The False Dichotomy: Psychiatry versus Psychology

I see this in my psychiatrist. He would make a great therapist as well, except for the fact that he really is limited to only brief contact and dispensing medications due to time constraints.

Having the two combined would be ideal, but until then, I’ll continue with my separate therapist.

Hi, John–I very much agree with the spirit of your blog (and as someone who lives in a family with a psychiatrist, a psychologist, and a social worker, I guess I had better be open to your position!).

Of course, one can advocate respect and collaboration between the mental health disciplines, without taking the position that
we are all interchangeable. I do think each discipline (psychiatry, psychology, and social work) brings different skills and talents to bear on human suffering. The question is how best to provide help to those who need it–and
that is where a comprehensive and integrated mental health system is sorely needed.

Here is the comment I posted on Dan Carlat’s website:

I very much agree with the spirit of your posting, Danny (though I still favor psychiatrists going through medical school, I would like to see an expanded residency, enlarging on the “psychosocial” dimensions of illness).

I believe the philosophical roots of these so-called “turf wars” lie in the heritage of Descartes, with his mind/body dualism. This has led, in my view, to sterile debates regarding whether people have “mental” or “bodily” disease. The late R.E. Kendell MD argued that “disease” is properly predicated of persons–not minds, brains, or bodies. Maimonides said much the same thing eight centuries ago: we try to cure not a disease, but a diseased person.

Ron Pies MD

As someone who has bipolar disorder, I have found that psychology, psychiatry, and my faith have all helped me to know great peace for over three peace. My graduate degree in psychology actually made me suspicious of psychiatry and medication. Fortunately, my experience finally convinced that if I had a physical problem I was going to need a physical solution. I started taking medication – reluctantly. For years I went on and off the meds. Not anymore. I also continue in talk-therapy with a social worker. This dual treatment and my Christian faith gave me the clarity to write Blessed with Bipolar in which I look at the potentially beneficial attributes of the disorder. http://bipolarman.org

Taggi36 Their are SO many different professionals that contribute to the mental health profession. I think this post just mentioned those three because they are the most common.

There desperately needs to be a clear divide between psychiatry and psychology, if for no other reason than the very fact that as a provider trained in medicine, the psychiatrist should confine him/herself to the MEDICAL aspects of the case and not be doing therapy, which can clearly be given just as effectively by thousands of other (and less expensive) providers. There is no reason for someone with advanced medical training to do “talk therapy” in this day and age; it is a waste of resources and training. It would be nice if the psychiatric profession finally made a break from analysis, therapy and the like and forged headlong into the areas of medicine and brain science on the cellular level–sciences that they should be trained to understand more comprehensively than a psychologist. So too, psychologists have the advanced training to fully appreciate and apply the many varied methods of therapy, as well as provide the kind of support and access that a medical doctor has a difficult time providing. In this age of decreasing funding for expensive health care, it would be more advantageous to have these professionals look to what is the best use of their skills for the patients that need to be treated.

We see this kind of division at work already in the area of physical therapy; the neurologist and physical therapist have entirely separate roles to play and they are able to work together for the patient’s interest. Medications are adjusted by the neurologist, and the PT is able to provide all the support that the patient requires on the emotional and (in this case) physical level. It works in this case, because each professional has a clearly defined role for the treatment of the patient.

Yet, in the case of mental health, to have this continued “duality” in treatment is damaging to patients. Both psychiatrists and psychologists want to have one foot in either camp, and neither is fully trained in both disciplines and therefore the resultant care is compromised. It may take a lifetime for an individual to fully study and appreciate their own discipline, so why try to attempt a second discipline? The very fact that the mind/body problem is so very complex is even more reason that these disciplines must break apart and intensify their research, training and treatment in their respective areas, BEFORE one can ever address the mind/body problem.

The time has come for psychiatrists to become DOCTORS again, and deal with the brain as an organ that must be investigated medically. Once true meaningful research into brain functionality and pathology is able to be determined with more certainty, both professions can begin to merge their respective data and responses to form a more comprehensive picture of the mind/body dualism which continues to vex both professions. The difficult path of neuroscience needs highly trained medical professionals to do the important work that will shed more light into the complexities of mind on the physical level. Any distractions and continued forays into the therapy arenas by psychiatrists are merely prolonging the suffering of patients who are desperately waiting for answers and good, reliable, CURES.

I have been a psychiatric/mental health nurse for 30 years now and have currently practiced in both an urban and suburban emergency department as a psychiatric crisis nurse for the last 7 years. You mention psychiatrists, psychologists and social workers in your posting but little is said of the role psychiatric nurse hold. As a crisis nurse, it is my job to assess and determine the level of care for patients who present to the ED with an array of complaints and symptoms from an exacerbation of an acute or chronic mental illness such as schizophrenia, bipolar disorder, major depressive disorders, etc. or those who have expressed suicidal or homicidal ideation with or without a viable plan or those who have attempted suicide either via overdose or self inflicted mutilation of themselves; those under the influence of alcohol, illicit or overuse of prescribed or unprescribed medications; families of trauma victims, patients who have expired or are acutely ill, victims and perpetrators of domestic violence or sexual assault; prisoners who have attempted or expressed suicidal ideation while in custody or those who made bail after hours who were being maintained in the psychiatric ward of the prison; those with anxiety and panic attacks, drug seeking (narcotics and anxiolytics) patients; those who have presented multiple times to the ED in a short period with somatic complaints that no etiology can be identified so therefore “there must be a psych component” and a host of other concerns. I often must interact with insurance providers to obtain authorization and “pre-cert” both in-patient, partial hospitalization and intensive out-patient courses of treatment; manage psychotic and aggressive patients, initiate emergency committals, recommend and administer antipsychotic, anxiolytic and analgesic medications and monitor its effectiveness; offer family and individual counseling and brief interventions and field calls from our crisis hotline and assist patients in obtaining emergency doses of their prescriptions until they can get refills.
I have had the opportunity to work with a team of nurses, psychiatric social workers and mental health assistants with years of both emergency and inpatient and outpatient mental health experience, many of whom are board certified by the American Nurses Credentialing Center in psychiatric and mental health nursing, who also hold advance practice degrees as nurse practitioners, clinical nurse specialists, nurse educators and nursing administration and psychology and clinical counseling degrees. We are in a unique position to bridge the gap between the psychologists and psychiatrists with our knowledge of both medicine, therapy in an integrated and holistic approach to both mental health and illness along with wellness promotion.

In a typical psychiatrist fashion, Dr. Pies reasons that the all-knowing, all-seeing psychiatrist should train in multiple disciplines and be some kind of “renaissance man of medicine”. Sadly, the paper he points to continues this kind of ego rhetoric. The brain and mind/body duality is a difficult enough endeavor for today’s medical students–so he posits that an expansion of their training with additional liberal arts subjects is warranted, in the hope that by spending some 6 or 7 years immersed in various subjects these students might actually become experts at 5 fields instead of the single one that they need to be trained for.
In a perfect world, with unlimited resources, a few individuals MIGHT make a stab at being renaissance men/women, but there is little proof that adding liberal arts to the already difficult and burdensome study of the brain and mind could possibly bring cures or even more effective treatment to the fore.

The old saying, “keep it simple stupid” is one that psychiatrists should use to tamp down that ego of theirs to control every aspect of their field. If they were able to finally break away from their hold on psychology and leave it to the vast majority of therapist professionals that can do just as good a job, MORE focus could be given to the study and treatment of the medical aspects of the field that the therapist professionals CAN NOT DO. That is the bottom line.

I am certain that whatever studies Dr. Pies wants to point to to “prove” his assertion that “combined treatment by a psychiatrist cost about the same or less than split treatment”, I would argue that whatever fiduciary benefit is realized pales in comparison to the number of patients without good psychiatric drug treatment, who cost society much more by comparison. In many communities there is a shortage of psychiatrists and an abundance of psychologists and therapists. This has created a condition where it is extremely difficult to get pharmacological treatment, and has forced family practitioners to dispense these medications, with sometimes unfortunate results. Therefore, the ramifications of what a psychiatrist chooses to do or not do, is paramount in the treatment of the community at large. You may not like it that your field has been directed toward short “medication management” appointments, (what you deem “market forces”) but that is exactly what the community at large needs, in order to make “best use” of your skills and your training. Insurance companies know this, and that is precisely why the trend has been pushed in this direction. If psychiatrists want to do therapy, then they shouldn’t have gone to medical school and wasted our tax dollars for student loans to study medicine, liberal arts, and psychology.

The real false dichotomy here is the psychiatric profession deems itself renaissance men, when they have chosen the easiest residency in medical school. Perhaps they should be forced to do a neurology residency as Freud did, and get even more MEDICAL training and to do more MEDICAL research that psychologists can NOT do. Even Freud finally realized that the discovery of PROOF of brain functions on a molecular level was the future of the field, and 100 years hence it is high time that the experiment “to understand both motives and molecules, treating the complete person” be delegated to the professionals that can best do the job, expeditiously. That means that psychologists should be allowed to to what they do best, and psychiatrists should confine themselves to what their training has prepared them for and seek a full understanding of the medical aspects of psychiatric disease–an understanding that they clearly do NOT have at present.

The “mean time” should not continue a single day as long as people are suffering from diseases like schizophrenia, bipolar disorder, and OCD. Diseases that “talk therapy” can not treat efficiently. Diseases that ruin lives and cost society endless suffering. That is the psychiatric professions’ FIRST responsibility, to cure the community of the suffering. How can they best meet this challenge? By letting go of things that can be done by others, and focusing energies and resources on what is NOT known, to find answers for these suffering people.

I find it disappointing—and not a little perverse—that my call for broader, deeper and longer learning in psychiatric residency is somehow perceived as “ego rhetoric”. Far from believing that psychiatrists are–or ever could be– “all-knowing [and] all-seeing”, I believe we have great gaps in our knowledge that must be filled. That is why I advocate a longer residency program that would include not only more neurosciences, but also greater exposure to psychology, psychotherapy, and the humanities. (This, by the way, applies to the years after medical school).

Separating “medical” from “non-medical” dimensions of illness—or biological from psychosocial—misunderstands both the historical role of the physician as healer, and the essential function of the psychiatric physician. Consider the patient who is depressed after a stroke. We know that strokes can knock out neurotransmitter tracts in the brain that affect mood; we also know that strokes often represent a tremendous symbolic loss to the patient. So is the person’s depressed mood the result of “medical”/biological or “non-medical” /psychosocial factors? What investigation would one do to determine the percentage contribution of each?

Most experienced physicians will appreciate that these questions are shallow and nonsensical. The person cannot be balkanized according to such a simplistic dichotomy, and there is not an iota of evidence to suggest that the best care for the depressed patient requires parceling out the work of healing to “medical” and “non-medical” personnel. A psychiatrist is a physician. Physicians need to treat the whole person, no matter how distorted that role has become in the current money-driven environment we call the “health care system”. And yes, I am painfully aware of how many of my colleagues have been reduced to the status of “assembly line workers.”

That said, as my colleague Nassir Ghaemi argues in his book The Concepts of Psychiatry, there may indeed be cases and conditions for which a “split” model of treatment works to the patient’s advantage: this is an empirical question to be answered–condition-by-condition– through careful, controlled research, not by ideology or the monetary interests of insurance companies.

The humanities are not a distraction from medical science; they are the foundation for a humanistic science of medicine. In an essay on one of the giants of modern medicine, Sir William Osler, James A. Knight MD wrote:

“Besides being a superb diagnostician who promoted the highest standards of medical education, practice, and research, Osler was a cultured person of broad intellectual and artistic interests [and] a recognized classics scholar and humanist…The enormous amount of time he spent in literary and historical studies did not divert him from his commitment to medicine, but rather enhanced his clinical skills.” (“William Osler’s Call to Ministry and Medicine”, in Journal of Medical Humanities, March 1986).

It is of course critical for psychiatrists—like all health care professionals—to focus on the reduction of suffering. Having spent nearly 30 years with some of the sickest patients in two state mental health systems—yes, I have spent lots of time in the “trenches”!–and having seen the anguish of the families of those afflicted by severe psychiatric illness, I am well aware of the psychiatrist’s responsibility to relieve suffering. However, it is a profoundly naive and misguided notion to suppose that the physician’s reduction of suffering can ever be divorced from a deep understanding of the patient’s psychology. As my colleague Glen Gabbard points out in an important essay [See psychiatrictimes.com , September 3, 2009]

“Psychotherapeutic skills are needed in every context in psychiatry because the same phenomena that emerge in psychotherapy—transference, resistance, countertransference, schema, automatic thoughts—appear in other contexts.”

This includes the famous (or infamous) “15 minute med check”. Though both Dr. Gabbard and I lament this sort of “McDonaldization” of psychiatry, we both understand that many of the skills of the psychotherapist are needed in these brief encounters. As Gabbard notes,

“Patients are not likely to buy into the same conceptual model that treaters attempt to impose upon them. In other words, they don’t go to their doctor’s with the assumption that “brain” and “mind” are separate, and they don’t necessarily view psychotherapy and medication as separate entities. When they show up at their pharmacotherapy appointment, patients are not inclined to limit the content of the appointment to the side effects or therapeutic effects of the medication.”

For all these reasons, as Nassir Ghaemi MD argues, psychiatry needs “…a psychopharmaoclogy that is informed by psychotherapeutic methods.” (The Concepts of Psychiatry, p. 303)

William Osler—a physician’s physician who was at home in both the laboratory and the library—put it this way: sometimes, “…it is more important to know what kind of person has a disease than to know what kind of disease a person has.”

Ronald Pies MD

As a psychologist, here is what I see as the problem: there is a disconnect between what many psychologists think they can do and what they can actually do (especially in reference to an everyday clinical environment). I believe this attitude arises from the medieval attitudes rampant in academia from which doctoral psychology degrees originates (research and academia). Strictly speaking psychologists only provide two distinct/ separate services in the medical world: testing/ assessment and research… However, it is my belief that I have seen some of the best MH outcomes from psychologists when compared to other providers. Thus, here-in lies the dilemma, psychologists know they have good outcomes, patients to do, but “these treatment outcomes” are difficult and complicated to justify and prove (that is, the efficacy of our BH treatments are hard to justify). I suspect that if psychologists/ or psychology in general doesn’t make some changes to the clinical aspects of our field and the scope of our privileges or rather how we are integrated into medical care (e.g. like rx privileges) that in 20 to 30 yrs, except the degree to revert back to more research and strictly academic area of study (maybe that’s not a bad thing, but I think overall MH patients will suffer as a consequence). I think clinical psychology has failed in several ways, just like or rather similarly to psychiatry being unable to attract new recruits even with demand for psychiatry services so high. First, psychologists don’t have good training in how to talk to and deal with MDs for that matter, especially in a primary care model of treatment/ management (which is probably one of the main modes of health care of average individual). Secondly, psychologists have become too defensive in the psychology vs. medical model debate and assert that the medical model is a poor or inferior way to understand/ deal with patients (that maybe be so, but by withdrawing from the debate or not meetings MDs half way, many MDs have just become confused by psychology training or what psychologists can offer in a clinic; and a side note, time and time again, psychologists fail to “set up to plate,” and make MDs realize that the strength of a psychologically driven model of disorders is quite helpful as through that lens we can better predict who is –or is not, going to benefit from treatment and/ or get better). Thirdly, psychologists vis-à-via the field of psychology has gotten too much in the field of “making psychologists/ training psychologists,” which has caused supply to vastly out number or strip demand (case in point some 30 percent of psychology students are not matched to APA internships, which almost immediately bars them from the best jobs post grad school – and I have seen far too many talented psychology students not get placed APA and far too many inferior ones with better CVs get placed because they look better “on paper,” – that’s sad . The cost of the degree (PhD or PsyD outside of a more traditional university – is really not worth working in a prison system for 60k or with homeless SSI patient; thus many psychologists turn to cash only private practice, further isolating the field. What this has cause is a MH field where there are so many competing for so little – LCSWs, MSW, OTs, PAs, GPs, NPs, life coaches, MA counselors, unlicensed psychotherapists, MFTs all doing the same thing. And psychology’s response is to create more psychologists: PhDs, PsyDs, Counseling PhDs, MFT PsyDs., and so on with specializations and fellowships not do bridge the medical-psychology gap either (even in Health psychology). Pediatric psychology (not child psychology), a field that emerged in the early 60s is a good example of psychologists well integrated with treatment teams and being do to psychotherapy/ assessment as well as speak to and work alongside both MDs and LSWs – with the benefit of family/ child/ patient at heart. I suspect at this rate, the field of psychology and MH and psychiatry may eventually collapse in on its self with more GPs/ NPs/ PAs picking up the burden and neurologists filling the gap for what was traditionally psychiatry (and when I meet psychologists who are strictly in the business of supervision/ teaching supervision/ supervising other psychologists – I just think what a pyramid scheme; but I guess we have to pay the bills somehow).

Chiming in here as MH consumer. I put my vote in for psychologists as being the go-to for treatment. LPC’s/LCWS are not allowed to diagnose (at least in LA anyway). How in the heck can they come up with a treatment plan if they can’t officially tell me what my dx is?!!!!! Makes no sense to me. I have had negative experiences with the LPC/LCSW sorts. My teenager had a dx of anxiety disorder. Took her to a LPC because I couldn’t find a psychologist who was accepting new clients. Looked for a month–frustrating. So I bring the psychologist’s report ($1500) stating a dx of anxiety disorder to the LPC. The LPC spent 2 sessions (and took $200 of my $$-we didn’t have MH coverage at the time)to work with her on study skills!! I called the LPC and asked about the treatment plan & that’s what she told me. She planned on releasing her from treatment after just 2-3 sessions w/out ever treating her for anxiety. I asked her why she didn’t treat for anxiety, and she said, “I guess because she didn’t verbalize it!” Excuse me? I went to 2 different LCSWs with about as much luck. I had to wait to see one of them for 6 weeks after striking out with the other LCSW. I told her that I had dx of depression. She never monitored me for depression symptoms. To sum it up, she was an idiot. I had NO confidence that she had any idea as to what she was doing, and she TEACHES at a major university! Scary. So I’ve now gone MONTHS w/out anything but med checks for ADHD/depression with my psychiatrist. And my psychiatrist thought I was getting counselling. I love my psychiatrist, but he has 1000 patients. I have felt so pissed off–trying to get help and getting nothing but incompetence. I’m now trying a psychologist. I’ve only seen her once, but I feel much more confident about her abilities–just got a better impression of her after my one hour. I really put my vote in for psychologists with a psychiatrist having a RN or NP coordinating care with a psychologist. WHY IS THIS SO HARD?!!