it was not justified to allow him to leave the office. Rogers argued that he did not have the right to do otherwise, that the patient would have to solve his own problems, and that to take responsibility for him would be an unpardonable infringement which might cause serious harm. It does appear, in that case at least, that Rogers' faith in his relationship with his client and in his client's basically healthy core was justified.

It should be noted, however, that Rogers maintained that even if the patient had committed suicide he would still not have had the obligation nor even the right to prevent him from leaving his office. By the same token, he would have argued that it would have been counterproductive to advise the patient that he should not commit suicide.



It is not intended here to argue the merits of client-centered therapy. Certainly in proper hands it can be a more formidable therapeutic procedure than is generally recognized within psychiatry, nor, as a practical matter, is the difference between selective reflection of feeling and properly timed explicit interpretation as great as might be supposed at first glance. The important matter is the radical difference in the manner in which the role relationship between therapist and patient is conceptualized. By external criteria the rogerian therapist is still defined as an expert, and he certainly maintains the accouterments of an appropriate office, clients seen by appointment, professional status, and the like. Nonetheless, in explicitly refusing to provide any advice whatsoever, refusing to take any responsibility for the patient's behavior, and insisting that decisions at all times are the patient's responsibility, the approach is truly nonmedical.

Rogers' pivotal role developed certain attitudes within psychology and had profound effects on a number of the newer psychotherapies which emphasized the primary importance of feelings in the therapeutic process and the refusal to accept responsibility for the patient's welfare (various forms of Gestalt therapy, rational emotive therapy, aspects of psychodrama, and so on). Nonetheless, neither the therapies nor the quasitherapies whose origins can be traced back to the influence of Rogers' ideas nor the psychotherapy research which owes its beginnings to Rogers' influence have had much impact on psychiatric thought. Until relatively recently, the fact that these therapies were generally applied to individuals who had not defined themselves as, patients and that psychotherapy research usually involved psychologists as therapists unfortunately prevented the studies from being recognized as salient by most psychiatrists. It is only recently that T-groups, Gestalt therapy, sensitivity training, EST, and a myriad of other popularizations of these various procedures have achieved phenomenal popularity within our culture and have therefore come to the notice of the psychiatric community. In some areas these various approaches have begun to provide serious competition as alternatives to psychiatric help that troubled individuals might choose to take.

An entirely different challenge to dynamic psychiatry developed from Eysenck's (1952) classic criticism which emphasized the lack of evidence documenting the effect of psychotherapy and suggested that, regardless of the therapist or his technique, one third of the patients get better, one third get worse, and one third remain unchanged. Though this critique attracted much attention, it did not basically challenge the medical model of treatment; it merely took the practitioners to task for failing to be effective physicians. Only when this critique was combined with the renewed interest in behavior therapy, which served to provide an alternative for troubled individuals, did it begin to pose a serious challenge to psychodynamic psychiatry.

It seems unnecessary to review the history of behavior therapy in this context. (See Birk et al., 1973; Herson et al., 1975; Yates, 1975 for appropriate reviews.) There is a growing understanding and awareness of behavioral approaches in psychiatry. From the point of view of this discussion, there are two aspects of behavior therapy which make it relevant:



1. It challenges the medical model as it rejects the notion that symptoms inevitably reflect an underlying process. In the case of phobias, for example, the symptom may well be the illness. Removal of that symptom does not usually appear to result in other symptoms as would be predicted by the psychodynamic model; rather, that improvement may produce unexpected and unanticipated improvements in other areas. While behavior therapy itself is in the process of maturing as a field, there is some awareness that certain symptoms do indeed reflect underlying problems but that the specific and direct treatment of some psychiatric symptoms is clearly effective and appropriate. Further, even in instances where one is dealing with a major psychosis, significant salutary changes can be brought about by behavior therapy. Thus, the success of behavior therapy in some areas of psychiatry in bringing about enduring relief of symptoms serves to challenge the basic validity of the dynamic model as explaining all psychopathology.

2. Behavior therapy has provided an alternative model for psychopathology derived from theories of learning. It proposes that just as we have learned motor skills and coping mechanisms, we also learn maladaptive processes which descriptively fall into the category of psychopathology. To the degree that one can successfully conceptualize significant aspects of psychopathology as problems of learning, one inevitably puts the treatment of these disorders into the domain of learning and out of the domain of medical therapy as usually defined. The basic science relevant to behavior therapy is presumed to be academic psychology, and its treatments take their roots in psychological experiments.

Not only is behavior therapy a treatment developed by psychologists, but it appears to be based on sound theory derived from a solid body of scientific knowledge. It matters less whether these claims are fully justified than the fact that they have been successfully asserted. Most importantly, this view has gained credence not merely among the general public but within large segments of the scientific community itself.

Though behavior therapy challenges some aspects of the medical model, it emphatically does not challenge other significant aspects. Thus, the role relationship between the behavior therapist and his patient is closely analogous to the relationship of the nonpsychiatric physician and his patient. He is the expert, administering a treatment with the patient's consent. He defines what constitutes improvement and how it shall be evaluated. He is carrying out a treatment that is presumed to be rational and specific. He has taken a careful history and keeps careful notes on the patient's progress. Thus, while behavior therapy challenges the psychodynamic view of the medical model, in many regards it is eminently compatible with the medical approach. One important similarity that is easily overlooked is the extent to which there is consensus about the kinds of difficulties that are symptoms and should appropriately be modified. Just as there is no doubt in a physician's mind that a fever or an increased blood pressure represents something to be remedied, so is there little question in the behavior therapist's mind that a phobia, a psychotic symptom, or, anorexia constitute symptoms that one should strive to eliminate.



The challenge of social psychiatry and the community mental health movement. During the 1950s the demand for psychiatric services increased as the medical profession came to accept the psychiatric services and the public at large increasingly sought out such help. As soon as a new psychiatric clinic was opened, it developed a backlog of patients who had to wait months or even years before they could be accepted for treatment. Epidemiological studies, such as Mental Health in the Metropolis (Srole et al., 1962), revealed a profound and shocking incidence of severe disturbance among the population of a large city, and the Joint Commission on Mental Health proposed concerted action to help relieve the problem of widespread incidence of psychiatric difficulties.

The Community Mental Health Act represented a mammoth effort to provide psychiatric services on an unprecedented scale. Reflecting the widespread dissatisfaction with the large mental hospital as a warehouse of human misery, far away from the patient's former associations, a new impetus was given to provide early treatment in the patient's community, preventing if possible the initial hospitalization and keeping the individual within the community. The community mental health center was intended to obviate the need for prolonged custodial care and to allow the gradual phasing out of the large hospitals, to be replaced by treatment-oriented institutions of manageable size. When one considers the magnitude of the problems of building and staffing new institutions, recognizing that the staffing needs of these institutions far exceeded the available number of psychiatrists, clinical psychologists, and social workers, it is surprising that they were not less effective than was actually the case.

It is not possible here to review the aims, achievements, and failures of community psychiatry--only to focus on three aspects which profoundly affected psychiatrists' self-perception.

1. It quickly became apparent that there simply were not enough psychiatrists to be primary providers of services. Whereas psychiatric clinics had been staffed by residents, there were not nearly enough residents to staff the mental health centers, nor were there enough clinical psychologists or social workers. Leaning heavily on promising results with highly selected, unusually mature older women reported by Margaret Rioch (Rioch et al., 1963), the concept of the mental health worker rapidly evolved. Part of the justification derived from the remarkable lack of success which middle-class psychiatrists encountered in attempting to treat lower-class patients. They simply were unable to identify with the incredibly deprived and often emotionally barren backgrounds of these persons, and were frightened and often dismayed by the widespread physical violence within their lives. The notion that individuals could be found who might lack formal academic training but had the maturity and appreciation of the subculture necessary to empathize with and help the troubled minority member from a deprived environment made a virtue of necessity. Unfortunately, in most instances the selection of the mental health worker in no way paralleled the care which Margaret Rioch had taken, nor were these individuals given the prolonged supervision and extensive training that provided the initial promising results.



There is no doubt that there are many devoted, committed, and hardworking professionals on the staffs of community mental health centers seeking to provide the best possible service to their patients. Unfortunately, the yardstick by which the amount of work carried out is measured involves the number of patient hours provided, and it is hardly ever considered whether the training or the skill of the individual who actually has contact with the patient is adequate. In most instances, such an arrangement will rapidly create the situation where virtually all services are provided by those individuals with the least training, since they apparently are the most cost-effective workers. The highly trained individuals on the staff are reserved for supervision, training in the treatment of special problems, and representational functions vis-a-vis other agencies.

2. The psychiatrist's role in the context of a mental health center tended to involve a broad range of nonmedical functions, including consulting with a wide range of agencies and the nominal supervision of a large number of paraprofessional workers. At the same time the psychiatrist's medical functions tended to become quite routine, often seeming to involve an exploitation of the psychiatrist's license to practice medicine in order to prescribe psychoactive drugs that the nonmedical staff thought were needed. Under these circumstances it is hardly surprising that the psychiatrist would perceive his psychiatric functions as largely unrelated to medicine, while his medical role was at best technical, requiring relatively little of his training and skill. In a community mental health center there was no question who would do therapy, and it was very clear that medical training was not the crucial skill in making the therapy successful. By the same token, the psychiatrist was made forceably aware of his limitations and the importance of social and cultural factors. Many psychiatrists working in community mental health centers found it difficult to remain comfortable about their professional identity. Unavoidably, the fact that the bulk of treatment was carried out by essentially untrained individuals would tend to denigrate the psychiatrist's function as a psychotherapist and diminish his pride in the hard-won skills that he had achieved in the practice of psychotherapy. It becomes increasingly difficult to insist that psychotherapy is a medical discipline while simultaneously assigning patients to paraprofessionals for treatment.

3. The. impact of the community mental health center has thus been to deprofessionalize the enterprise of psychotherapy as such. In many ways the psychiatrist virtually became superfluous. Psychotherapeutic functions were being filled by paraprofessionals, the administrative functions were gradually taken over by administrators, and the educational, supervisory, and representational functions were increasingly filled by social workers and psychologists. While a physician was needed to prescribe drugs, this function could be--and at times has been--filled by general practitioners. The medical aspects of the psychiatrist's skills had relatively little value in the setting, and in terms of identification, those psychiatrists who stayed with community mental health centers tended to move further and further away from an identification with medicine. A small group of psychiatrists



have indeed established new role models in social psychiatry and have become effective by seeking to work through a number of institutions such as schools, the welfare system, industry, the courts, and so on. The sphere of action of these colleagues is far removed from the usual medical model, and one might appropriately ask to what extent medical training itself specifically facilitates the work of these social psychiatrists. Probably, for these colleagues, the most benefit that medical training provides is to legitimize their status while their substantive skills are more closely related to those of the anthropologist, the sociologist, and the psychologist, combined with the skills of modern management.

There is no mental illness—only troubled individuals with problems of living

Perhaps in reaction to the large mental hospitals, and to the often disastrous effects of labeling an individual as mentally ill (Rosenhan, 1973), an increasingly powerful tendency to reject psychiatric classification and to deny the concept of mental illness became apparent. Szasz’s (1961) position represents a relatively scholarly attack of this kind. Taking the model of hysteria and extending it to schizophrenia, he argues that all manifestations of major psychoses are largely iatrogenic. Those which cannot be laid at the physician’s door can at least be blamed on the culture.

Others have emphasized the pathogenic aspects of modern society and argued that one cannot be well if the society as a whole is sick. Perhaps the most popular argument of this sort has been put forth by Laing (1957), who treats schizophrenic patients by helping create a milieu which tolerates their psychopathology and allows them to experience their psychoses as an aid to their ultimate development. Psychopathology in such an environment is not to be feared but rather to be understood, empathized with, and integrated in a creative way. The appeal of such a point of view to the idealist as well as to the social reformer was great indeed. In interesting ways some very gifted individuals have sought to make these views work. It is hardly surprising the some antiestablishment themes are easily discerned in this position, and it is worth noting that one of the most constructive aspects of the counterculture movement has been its tolerance for deviance of all sorts, including mental illness. It is understandable why the philosophical and political implications as well as the demand for tolerance of individual differences would appeal to the creative instinct and attract members of the counterculture, providing one of the most socially constructive rallying points.

It is too early to judge the true merits of Laing’s position and its variants. Undoubtedly there is some justification for rejecting premature labeling and considering alternative approaches to mental illness. Above all, it seems desirable for society to develop greater tolerance for deviants, even those not wealthy enough to be called eccentric. Nonetheless, the rejection of systematic efforts to classify, predict, and understand mental disorders seems a large step backward. As much as we might like to



believe that love and tolerance will conquer all, the evidence that they are a sufficient treatment for schizophrenia remains wanting.* Similarly, the assumption that it is ever good to encourage a full-blown schizophrenic episode is undocumented. If the assumption were correct, to encourage the psychosis to develop in the course of treatment would be a draconian measure, and if the assumption is incorrect, it would be the worst kind of mishap.

It is not intended, however, to go into the merits or demerits of this view, only to point to its effect in contributing to the identity crisis of psychiatry. Those of us who think about what we do and why we do it have always been troubled by the greater number of questions than answers that characterize our field. To now find our most basic notions under attack is troubling indeed.

The challenge to the established order and the distrust of rationality. As long as the cultural values were essentially stable, the psychiatrist's basic role within the culture was reasonably clear. Certain kinds of deviancies were defined as medical problems and dealt with as such. While such a solution was not necessarily satisfactory and might lead to new problems (as, for example, the use of indeterminate court sentences for the treatment of sex offenders), on the whole the psychiatric approach appeared to be an enlightened substitute for the punitive control of deviancy which preceded it. Psychiatrists were characteristically both products and carriers of middle-class values. It was usually assumed that health and a reasonable adjustment to the cultural norm were inevitable concomitants. While psychiatrists tended to hold liberal views, they tended to take the basic values for granted. There were always isolated radical individuals who challenged the psychiatrist's liberal assumptions and argued that psychiatry is basically a tool of the establishment and a modern means of supporting the status quo.

As the unpopular Vietnam war increasingly polarized society, this type of criticism became increasingly strident, with extreme groups accusing various groups of psychiatrists, psychopharmacologists, dynamic psychiatrists, and behavior therapists of being apologists for the establishment, seeking to eliminate dissent hand-in-glove with other repressive elements of society. The scandals about the political use of psychiatric commitment in the Soviet Union have not served to make any of us more comfortable and seem to lend credence to the possibility that psychiatric methods can indeed be used in the service of totalitarian regimes. Similarly, the documented effectiveness of coercive persuasion as a political tool in China, and some of the similarities which can be drawn between that process and some psychotherapeutic efforts in a hospital setting, cannot help but make us uncomfortable.

It is not that many of us have had any serious questions about what we ourselves do in actual practice; rather, these issues have made us aware that it is virtually impossible to practice psychiatry without waking innu-

* lt is interesting that depression, being a disease of older people, is rarely treated in the same way as schizophrenia, which occurs in young individuals.



merable implicit value judgments. When criticized for supporting non-American researchers with government research grants, our Secretary of Health, Education and Welfare was able to assert that it mattered little whether it was an American or a Russian that found a cure for cancer. We would all benefit. The issue is considerably more complex when we contemplate psychiatric treatment. What constitutes mental health for a member of a commune may be quite different from what constitutes mental health for the junior executive.

With the development of so-called alternative life styles, the determination of whether certain types of adjustments are healthy has become increasingly difficult. This is often referred back to the question of how a healthy individual can successfully adjust to a sick society.

It would, I believe, be inappropriate to view some of the current influences on psychiatry in isolation from the profound anti-intellectual bias that has developed throughout the western world. It is not surprising that psychiatry would be profoundly affected. Thus, while the subject matter of psychoanalysis has always been the unconscious, and psychodynamically oriented psychiatry is inevitably focused or unconscious motivation, its goal was well enunciated by Freud when he said, "Where id was, ego shall be." The mainstream of dynamic psychiatry did not encourage the expression of emotion for its own sake. Similarly, the supportive therapy practiced by biological psychiatrists and the work of modern behavior therapists emphasized rational approaches to treatment. Recently, however, a number of movements which have impinged upon psychiatry to varying degrees have emphasized the virtue of affect for its own sake and the importance of dealing with irrationality on its own terms. We have already commented on the work of Laing in this regard. However, this view is equally pronounced in the various Gestalt therapies, in the increasing popularity of some reichian approaches, and in the encounter or T-groups as well as the far more extreme variants of this genre. The importance both of scientific proof that a method works and of professional expertise is minimized.

In this context the rapid spread of the use of drugs solely for the purpose of altered subjective experience among the youth and counterculture is also relevant. Whatever else the drug experience may do, it inevitably allows the individual to escape the constraints of accurately perceiving the real world. Often the same individual takes "uppers" and "downers" as well as hallucinogenic drugs. It seems unlikely that he is seeking a specific type of high as much as some kind of new sensation. While the reasons for drug use in our society are complex and some intoxicants have been in use since before recorded history, the deliberate and widespread use of hallucinogens is a new development. Though the specific long-term effects of these agents remain controversial, they inevitably involve an individual's purposive decision to distort his perception, experience, and feelings. It does not seem accidental that the use of agents designed to temporarily induce irrationality is closely linked with other evidence of the wish to



reject social norms. The cultural values that are espoused by these segments of the counterculture emphasize the rejection of the work ethic, a lack of obligation to be one's brother's keeper, the assertion of an individual's right to do his own thing almost to the exclusion of a concern for its effect on others, and the view that feeling is in the final analysis more important than reason.

The psychiatric community was initially intrigued with reports of the effects of hallucinogens, and there were some efforts to use them therapeutically. However, vis-a-vis the drug culture and its various manifestations, most psychiatrists felt peculiarly helpless. The success of psychiatric treatment of runaways, dropouts, and active participants in the drug culture is limited at best. The bulk of the psychiatric community was torn between an intellectual commitment to encourage growth development, creativity, and experimentation and a frightening awareness that this new social phenomenon defies ready explanation in psychiatric terms.

The ambivalence of the psychiatric community toward the drug culture is not surprising. In a true sense this group showed the close link between the rejection of rationality as a necessary good along with the rejection of many other values of traditional society. Psychiatrists as a group tend to share some of the concerns expressed by the counterculture but, despite the important differences between dynamic psychiatrists, biological psychiatrists, and behavior therapists, there is a shared commitment to seek rational solutions to man's problems. The sharp controversy about what constitutes the most appropriate scientific approach is matched by an equally profound consensus that a scientific approach is needed. It appears to me that a significant trend which crosscuts the various orientations of psychiatry is the rejection of the scientific method and the emphasis on experiential learning. The greater acceptance of Laing's views, on the one hand, and the T-group, the marathon therapies, the reichian approach, on the other hand, among groups who identify more closely with the counterculture makes sense in that these trends within psychiatry appear to be reflections of the larger anti-intellectual, antiestablishment trends within society.

Though there is little doubt that some very important positive insights have emerged from our colleagues in humanistic psychology and the renewed awareness of the importance of affect, it also seems evident that we cannot afford to give up the search for satisfactory criteria by which progress can be evaluated, and the means of phrasing our knowledge in terms that can be understood by others. However, psychiatry today finds itself not only confronted with rapidly changing values within society but also with having to deal with challenges to the most basic notions upon which any scientific discipline must rest. Thus, while most of its have been concerned about the relatively inadequate way in which psychiatry lives up to its scientific ideals, we now find that some of us point with pride at these very inadequacies and reject the notion that we should ever base our work on scientific knowledge.



What Shall Be the Appropriate Training for the Psychiatrist?

An effort has been made to sketch some of the diverse trends within modern American psychiatry. Not only is there disagreement about how scientific psychiatry should proceed, whether our basic sciences are physiology, molecular biology, neurochemistry, and electrophysiology, or whether they should more appropriately be sought in the social sciences, but even our definitions of what constitutes illness vary, and the relevance of diagnosing illness has been challenged in some quarters. Finally, there are very wide differences in how the role of the psychiatrist in society is conceived.

One of the reasons for the review of these issues is to make clear that the differences in the role that the psychiatrist plays in different contexts cannot be dealt with simply by analogy to different medical specialties. Thus, the training of a community psychiatrist demands a range of skills which are almost totally divorced from those required of the psychopharmacologist which, in turn, are radically different from those needed by the behavior therapist. It is in such a context that we must weigh the relative merits of different kinds of training for the psychiatrist.

Traditionally psychiatry has been a medical specialty, and as such medical training was a prerequisite to the beginning of specialty training. Not only is medical training difficult to obtain and requires a great deal of effort and commitment from the student but, in contrast to other medical specialties, its relevance to the day-to-day practice of many psychiatrists is far from clear. Further, it has been argued that by focusing the psychiatrist's attention on diseases of the body, medical training may actually be counterproductive. Thus, the search for physical causation may prevent a full, appropriate appreciation of psychological causation. The search for physical factors causing derangement within the individual may prevent the recognition of effects caused by a maladaptive social system, and so on. Finally, given the shortage of physicians in general and the difficulties of expanding the number of places in medical schools, questions have been raised about the advisability of allocating a large number of training opportunities to individuals who will make limited use of their training. One might well wonder why a community psychiatrist, working as a consultant with a school system, needs to have attended medical school; similarly, why should a behavior therapist be required to know how to deliver a baby or hold a retractor during a gallbladder operation? The psychotherapist's skills demand the kind of experience in interpersonal relationships and an appreciation of the nuances of psychological causality which some have argued is deterred by the kinds of attitudes that characterize the doctor-patient relationship usual in medical practice.

Part of the difficulty of assessing the appropriateness of different kinds of training for the psychiatrist is the large number of subspecialties within the field. The differences between the day-to-day activities of psychiatrists in different subspecialties are often greater than the similarities. It seems



necessary therefore to consider what the core area of psychiatry is and what basic skills should be common to all psychiatrists. For the purposes of this discussion we will consider the evaluation and treatment of individuals who are sufficiently disturbed to seek help--or who sufficiently disturb others to be sent for help--as the core skills which all psychiatrists should have mastered.

As soon as such a heuristic position is spelled out, each professional is quick to point out the obvious importance of his particular discipline. "Is it not absurd," the psychologist will ask, "to have psychiatrists without any training in the systematic study of behavior?" He may go on to say, "Does it seem sensible to have those individuals who expect to treat abnormal behavior lack any understanding of the normal individual? Can you imagine a pathologist who had failed to study normal histology or a surgeon without a knowledge of anatomy?"

The sociologist will ask, "How can you begin to evaluate an individual without a full appreciation of demographic variables?" He will emphasize the significance of the individual's unique background, the structure of his family, the impact of role expectations, job opportunities, social pressures, and changes within the family, perhaps in response to broader social trends. He may well ask how psychiatrists can hope to understand the significance of a patient's actions without a broader appreciation of deviancy within our society, recognizing that the same problem treated by the psychiatrist might, under slightly different circumstances, be "treated" by the police, the courts, or the penal system, and under still other circumstances be tacitly tolerated in some communities (e.g., incest). The anthropologist will argue that without an understanding of other cultures it is inevitable that we confuse the social arrangements of our own society with what is normal, instinctive, right, or desirable. Similarly, he will point out that manly attributes highly valued in one culture are seen as pathology in another: that one tends to assume the role which is normal for a man, a woman, a child, or an adult is somehow preordained, whereas, in fact, these roles show a remarkable degree of plasticity across cultures, and so on.

If, after consideration of such viewpoints, one decides that psychological training, augmented by familiarity with some of the other social sciences, ought to be the basic training for psychiatrists, the physician will ask how one can possibly hope to treat mental disorders without a thorough understanding of the myriad of physical causes of psychological difficulties. Certainly he would say that one would need to make the differential diagnosis between hyperthyroidism and an anxiety state, between a hysteric seizure and epilepsy, and between depression and postinfectious debilitation, as well as to recognize other instances where organic problems present as psychological symptoms.

The fact of the matter is that knowledge of each of the disciplines is relevant to the psychiatrist's function. It is true that the psychiatrist needs to understand what constitutes normal behavior, ideation, cognitive processes, and the like; that he should have a true appreciation for the



systematic study of psychological processes, both normal and disturbed; that he should be able to quantify his findings and test their validity in a systematic fashion. Certainly he needs an understanding of the social system within which he works, nor should he believe either that his personal values are of necessity the best guides for his patients to follow or that everything he finds personally offensive is of necessity serious pathology. By the same token, he must also have an appreciation of how organic factors can cause psychological symptoms and have the ability to properly utilize psychotropic agents in his work, not to mention a broad understanding of basic medical science. Ideally, then, he should have training in each of the formal disciplines we have touched upon and, of course, if he is to do psychotherapy, he should have acquired that skill by dint of extensive training and supervision.

Psychiatry as it is currently conceived has its roots in a large number of disciplines, each of which is important for the psychiatrist's development. We need to recognize, however, that it simply is not possible to demand an in-depth knowledge of each of these areas. To do so would further extend the length of training required of the psychiatrist. From an economic and social point of view, such a solution would hardly be acceptable.

Because of these difficulties, the suggestion was originally put forth by Lawrence Kubie (1950) that a special curriculum be developed for psychiatrists analogous to the way special training has been developed for dentists. By eliminating those aspects of medical training least likely to be relevant to the psychiatrist's work and substituting more relevant training in psychology and the social sciences, he argued, a better use of the students' training period would be made. Certainly this general notion requires careful consideration.

In the succeeding section we shall seek to compare some of the advantages and disadvantages of the three most likely alternatives which have been proposed as appropriate training for psychiatry: medical training, training in psychology and related social sciences, and some new curriculum, leading to a new kind of degree and involving a hybrid training of medicine, psychology, and the social sciences.

At the present time, those individuals who ultimately become psychiatrists will have taken premedical courses in college, usually with a strong emphasis on biology and biochemistry because most college premedical counselors feel that this gives the student the best opportunity to gain entrance to medical school. Relatively few students take advantage of the opportunities to obtain a thorough grounding in psychology and the social sciences or a broad liberal arts education during their college years. The psychiatrist-to-be then enters medical school, which emphasizes the basic and clinical sciences necessary to graduate a student capable of dealing effectively with a broad range of medical problems.



While in recent years in many medical schools psychiatry has been able to obtain a somewhat larger number of hours than was the case some years ago, and more medical schools now include a few hours of behavioral science during their preclinical years, the major task facing the student is to master the skills necessary to be a general physician. In theory at least, the student on graduation should be capable of handling the duties of general medical practice. Since in such a context psychiatry must of necessity play a limited role, it is not surprising therefore that the focus of medical school is on the acquisition of knowledge which is not directly relevant to psychiatric practice. Further, despite the efforts to introduce the concept of psychological causation as an integral part of the medical curriculum, the overall program must maintain as its focus the identification of organic causes to explain the signs and symptoms with which patients present. Usually there is little more than lip service paid to the recognition of psychological factors and their effects on patients, except perhaps to explain those cases where no organic etiology can readily be identified.

All too often the presumptive diagnosis of psychological factors is presented in a pejorative manner in a medical setting and related to patients who are unattractive or unpopular, the "crocks" of the medical clinic. (Regretably, it is precisely this type of patient who is often not properly worked up and in whom organic factors are overlooked.) It is not surprising that few medical students are able to integrate psychiatric principles into their medical thinking. Though the number of hours devoted to psychiatry in the curriculum may have increased, the perceived significance of psychiatric principles remains quite limited compared to other aspects of medical training.

Though some medical schools do provide a considerable amount of elective time, making it possible for an interested student to obtain additional exposure to psychiatry, such exposure is almost always at a purely clinical level and does not include any systematic training in psychology or the social sciences. Rather, it is the beginning of the apprenticeship by which the psychiatrist ultimately obtains his training and professional identity.

After the completion of medical school and some medical internship,* the true training of the psychiatrist begins. From the onset of his residency the student is asked to treat troubled individuals, usually on an inpatient service. By this time, the psychiatrist-to-be will at least have acquired some feeling of identity as a physician; he will be capable of conducting a reasonable physical examination and obtaining a medical history but will have had very little training or experience in the treatment of psychopathology. It is typically in the context of working on an inpatient service in psychiatry that he becomes familiar with psychopathology, begins to appreciate the effects psychotherapeutic interventions can have even on individuals who are severely disturbed, and comes to recognize the effects of a therapeutic milieu. The training of a psychiatrist is in a true sense an

* This requirement, which had been dropped in order to shorten the length of training, is for a variety of reasons being partially reinstated.



apprenticeship. While good residency programs offer some formal courses and attempt to encourage the resident to familiarize himself with the literature of his field, the most significant aspect of training remains the day-to-day care the resident gives to his patients, accompanied by both formal and informal supervision by preceptors, service chiefs, senior residents, his colleagues, and other staff within the therapeutic setting. The training obtained prior to the beginning of residency has only limited relevance to the training which occurs during residency. Whereas it would be hard to conceive of someone without medical training taking a residency in internal medicine or surgery, it is possible for someone without any medical background to participate in virtually all the activities of a psychiatric residency.*

The resident, when he completes his training, will have acquired an identity as a psychiatrist. He will have learned to conduct a psychiatric examination designed to assess the psychological functioning of a patient and to classify him according to the current diagnostic scheme. He will have become familiar with a variety of therapeutic approaches and developed an appreciation for the effects of psychotherapeutic intervention. He will have seen a large number of troubled individuals, some troubled children, and have been responsible for the care of many of these individuals with varying degrees of supervision by senior psychiatrists.

Though the psychiatrist will have acquired these skills, it is entirely possible that he will never have had a single course in psychology, sociology, or anthropology. His appreciation for what constitutes normal behavior will be based almost entirely on his personal life experience with people whom he considers normal and whom he has, of course, not studied the same way and under analogous circumstances to those under which he studies his patients. From this idiosyncratic data base he will extrapolate how the patients he sees ought to be if they were "normal." In most training programs the resident will have become familiar with one or another theory for the understanding of psychopathology. However, if he has been trained in a psychoanalytically oriented program, he will have had almost no exposure to behavioral approaches. Further, he may be totally unfamiliar with concepts of learning which are basic to behavioral approaches. Similarly, if he has been trained in a family therapy tradition, he may have little experience with individual therapy and less concern about making a precise diagnosis of the patient's difficulties. A residency oriented to biological psychiatry will provide experience in careful observational diagnosis and drug and other organic therapies but may virtually ignore dynamic factors both within the patient and in his interaction with his family.

Current psychiatric training, in other words, begins after the trainee has obtained his medical training and involves an apprenticeship. While there are, of course, some basic principles which are communicated in virtually

*One residency with which I am familiar trains a small number of psychologists along with psychiatric residents and, except for the administration of drugs, there is no material difference in how these individuals are trained or the duties to which they are assigned.



all residencies, the nature of the training is highly specific to the kind of patients who are treated and all too often lacks a comprehensive framework within which it is taught. There are approaches which are taught to the resident in a reasonably systematic fashion, such as psychoanalysis, group therapy, behavior therapy, psychopharmacology, and so on, but to the extent that the psychiatrist develops a broad systematic overview of his field, he is required to do so largely on his own. While medical training helps to provide the skills to assess biochemical and physiological theories, he lacks many of the intellectual tools which have been developed by psychology and the social sciences to deal with the kinds of issues that concern the psychiatrist.


If it is true that the core of psychiatric training begins with the residency and medical training is not particularly relevant as preparation for such a residency, why should medical training be required? Would it not make more sense for psychiatrists to be thoroughly grounded in an understanding of psychological mechanisms as they occur in normal indviduals, to develop the kind of intellectual tools which allow one to assess a psychological theory, much in the way medical school helps the physician to assess an organic theory of disease? Instead of learning about physical illness, his time would be well spent in developing an understanding of the laws governing learning, cognition, and motivation, theories which are rigorously stated and can thus be systematically evaluated. Similarly, if the psychiatrist is to understand the effects of interpersonal interactions, would he not benefit more from a systematic understanding of social psychological principles? Would he not need an understanding of sociological factors and their effect on health and illness, or the effects different cultures have on the development of personality structures?

For reasons such as these, the virtues of psychological training as the appropriate preparation for the conduct of psychological therapies have been vigorously put forth. While in the abstract such a view can hardly be faulted, the issues become somewhat more complex as one seeks to design an appropriate curriculum. Just as it was necessary to consider current training for the psychiatrist, it is necessary to consider the kinds of training available in psychology. Since World War II the discipline of clinical psychology has gradually evolved from its original interest in the understanding of psychopathology and its diagnosis to encompass and focus upon the modification of psychopathology either by way of the dynamic psychotherapies, client-centered therapy, behavior modification, or some of the more recent approaches focusing almost exclusively on feelings.

The claim for legitimacy. Just as the psychiatrist established his legitimacy by way of his medical training and leaned heavily on the prestige of his colleagues in other specialties, the clinical psychologist established his legitimacy on the basis of the intellectual achievements of his experimentally oriented colleagues. Until relatively recently the training programs for



clinical psychologists demanded that the student develop a broad understanding of the discipline of psychology, that he pass qualifying examinations in a number of established areas, and that he become intimately familiar with the research techniques by which psychology has sought to put its theories to the test. The clinical psychologist, like any of his colleagues in other parts of the field, was required to carry out an original, meaningful, and methodologically sound piece of research as his dissertation in order to obtain his Ph.D. As a consequence, a major portion of psychological training involved becoming a psychologist, and a relatively small portion of time was devoted to the task of becoming a clinical psychologist.

It is probably fair to say that the most prestigious programs were those which made the greatest demands in terms of general psychological knowledge, and it was felt that the in-depth, applied aspect of clinical psychology could easily be acquired on a postgraduate basis. One important aspect of clinical psychology training involved an internship in which the training followed the apprenticeship model far more closely than is usual in graduate school. For a number of reasons, however, the psychological intern was rarely in a position fully analogous to that of the psychiatric resident. An important distinction is that the resident has already earned his doctorate and is a licensed practitioner, whereas the psychological intern is generally in his third year of graduate training, obviously lacks the title of doctor, and has no prior experience in dealing with patients. The beginning resident, while lacking in psychiatric skills, would have had some experience in taking care of sick individuals.

The usual time devoted to obtaining a doctorate in clinical psychology was four years; the internship year was fully taken up by the task of acquiring basic clinical skills, learning something about applied diagnostic procedures, and becoming familiar with some basic procedures of psychological therapies. The major portion of the final year would have to be devoted to the dissertation, and if the student hoped to make a truly meaningful contribution, a greater expenditure of time would be needed. Whatever systematic training was to be part of the program would have to fit primarily into the first two years, with, as we have already noted, a major portion devoted to the task of becoming a psychologist.

Once clinical psychology had successfully established itself as a profession, the conflict between psychologists oriented primarily to clinical practice and those interested in clinical problems but with more strongly academic orientations was soon joined. It was cogently argued that a broad knowledge of general psychology, an understanding of statistics, a knowledge of research methodology, or the experience of having carried out a meaningful dissertation had very little to do with the effectiveness of the student as a clinician. In the short run, at least, the most important experience for the student was an understanding of technique and supervised practice. Further, clinical students found it both tedious and difficult to study the large body of knowledge in such traditional areas as perception, psychophysics, physiological psychology, and especially statistics. The



dissertation requirement was in many instances seen as a necessary evil. In many departments of psychology, clinical students were notorious for submitting dissertations which would not be acceptable in any other area.

The conflict between psychologists in areas other than clinical seeking to maintain standards of their field and the pressure to turn out clinical practitioners led to a variety of partial resolutions. To preserve the integrity of the Ph.D. while at the same time to do away with the requirements for dissertation, languages, and statistics, a degree of doctor of psychology was introduced in some institutions. More recently, schools of professional psychology have been developed to accommodate a more applied training program which would focus even less on the traditional areas of psychology. While it is not possible in this context to review in depth the changes within clinical psychology training programs, and indeed opinions remain strongly divided within the field of psychology in general and clinical psychology in particular about which approach is most desirable, the changes seem to illustrate a conflict between two basic points of view.

The first recognizes that clinical psychology's legitimacy owes a great deal to the acceptance of psychology as a science. It insists that the clinical psychologist-to-be must first and foremost learn how to think like a psychologist, because this provides the essential intellectual tools to allow him to gain perspective on his day-to-day activities. While this view acknowledges the importance of technical skills, it also recognizes that the field of clinical psychology has changed a great deal over the past 30 years and only those individuals with a broad background were able to adapt effectively with the changing field. Finally, it is recognized that clinical psychology's strength depends upon its continual renewal by progress in the larger science of psychology. Therefore, if clinical psychology became truly autonomous, it would lose not only its legitimacy but also its future.

The opposing position emphasizes that training in academic psychology has no discernible relevance to the effectiveness of a clinical psychologist either as a therapist or as a diagnostician. The proponents of this view argue that the need for services is sufficiently great and the time of training already so unduly extended that we cannot afford to load the curriculum of future clinicians with material of largely historic interest and thereby deprive them of time devoted to the truly relevant aspects of training. The fact that some of the requirements, such as statistics, have been a stumbling block to some individuals who eventually became effective clinicians is used as an argument that the requirement is counterproductive. The fact that the median number of publications by clinical psychologists is zero is used as an argument that it is wasteful to train future clinicians in those skills which are needed to contribute meaningfully to the literature of the field, and since most clinical dissertations do not lead to publication and often are seen as merely an onerous stumbling block to be overcome, they feel the requirement should be eliminated and the student's time would be better spent in honing his clinical skills, which would allow him to best serve his future clients.

It would appear that just as psychiatry derived much of its credibility



from the fact that it was practiced by physicians, clinical psychology derived its credibility in large part by being practiced by individuals who had achieved a doctorate in the basic scientific discipline of psychology. Yet, in each instance the relevance of many aspects of the training is not immediately apparent to some practitioners, and pressures are exerted seeking to eliminate some of the "unnecessary" hurdles in the way of someone's wishing to practice psychiatry or clinical psychology. Later the significance of a therapist's right to call himself "doctor" and the consequences of easing the task of obtaining such a title will be discussed in more detail. Suffice it to say that in this matter, as in most others, there is no free lunch.

In considering whether psychological training is a viable substitute for medical training for the psychiatrist-to-be, one needs to ask whether we are discussing a more or less traditional program in clinical psychology, which provides a broad background, or the highly applied emphasis of the schools of professional psychology. It seems likely that the latter type of training would, like present day psychiatric training, not provide the broad understanding of psychological issues and theories which would help the student gain perspective on his field. Of greatest concern, however, is the fact that the very same issues that are raised against the appropriateness of medical training for the psychiatrist are now being raised by some clinical psychologists against training in general psychology as not being relevant to the practice of clinical psychology. Though I personally would strongly disagree with either view, it seems important to recognize how difficult it is to document the relevance of any basic training program for an individual who is concerned with providing psychiatric care, broadly defined.


Many of the difficulties characterizing both medical training and the graduate program in psychology could be obviated if the suggestion put forth by Kubie (1950) some years ago could be adopted and a special degree of Doctor of Medical Psychology could be offered within a medical school setting. It is hard to quarrel with the view that the psychiatrist is required to learn more physical medicine than he will actually use, and that some of this time could be well spent in acquiring relevant training in psychology and the social sciences. In principle, the idea can hardly be faulted. The development of such a program would have to take place somewhat analogously to that of dentistry. At one time the rudiments of dentistry were taught in some medical schools, and only with the development of the field did dental schools and dental curricula evolve. Certainly today there would be little support for the view that dentists ought to complete medical training to be fully qualified. While there is some overlap in the basic sciences between medical and dental training, there is a high degree of consensus about the large body of specific relevant training and skills that the future dentist must acquire.

It is on this very issue of consensus that the hybrid curriculum breaks



down. Thus, if one asked a number of outstanding psychiatrists to plan a curriculum leading to a degree in psychiatric medicine, it is highly unlikely that one could obtain consensus from among psychiatrists of different theoretical orientations. The biological psychiatrist would probably demand medical training, supplemented by additional emphasis on biochemistry, pharmacology, and genetics. The psychodynamically oriented psychiatrist would lean toward a program along the lines of that proposed by Kubie, which emphasizes psychoanalytic training, psychology, and the social sciences as well as some core medical training. The social psychiatrist would focus more on epidemiology and the social sciences, whereas the behavior therapist would insist on a solid background in learning theory and classical conditioning. There simply is not the consensus necessary to design a program which would provide the basis for a new discipline that is not a specialty of a larger discipline such as medicine or psychology but a true discipline in its own right.

This problem is by no means unique to psychiatry but can best be understood in a broader perspective in the history of science. New disciplines arise whenever there is a sufficiently large body of knowledge upon which there is basic consensus within the field to justify the new area of science. For example, biochemistry and nuclear physics are two fields that emerged in recent times and are clearly delineated as disciplines. In contrast, there were several efforts to create the discipline of social relations. Harvard, for example, combined sociology, social anthropology, social psychology, and clinical psychology as a new field and began to offer degrees in social relations. Though the department had outstanding faculty and attracted excellent students, the field did not conic together as a coherent whole, and after some 10 years the department was disbanded and its components reconstituted along more traditional disciplinary lilies. While similar attempts in other universities persisted for longer periods of time, no real field evolved because there was a lack of consensus about what constituted this new discipline, and members of such departments tended to identify themselves more closely with colleagues in the academic disciplines whence they came than colleagues within their own interdisciplinary department. It appears that present-day psychiatry lacks the kind of consensus necessary for the evolution of a new discipline truly independent of medicine. Unless this condition existed, however, any effort to put together such a training program would be doomed to failure. Unless the program caught on, graduates of the program would find themselves without acceptance either by medicine, by psychology, or by the social sciences, and they would then lack the kind of backing essential for effective professional practice.

How justified is medical training for the psychiatrist?

The preceding discussion has tried to demonstrate that none of the proposed training programs begin to provide a good grounding in all of those areas which may reasonably be considered basic to psychiatric prac-



tice. While most psychiatrists are likely to agree with the need to add certain specific educational experiences to the training of the psychiatrist, the precise nature of this additional knowledge will vary with the theoretical predilection of the psychiatrist being asked. Despite the fact that the training of psychiatrists requires at least seven years (four years of medical school and three years of residency), it would hardly be possible to design a program to train psychiatrists in all of the areas which may ultimately be deemed relevant. Nonetheless, the fact that even a seven-year training period fails to provide a graduate with the knowledge which would seem desirable makes it all the more reasonable to ask why the training should take so long when the clinical psychologist's basic training is completed in four years. What benefits does medical training provide the practitioner to justify an additional three years of training as well as the extremely arduous demands that have typically been required of those admitted to medical school and have characterized medical training in years gone by.

There are a number of self-evident arguments which have been put forth to justify the requirement that psychiatrists complete medical school before being admitted to residency training in their chosen field. These include an emphasis on the role organic factors may play in bringing about specific psychological experiences, how what appears to be an anxiety may actually be due to hyperthyroidism, how a temporal epilepsy may mimic episodic thought disorders, and so on. Again, it is obvious that medical training is useful for the appropriate use of psychotropic agents whose role in psychiatric treatment is likely to increase as more powerful drugs with even more specific effects on psychological symptoms are developed.

It is not intended to minimize the advantages of medical training regarding these issues. However, it is by no means clear that these benefits are sufficiently great to justify the expenditure of effort needed to acquire a medical degree for those individuals who do not go into biological psychiatry. One might well argue that the amount of knowledge required in modern medicine is sufficiently great that collaborative treatment efforts are becoming the rule rather than the exception. Consequently it might be far more efficient for practitioners of psychotherapy, for example, to work collaboratively with medical colleagues without themselves having had to acquire such training. One biological psychiatrist might deal with the medical diagnostic problems and the administration of organic therapies in collaboration with a number of nonmedically trained psychiatric practitioners, leading to a more effective utilization of manpower.

While there is no doubt that medical training facilitates an appreciation of organic issues and provides some definite, specific information occasionally useful even for the practitioner of outpatient psychotherapy, the actual use that is made of medical knowledge in outpatient psychotherapy is limited. Except for those colleagues who specialize in drug therapy, many psychiatrists have a very limited knowledge of psychopharmacology at a level that might easily be acquired by nonmedically trained individuals. Finally, even in those instances where medical training would seem important for the psychotherapist--the occasional patient with hyperthyroidism,



Addison's disease, brain tumor, and the like--there is no assurance that such a condition will be recognized by the medically trained psychotherapist who may have a low index of suspicion, particularly if the patient has been referred by an internist. An argument could even be made that an individual without medical training who has been taught to look out for certain conditions, lacking the false sense of security provided by largely forgotten medical training, might be more likely to investigate the possibility of relevant physical factors affecting his patient.

It seems to me that the real benefits of medical training for all psychiatrists involve a number of issues that are rarely explicitly discussed. These additional aspects of medical training which, in the final analysis, seem to justify the expenditure of time and effort can be summarized as follows: (1) The medically trained psychiatrist has the option of combining psychological and organic treatments without being restricted by a limited licensure. (2) Medical training makes the psychiatrist a member of a larger discipline, facilitating communication with medical colleagues in other specialties and allowing for integration into an overall health care system. In addition to specific knowledge, professional training serves the function of (3) legitimizing the professional knowledge and skills vis-a-vis his patients and society at large, and (4) providing him with the attitudes and beliefs of his profession which serve as guides to behavior that is acceptable to his profession and society at large. It is these four upon which we will seek to expand.

Medical training as a means of providing the psychiatrist with a choice of treatment. While at one time the split between psychodynamic and biologically oriented psychiatry was very sharp, I know of no contemporary psychiatrist, regardless of his orientation, who has either never employed psychotropic drugs as an adjunct to treatment or who has sedulously avoided using all forms of psychotherapy, Thus, today the merits of combining therapies, at least in some cases, are almost universally accepted in the field. As has been pointed out earlier, it is, of course, possible for a nonmedical psychotherapist to collaborate with a medical colleague in order to provide the benefits of both psychological and organic treatments. However, it would be difficult to avoid being influenced by the fact that one is trained to provide psychological therapy but must work collaboratively to provide drug treatment. One of the reasons I personally chose to obtain medical training was because it seemed important to me to avoid placing myself in a situation where I might be biased against a given therapeutic approach because of being legally prohibited from utilizing it.

It is, of course, true that bias is unavoidable, since each of us will interpret available data slightly differently. Nonetheless, it seems likely that decreasing the reality obstacles to employing a variety of treatment modalities will decrease the likelihood of systematic bias. Consider as an example the change that has taken place over the past 20 years among medically trained psychotherapists. In the late 1940s psychoanalysts were almost unanimously opposed to the use of medication as an adjunct to treatment, a view they shared with clinical psychologists. With the increas-



ing effectiveness of drug therapy, it is the consensus among psychoanalysts, as we have noted earlier, that medication is an appropriate adjunct in suitable cases, while there is considerably less agreement in this regard among our colleagues in clinical psychology. It seems difficult to avoid the conclusion that the legal right to employ psychotropic agents when indicated makes it easier for the medically trained psychotherapist to change his attitude toward their use.

Now, more than ever, psychiatric therapy is in a state of flux, and new therapeutic approaches are constantly being evolved. It seems likely that a dispassionate appraisal of the merits and demerits of a given approach will be more likely achieved by professionals who have the widest possible degree of freedom in employing any procedure that may prove to be safe and effective.

The merits of medical training to facilitate communication with other specialties. The differences between the day-to-day activities of different medical specialists are often greater than the similarities. The more specialized the branch of medicine, the more difficult it is for the physician to keep up with progress in other fields. This is as true for the roentgenologist, the dermatologist, and the allergist as it is for the psychiatrist. While colleagues in these and in many other fields would encounter much difficulty in again passing their national board exams, they nonetheless share an exposure to a core curriculum of medical training. Though much of the detail will have been forgotten, and few colleagues in the above specialties would contemplate carrying out even the simplest surgical procedure, communication is greatly facilitated by their shared training. With relatively few questions, it is possible to follow a case history outlined by a colleague in another specialty. Thus, even a cursory analysis will show that a good deal of medical training is not relevant to the practice of most specialties. No one has yet suggested that the concept of medical school be abandoned simply because a shared training is essential in order to meaningfully communicate with physicians in different fields.

For these reasons, even if one were to argue that medical knowledge were totally irrelevant for the psychiatrist (a view with which I would certainly not agree), it would still be of great importance in facilitating communication with medical colleagues. The integration of the psychiatrist into the modern medical center would simply not have occurred without this shared background. Thus, while some clinical psychologists may work in medical settings, they tend to relate through a department of psychiatry which forms a bridge. Similarly, some psychologists may work in a department of neurology, providing special expertise in the diagnosis of organic disorders, but here again their input is through the neurologist who finds the psychologist's contribution worthwhile and makes it a part of his own workup. While a similar relationship exists with other nonmedical professionals who are part of a modern medical center, such as clinical biochemists, bacteriologists, biomedical engineers, and so on, each of these relates either to a specific medical specialty or to a small subset of medical specialists and simply



does not have the same kind of broad interaction which characterizes most medical specialists' roles vis-a-vis their colleagues.

Thus, medical training serves the psychiatrist in making possible his acceptance by his colleagues and his integration into medical practice as a whole. It provides a ready access to needed information from any of the specialties. To the extent that psychiatric therapy is to be an integral part of other forms of medical treatment, such integration is essential; to the extent that it is seen as a totally different kind of service which must be identified and sought out by the patient independently, it becomes less important.

The need for the therapist's ability to be legitimized. A number of authors, most notably Frank (1961), have emphasized that in all societies healers must go through a process of legitimizing their abilities. Usually this involves arduous training for some form of priesthood, and in addition it may be necessary to demonstrate one's gift by evidence of supernatural favor. Though from the physician's point of view he practices rational and scientifically based medicine, it is worth keeping in mind that the patient rarely is able to judge the scientific merits of the procedure. For example, the reasons underlying some of the simple aspects of a physical examination such as percussion are not understood by most patients but are accepted by them on the same basis as the Navajo Indian accepts the treatment by his native singer--faith.

The average patient believes in "science" in much the same way as the native patient believes in witchcraft. In other words, these are special professional skills, explicable to those individuals who have by dint of hard work and training achieved competence to evaluate what goes on. Nor is the modern man's faith in science nearly as secure as we might like to believe. The difficulty in eliminating the cancer quacks, not to mention the psychoquacks, is ample evidence of modern society's ambivalence.* Nor ought we to fault the layman for being taken in by the chiropractor who uses some machine with flashing lights to detect "cancer," since it is by no means easy for the layman to differentiate between the scientific and the pseudoscientific procedure, and the chiropractor who has the right to call himself "doctor" is careful not to emphasize the distinction between himself, an osteopathic physician, and a medical doctor.

As has been emphasized earlier, the physician's role in modern society is a uniquely powerful one, and despite a lack of full understanding and some ambivalence, the public tends to trust the physician's judgments on medical matters. The psychiatrist has in the past used the medical degree successfully to augment his prestige and lend credibility to his observations concerning troubled individuals, taking advantage of the physician's acceptance as the culturally defined authority on matters of health.

In a number of areas, the shortage of physicians and the inevitably relatively high cost of services by highly trained individuals has led to the

*Note, for example, that six states have legalized Laetrile despite repeated, carefully documented negative results.



development of health professionals other than physicians who compete with some medical specialists as providers of some specialized services.

It seems clear, however, that the medically trained physician is acknowledged by contemporary American society as the most desirable health care provider--all other things being equal. The medical degree inspires the greatest confidence and has the highest degree of social acceptance. This is not surprising insofar as the medical degree is known to be the most difficult to obtain. Medical schools are widely recognized as being the most highly selective professional schools, making them the most difficult to gain entrance to. Medical training is generally recognized as being the most arduous, making the greatest demands, both intellectually and in terms of actual work expended. Finally, medical training, combined with specialty training, takes the longest time to acquire of any professional training in our society.

Those professions which are known to be the most difficult to enter, make the highest demands upon the trainee, and require the longest period of training tend to be the most highly valued. Similarly, those priesthoods which are most selective, require the most of the neophyte, and whose training period takes the longest and involves the greatest amount of sacrifice are typically able to command the greatest respect.

Thus, even if medical training were totally irrelevant to the task of the psychiatrist, it would still be of considerable advantage to the practitioner to have established his legitimacy by his medical credentials. While we as psychiatrists are understandably concerned with .emphasizing the specific skills of our profession, the public's attitude toward the physician is a major asset. A wise old uncle can and often does play an important supportive role within the family. His status within the family--inevitably affected by his status in society as a whole--will often be important in making it possible to be of help to those who consult him. Though such an individual may have acquired through his experience and learning a degree of understanding and empathy for the problems of others--he may even have learned to listen and seek to understand rather than seek to give gratuitous advice--nonetheless he will tend to be significantly less effective than a psychiatrist with no greater interpersonal skills, simply because the latter's role has been legitimized by society. The wise uncle may categorize behavior as foolish and may empathize with someone whom he considers troubled or perhaps even a peculiar person; his statements do not, however, define someone as sick or healthy.

The question remains whether medical training can be replaced by an easier, less time-consuming, and more relevant alternative. Thus far we have discussed the not inconsiderable sociological benefits of medical training for the psychiatrist. Does that mean, since medical training merely serves to legitimize the psychiatrist's work, that another form of training, less time-consuming and more efficiency acquired, involving more specific skills germane to the psychiatrist's duties, would serve equally well?

In considering such an argument, it should be clear from the outset that there is a contradiction in the view that equal status can somehow artificially be conferred by virtue of a training procedure which is inherently less



demanding, intended for a profession which is inherently less selective. As has been emphasized earlier, members of a community tend to be keenly aware of the amount of investment which a particular type of training involves. One has but to look at the evolution of professions in the United States over the last 30 years to see how quickly it is decided to make the selection criteria more rigorous, the training more difficult and arduous, and to increase the length of time required. This has been true of every emerging profession, whether it be nursing, social work, occupational therapy, speech therapy, or for that matter, osteopathy. In each instance, as the training demands increase--without necessarily a commensurate increase in relevant performance of the graduates--the status of the profession increases. This increase is typically expressed not only in intangible status but also directly in terms of income. The real beneficiaries of this process are, of course, not the new professionals who are compelled to undergo the increasingly longer periods of training (of questionable relevance to the professional's ultimate activities), but rather the existing professionals who are prescribing the increased period of training, since they obtain the benefits of the new-found status without having had to pay the price.


Though the knowledge involved in having delivered a certain number of babies has little specific relevance to psychiatry, having participated in this activity has much relevance to being a physician. Again, while the sad, frightening, and harrowing experience of having a patient die while ministering to his needs hardly involves the acquisition of knowledge, it is precisely the kind of experiential learning which ultimately helps an individual to better understand the role of the physician.

In the context of being overloaded with facts, having to face the inevitability of not knowing enough, and the need to nonetheless make decisions, facing the anxiety associated with failing to prevent the eventuality of death, and participating in the act of birth, seeing our fellow man reduced to his biological core in the face of pain and suffering and finally restored to a civilized, self-possessed human being with dignity as he recovers, we inevitably face experiences which are shared by other physicians but rarely by other members of society. To make it easier to deal with such issues, medicine has over the centuries evolved a set of values which have continued to stand it in good stead despite tremendous changes in the structure of society at large. Swearing the Hippocratic oath may strike us as quaint and anachronistic, yet it serves to remind us how remarkably similar are some of the issues faced by the physicians of ancient Greece and those today and how we continue to use an essentially stable code of ethics as a guide for action.

It is worth noting that the physician's values were different from those of other members of society. He typically had the role of the noncombatant on the battlefield, and was often allowed to treat, and heal if he could, enemies whom others would have been required to slay. He was permitted to breach



taboos which were placed upon other members of society, and his relationship with his patient was typically defined as going beyond a simple contract.

That the ethos of medicine and the values it embodied transcended physical illness was already clear in the writings of Hippocrates. Though the distinction between physical and mental disorders was not clearly articulated until relatively recently, the ancients had a considerable degree of understanding for what we would call today psychological factors in illness. Perhaps the most important single aspect of the medical ethos for the development of modern psychiatry has been the physician's role as a secular healer who was not expected to pass moral judgments on his patients' behavior, but rather to address himself exclusively to the restoration and maintenance of his patients' health. In this regard, an alternative basis for judging behavior was created, not in terms of right or wrong but rather in terms of health and sickness. Although the physician is inevitably a product of his time and culture, his role allows--demands even--that he have tolerance and understanding for behaviors and customs that are different from his own. Physicians often traveled a good deal and rose to positions of influence from relatively humble origins. In many ways, the physician saw himself not only as a member of a particular class or nation but as one of those whom society designated as healers, willing and eager to add to his skill from the knowledge of others. In this regard at least, his perspectives transcended the xenophobia of his particular culture.

In many regards the manner in which medicine solved some of the highly complex moral and ethical problems with which each practitioner dealt in his day-to-day activities provided an extremely useful framework within which to deal with deviancy. The fact that the physician's role makes him somewhat of an outsider and requires him, to some degree at least, to be a cultural relativist provided a remarkably stable guide to behavior. The medical ethos, evolving as it did over a long period of time under a wide variety of different political systems and in the face of changing social mores, has adapted to both dramatic changes in the effectiveness with which medical treatment could heal and drastic changes in the life styles where it is practiced.

The physician was able to maintain his role by remaining essentially apolitical, separating his medical activities from what would otherwise be his obligations as a citizen. Further, it was often necessary to divorce, as far as possible, religious obligations from the requirements of medical practice. With rare exceptions it was possible for the physician to behave in accordance with medical ethics, being excused from conflicting obligations either to the state or to God which would be expected from other members of the society. For example, a prisoner might be treated harshly, but if he became sufficiently sick for the authorities to call in a physician to treat him, it was generally expected that the physician would do what he could to help the patient who, while under his care, could and did receive better food and gentle treatment. Once the prisoner was no longer sick, however, the physician was not expected to have any say about his subsequent treatment. It was possible for the physician to minister to the sick, disregarding the



patient's status and the extent to which he might or might not be in favor with the prevailing political authorities--provided he limited his activities to healing. While he might have sympathy or compassion for his patients' lot in life, he was expected not to abuse the freedom which society accorded him.

It was a relatively easy matter to separate one's political convictions and religious beliefs from the practice of medicine as long as one was treating physically sick individuals. Physicians also concerned themselves with epidemiological issues and, once the effectiveness of the public health procedures became clear, they tended to become accepted regardless of the particular political system which prevailed. Since disease tended to spread to all segments of society, it is easy to understand why medical measures tended to gain acceptance.

Through the centuries physicians have practiced supportive therapy. It seems likely that the bedside manner of the nineteenth-century physician was in some ways better than that of his modern counterpart simply because he had less to offer by way of specific therapy and could ill afford to deprive his patients of the therapeutic effects associated with faith and expectation of cure. The development of modern psychiatry took place under the general umbrella of medical practice. It is difficult to imagine how any other umbrella would have permitted anyone to publish descriptions of sexual perversions in nineteenth-century Germany, or the details of sexual fantasies in nineteenth century Austria, the epitome of the Victorian society ruled by "his most Catholic majesty, the Holy Roman Emperor." It was possible within the context of the medical umbrella for Freud to ignore the taboos of his day, to avoid concern with right and wrong and substitute instead the concepts of health and illness. The medical role allowed the psychoanalysts to take insights from other scientific disciplines as well as the humanities without losing the advantages and status that academic medicine conferred upon them. The entire practice of psychoanalysis and psychodynamic psychiatry took place wholly within the context of established medical traditions. These traditions were adopted even by the nonmedical analysts and certainly guided the work of the psychodynamic psychiatrists in the United States.

On the surface the medical ethos appears to avoid the pejorative value judgments which pervaded Victorian society and seemed to allow the physician to transcend those restraints. Certainly to some degree this was true; more, careful analysis, however, shows that the definition of health and sickness inevitably reflected the value system of the psychiatrist which, while often different from that of society at large, involved no less a value judgment--though at times a less obvious one. Thus, the psychiatrist would carefully avoid calling a patient bad or evil; instead he might diagnose "moral insanity," or the patient's behavior might be termed "acting out," or he might be described as having a "character disorder." It is easy in retrospect to show how complex value judgments invariably crept into psychiatric therapies, or to use a current cliche, that psychoanalysis was basically sexist, or that psychodynamic psychiatry continued to be a product of and was consumed by middle-class society. Nonetheless, it is all too easy to overlook the fact that the medical umbrella provided the opportunity to develop viewpoints at sharp



variance with those that were currently acceptable for the society of the day, and despite some contradictions, it provided a framework within which clinicians were able to work effectively, interacting successfully not only with their patients but also with their medical colleagues outside of psychiatry and with society at large.


As has been pointed out earlier, the epidemiological approach applied to dynamic psychiatry must suggest that social problems are at the root of most psychological difficulties. Further there is a tendency for colleagues with liberal persuasions to be attracted to the social sciences in general and, as physicians, to psychiatry in particular. In working with individual patients, the therapist's biases may reflect themselves in the patient's response; nonetheless, what the patient says and does will tend to place some reality constraints on the therapist's beliefs about causative factors of his patient's difficulties. Unfortunately, the further we become removed from the treatment of actual patients, the easier it becomes to project our convictions onto the social system, particularly if we have no easy way of testing their validity. The distinction between the psychiatrist as a concerned citizen and the psychiatrist speaking as a trained specialist--analyzing the cause of various individual problems--is all too easy to overlook. The willingness, for example, of a significant segment of American psychiatry to diagnose Goldwater as disturbed prior to the 1964 election without access to the kind of material which would normally be considered essential for such a diagnosis is an unfortunate case in point. Similarly, we have been urged by colleagues to take positions as psychiatrists on a broad range of social issues which have great political significance but are far removed from both clinical practice and the area of our expertise. These tendencies have at times had particularly catastrophic effects on the functioning of some community mental health centers.

It would be well to remember that the unique role of the physician was made possible only by the physician's careful delineation of his professional responsibility. As long as he stayed within his area of special knowledge he could do much to make life more worthwhile. Psychiatry, of necessity, must deal with some issues which have political implications. If this is true, we must exercise more rather than less care that what we say is thoroughly documented and entirely within our special expertise. We can and should speak out as citizens for what we believe, but we must be careful not to confuse our role as psychiatrist with that of citizen. This confusion is likely to have much to do with the decrease in credibility that we have experienced in the profession. The medical ethos demands that we act responsibly, and if we fail to do so we will forfeit in time the benefits society accords the physician's role.

At some level colleagues who feel they do not wish to forfeit the opportunity to push their personal views by using their professional status recognize this paradox. It is likely that the wish to separate from medicine is



related to the wish for greater rather than less license to comment as social philosophers on social and political issues. As one examines the changes within American psychiatry over the past 20 years, it is difficult not to become convinced that we have all lost a great deal as some of us have moved farther away from medicine; further, that the confusion of political conviction and professional judgment has become increasingly costly for the future of psychiatry.

At the present time I know of no alternative to the medical ethos which provides as meaningful a guide to action in a complex and changing society. It is by no means a perfect solution, but it has stood the test of time. The combination of the humanism inherent in the concept of the art of medicine and the devotion to the search for solid knowledge inherent in the concept of the science of medicine continues to be the compromise most widely accepted by the public. While some particular social or political view might have greater appeal to relatively small segments of our discipline, none of these seems to provide a sufficiently broad umbrella to encompass the field as a whole.


Having reviewed where we have been, the problems facing psychiatry today, and the role of medical training in the development of psychiatry, I have become increasingly convinced that we do not have a viable alternative to medical training. I fully recognize that much of medical training has little relevance to the psychiatrists day-to-day functions. However, the same can be said for all proposed alternatives. At this time no evidence exists which would allow us to choose among the various kinds of training that have been proposed as alternatives.

The hope to develop quick and easy training for specific skills that are particularly relevant to psychiatry and that will result in a broadly trained clinician who can successfully attain high status within our society is by its nature doomed to failure. The arduousness of the training itself has much to do with the status it confers. The breadth and lack of specificity has much to do with preparing the psychiatrist for a future practice which is bound to be vastly different from what he does today, and finally and probably most important, medical training provides an effective, well-developed guide for the physician's actions which has stood the test of time and remains appropriate for clinical practice to the present day.

An analysis of the challenges facing psychiatry suggests that the solution is not to move farther away from medicine, though we can and should learn from other disciplines whenever appropriate. Rather than moving away from medicine, we need to work to rejoin it. This means accepting the strictures that have always applied to the physician--that he not confuse his personal sympathies with his professional duties. Similarly, at a time when anti-intellectualism is increasingly widespread throughout the world, we need to be doubly cautious not to confuse appealing ideas and good intentions with proven competence. Fortunately, medicine as a whole will continue to strive



to increase the scientific basis of its activities. By moving closer to medicine, we can make certain that we in psychiatry do likewise. This does not mean that we should neglect the significance of feelings, ignore unconscious motivation, or diminish our continuing efforts to be sensitive to the needs of our patients. It does mean, however, striving to put our beliefs to empirical test and becoming increasingly disciplined in the evaluation of what we do.

The changes that have taken place within American psychiatry and within the life style of the culture at large have contributed to the identity crisis we face as a profession. In our efforts to solve this crisis, we will need to partake of much relevant knowledge that has been generated in psychology, sociology, anthropology, and related areas--fields which are not generally considered medical disciplines. However, this in no way should lessen the importance of medical training which is shared with other physicians who also owe increasingly large debts to basic scientists in other fields. The unique contribution of psychiatry is likely to be not the creation of a science but rather bringing to bear a variety of disciplines on the clinical problems of psychiatry. As we recognize the area where we can contribute uniquely and begin to accept the limitations of our discipline, it is likely that we will become increasingly effective in its practice. Here too we can benefit from the model of other fields of medicine. One might hope that the psychiatrist of tomorrow will not seek to solve all problems of society but will instead successfully and efficiently be able to treat what we today call the major psychoses and the psychoneuroses. Whether these maladaptive syndromes are ultimately defined as medical illness, a form of social deviancy, or problems in living should not affect the psychiatrist's ability to seek out effective procedures derived from any or all basic sciences. While medical training is by no means sufficient to this task, it does form the basis for communication with other members of the healing arts and still remains the most effective preliminary training program to provide the kind of basic knowledge, social legitimacy, and eclectic tradition that allows the broadest range of therapeutic modalities to be integrated into the psychiatrist's therapeutic armamentarium.


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The preceding paper is reprinted from Controversy in psychiatry, J.P. Brady & K.H. Brodie (Eds.), "Should psychotherapists be medically trained? Let's consider the alternatives in light of what the psychiatrist does." by M.T. Orne, Pp. 43-81, copyright 1978, with permission of Elsevier. (Originally published by W.B. Saunders)