March 19, 1999

By Joseph M. Schwartz, M.D.

Our professional identity stems from psychiatry's being the branch of medicine that deals with disorders of mental life and behaviors. Psychotherapy is one of our tools and, though other professions also use it, is essential to the practice of psychiatry. One reason our ability to utilize psychotherapy is being restricted by forces outside the profession is that we have failed to define adequately what we do as psychiatrists and why we do it, including our use of psychotherapy.

The future direction of the psychiatric profession is a critical issue for early career psychiatrists. We came into the profession while it was in a state of flux and have continued to witness uncertainty about its outlook.

Of the many potential directions our profession can take, some do not include psychotherapy as a continued part of our therapeutic armamentarium. The loss of psychotherapy would be a tragedy for both psychiatrists and our patients. Regardless of whether this grim situation becomes reality is in part up to us, because it is our responsibility to define our profession and not leave the definition to others such as insurance companies.

In addition, we have the obligation to maintain certain professional standards because without them we cannot maintain a credible professional identity.

Because misguided egalitarianism within psychiatry has rendered all ideas equally valued and a tendency toward what Phillip Slavney calls "flabby eclecticism," we are left at best without a coherent professional identity, and at worst with a never-ending source of embarrassing material for television news magazines covering past life regression therapy and alien abduction psychotherapy.

If we don't delineate the distinction between valid treatment and quackery, it will be done for us in embarrassing ways, and none of us will be taken seriously. We are not the only medical profession currently in this type of predicament (remember fen-phen) but we do seem to suffer it in excess. If a surgeon wanted to graft spare arms onto people, no matter how well intentioned, the surgical profession would rise up and that person would no longer be practicing. We, however, tolerate our fringe and convince ourselves that a diversity of ideas (no matter how absurd they are) makes our profession stronger. In fact, our lack of high standards costs us our credibility and professional honor. Often these fringe ideas involve the misapplication of psychotherapy.

There is a way to recover from our current dilemma.

We need to clarify our professional standards and establish a position of credibility. We need to defend psychotherapy as the powerful tool that it is and establish guidelines regarding its use that bring us respect instead of ridicule and demonstrate psychiatry as the profession with the most expertise in psychotherapy. Psychotherapy's strongest defenders are often those most critical of substandard forms of the modality. Paul McHugh, M.D., although considered a heretic by some because of his public criticism of psychiatric misadventures, could be seen the same way protesters against the crusades might have been considered heretics even though they were in fact the true defenders of the faith. History will smile kindly on him because of the high standards he endorses for psychotherapy. Through the adoption of some basic principles that I learned from him, we can defend psychotherapy and reestablish a professional identity of which we can be proud.

To say that all disorders benefit from psychotherapy, although true if you use the broadest of definitions of psychotherapy, fails to demarcate what is special about psychotherapy by psychiatrists and the clinical situations that require our specialized training and experience. All physicians use some forms of psychotherapy as part of their healing art even if limited to reassuring anxious patients or persuading patients to comply with treatment. Psychiatrists are specially trained to use a variety of psychotherapeutic modalities and, more importantly, to know when to use which modality.

Since psychotherapy is a powerful treatment, we must also recognize that there are potential side effects. These include ones that are acceptable and expected as part of psychotherapy's appropriate use, such as heightened anxiety and other strong emotional responses, as well as ones due to its misapplication, such as incorrect interpretations and assumptions, that cause serious disruptions in a patient's life and the lives of family members when they are taken as historical truth. Past examples of these types of destructive interpretations include homosexual panic, penis envy, and schizophrenogenic mothers.

In my practice I make patients aware of these aspects of psychotherapy as part of the role induction process. We cannot ignore or deny the potential side effects of psychotherapy and maintain our credibility. All effective treatments have side effects. Only faith healers and vitamin manufacturers claim risk-free benefit. In some states there have been legislative initiatives to require written informed consent for psychotherapy. Although this is clearly not warranted or desirable, these initiatives spring from the void left by our profession in addressing these issues. I hope that this is changing. APA's Commission on Psychotherapy by Psychiatrists is working on a position statement on informed consent for psychotherapy, and in November the APA Assembly voted to oppose legislation requiring intrusive informed consent procedures for psychotherapy.

We must do more than oppose external regulation. We must establish our own standards. Most important, once we establish standards, we need to police ourselves. If we don't, eventually someone else will. We need to enforce standards publicly. The more outrageous the claim by a member of our profession, the more convincing the supporting evidence required by us should be. The concept of academic freedom should not be used to protect incompetence that injures patients.

APA has taken a position opposing the so-called reparative psychotherapies for homosexual orientation because of concerns about patient safety and lack of evidence of benefit. We must continue this process with other fringe psychotherapies. This will help reestablish our professional credibility and allow early career psychiatrists to continue to use all of the therapeutic tools that we are trained to use, including psychotherapy.

Dr. Schwartz is an assistant professor in the psychiatry department at Johns Hopkins University in Baltimore and Area 3's early career psychiatrist deputy representative to the APA Assembly.