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By Richard Karel
Since its inception, psychiatry has arguably been the most philosophical of the medical specialties.
Even as the psychopharmacological revolution rolls on, psychiatry continues its own searching self-examination. The profession has come to accept a collaborative relationship with psychologists, social workers, and counselors, while continuing to assert the primacy of psychiatry as the one mental health profession that provides comprehensive care for the mentally and emotionally ill. But a new movement to promote doctoral-level and master's-level philosophers as personal and corporate counselors has raised new quality-of-care issues for psychiatry and the traditional allied mental health professions.
The issue gained prominence when New York State Assemblyman Ruben Diaz Jr., a Bronx Democrat, introduced legislation last month to authorize licensure of philosopher therapists. A lobbyist familiar with the New York State legislature gave the bill virtually no chance of passage. With or without formal licensure, however, the philosopher-practitioner movement has begun to organize and to promote the virtues of the philosopher as counselor.
The driving force behind the movement is Louis Marinoff, Ph.D., a philosophy professor at the City College of New York. He is the executive director of the American Society for Philosophy, Counseling, and Psychotherapy (ASPCP) and president of the American Philosophical Practitioners Association (APPA). He spoke with Psychiatric News.
Marinoff disputes the characterization of what philosophical practitioners do as "psychotherapy." The use of the term as part of the title of the ASPCP is academic and refers to ASPCP's mission of "exploring the relation between philosophy, counseling, and psychotherapy," according to Marinoff.
Philosophical practitioners begin with the premise that there is nothing necessarily dysfunctional with those who seek their counsel. They eschew the medical model and refer to those who seek them out as "clients," not patients.
Marinoff, who has been seeing clients since 1991, charges $100 an hour for the client-philosopher encounter. This encounter is a dialogue in which philosophical wisdom is employed to clarify values and meaning in the client's life, he explained. Marinoff said he also sees clients on a pro bono basis.
Clients come to him for a variety of reasons. Some are "working with problems of their identities in terms of fulfilling their ambitions in life but feeling that they have been thwarted in one way or another, or indeed they are struggling with relationships in various ways, or they are seeking some kind of philosophical understanding of themselves and their roles," Marinoff said.
The perception that this represents an infringement on the turf of psychiatry is erroneous, asserts Marinoff. The motivation of the philosopher practitioner is to help people find meaning in their lives and, by doing so, help them to better cope with the challenges of life, according to Marinoff. In this respect, "we are definitely a helping profession," said Marinoff.
There is nothing sacred about the DSM-IV or the study of psychology and psychiatry, said Marinoff. "Psychiatrists are doctors in my book," he added, "so let them attend to the medical well-being of their patients and let the philosophers attend to the philosophical well-being of their clients."
"There are a great many people out there in [APA] who are extremely learned, and philosophical and erudite, and who of course realize that we serve a complementary and not a competitive function," said Marinoff.
Leading voices in psychiatry and psychology beg to differ.
"The Hippocratic imperative-first do no harm-governs the practice of medicine," said APA President Herbert S. Sacks, M.D. "Many nonmedically trained mental health professionals attempt to abide by this principal. Philosophers have not grown up in the medical tradition."
"It is not an economic issue. It's a quality-of-care issue-that people without systematic training, without supervised clinical experience, without a command of a 100-year-old [psychiatric] literature, and without medical education are engaging in the treatment of patients who Marinoff claims are not seriously mentally ill."
The ASPCP's standards call for engaging the client's "reflective powers and rational determination," said Sacks, but they ignore the existence of unconscious conflicts and other irrational forces. There is "no indication that [Marinoff] has any grasp of the theory and practice of psychotherapy, inclusive of the meaning of transference and countertransference."
His denials notwithstanding, Marinoff is "practicing medicine without a license" and treating patients for illnesses he is not equipped to diagnose and treat. People who may have serious problems thus run the risk of deferring effective treatment, Sacks concluded.
Philosophy is not an appropriate discipline within which to train counselors, said Dorothy Cantor, Psy.D., former president of the American Psychological Association. Philosophical practice is premised on "an intellectual split" that splits the intellect from the emotions, observed Cantor. "It treats people as if they are entirely guided by their intellect. This represents a major misunderstanding of how human beings function."
Philosopher practitioners are "trying to have it both ways-to be philosophers and yet give all the appearance of providing treatment and charging for that on a fee-for-service basis," observed Norman Clemens, M.D., chair of the APA Commission on Psychotherapy by Psychiatrists. "Philosophical discussion has always been important as people grapple with problems in their lives," he added. But it is disingenuous for these practitioners to claim that they are not "trying to be a health care profession and at the same time have all the trappings that go with a health care profession, such as professional licensing, restriction of practice to competent people, and a fee-for-service client relationship. They are doing all this without the foundation of systematic, objective, scientific study that underlies the psychotherapeutic techniques widely practiced today. It's hard for me to imagine that this proposal would be accepted by the [New York] legislature. But if it is, all I can say is 'caveat emptor.' "
The effort by philosophers to attain licensure is "a subset of a problem we've had in New York for about 20 years," said Herbert Peyser, M.D., APA's Area 2 trustee. "Bills keep coming up to license psychotherapists as though psychotherapy were a profession instead of a procedure."
The position of the state medical society and state psychiatric association, with the support of social workers, psychologists, and nurses, has been that "there are four professions historically recognized with standards and criteria for dealing with psychological difficulties," according to Peyser. These include medicine, nursing, social work, and psychology.
"The question of nonspecifically licensing others as members of the psychological healing profession has been fought in New York repeatedly with people trying to license family therapists, pastoral counselors, and others. I think you have to see this latest push, which is a bit idiosyncratic, as a subset of that."