General psychiatry, primary care, and medical primacy

Commentary and Perspective From time to time, the Journal receives manuscripts which can be thought of as opinion pieces, essays, or editorial comment on matters of topical interest. Such submissions will be refereed in the usual fashion and if suitable, published in this section. The Editorial Board invites Letters to the Editor or rebutting commentary with the understanding that all submissions are subject to editing.

General Psychiatry, Primary Care, and Medical Primacy Harold A. Rashkis, M.D., Ph.D. Institute of the Pennsylvania

Hospital,

Philadelphia,

Pennsylvania

Abstract: Nonmedical psychotherapists are able to present themselves to the public as psychiatrist-equivalents, except for prescribing drugs, because psychiatrists have neglected to emphasize the natureof medical responsibility, here called “medical primacy. ” Psychiatric identification with the psychoanalytic and public relations models is criticized. Three cases are presented to illustrate thefunctioning of thegeneral psychiatrist as a primary care specialist. It is acknowledged that all psychiatrists may not be attracted to this role, which intersects certain transference and countertransference vectors.

cise their natural advantage but also commit the same data-processing errors as do the general public. There are two kinds of data-processing errors: adaptive and nonadaptive. It is the thesis of this paper that the data-processing errors made by psychiatrists in their capacity as communicators to the general public are nonadaptive. A proposal is offered to remedy this situation.

The Concept of Total Care In our late twentieth century Western culture, two groups present themselves as psychotherapists: psychiatrists and nonpsychiatrists. Both groups endeavor to explain to the public what function they serve and why it is that they are uniquely prepared to carry out that function. In attempting to present their case, nonmedical therapists exploit certain data-processing errors characteristic of the individual minds of the public. Psychiatrists, however, with certain exceptions, not only fail to exer270 ISSN 0163~8343/79/030270-06MI2.25

Everyone needs a psychiatrist as his primary care physician. This is not because everyone is mentally ill, but rather because people who feel ill, especially when they feel ill, have no way of knowing whether their feeling of discomfort, pain, or anguish is caused by their current life situation, by reactivation of experiences in their personal past, or by a physical illness or genetic or constitutional disorder. This circumstance is an elaborate variation on the phenomenon long known as the stimulus error (l), General Hospital Psychiatry @ Elsevier North Holland, Inc., 1979

Psychiatry, Primary Care, and Medical Primacy

originally described by Titchener for the special case of determination of the two-point threshold, which is a familiar procedure both in neurology and in experimental psychology. The two points of a calibrated divider, set at various positions of separation, are applied to the skin of the subject, who is asked whether he feels one or two points. When the points are sufficiently close to one another, the subject is unable to make the required discrimination. If, at that time, he focuses his attention on the sensation, he will respond that he feels only one point. If he focuses, however, on his knowledge that two points are being applied, he may respond that he feels two points. Titchener’s contention was that the proper stimulus for the verbal response is the sensation and not the points of the divider. To respond on the basis of knowledge of the external physical stimulus rather than to the experienced sensory input is to commit the stimulus error. Patients commonly commit the stimulus error. When they say that they have a virus, that they have sustained a whiplash injury, that they were rejected by their parents, that harm is going to come to their children, that they have heart trouble or an ulcer, that their spouse is unfaithful, or unattractive, or no longer attracted to them, they are attempting to account for some experienced discomfort by attributing it to something that they know or believe to be true in the verifiable universe. They are not describing what they feel, and their attempt at causal explanation has a considerable probability of being wrong. Concomitantly, the closer the patient can get to a description of his actual feeling state, the greater is his likelihood of making a veridical statement. Admittedly, it is difficult to describe a sensation or a preverbalized feeling, but it is precisely in the elicitation of such material that the psychiatrist can be most helpful. As we well know, however, it is on the basis of the stimulus errorthat is, on the basis of what the patient assumes to be his problem-that he makes his self-referral to a cardiologist, a sex therapist, a marriage counselor, an orthopedist, or a chiropractor. Eventually, some of the self-referred patients may be referred to psychiatrists, but often after years of imprecise attempts at treatment. It would be more efficient if the patient were to see a psychiatrist initially and then be referred by him for consultation where appropriate . There are certain exceptions to the use of the psychiatrist as primary care physician: high fever, crushing chest pain, fractures, and other obvious conditions of an emergency nature, but it is not

difficult to design a system of care that will handle such cases. Indeed, we already have one. What we do not have is a system of total care. The principal objection to the concept of total care, I suspect, may come from psychiatrists themselves. It is quite comfortable to conduct intensive and extensive psychotherapy with intelligent neurotics, and it is not much less convenient to maintain a patient on lithium carbonate. It is usually not too taxing to conduct family or marital therapy or to desensitize a phobic patient or to prescribe antidepressants. And since it is not unpleasant to perform these tasks, this is precisely why so many nonmedical persons seek to earn their living in this way-excepting, of course, the prescribing of drugs, which would be left to the physician. But if the psychiatrist is not in fact accepting a broader carrying routine responsibility than out psychotherapy, there is no obvious reason why a sort of Gresham’s Law will not apply, with poorer or cheaper psychotherapy driving out better or more expensive psychotherapy. There are fitting reasons why psychiatry should not yield its preeminence. Psychiatry does not consist of a band of therapists who cleverly attached themselves to general medicine for added prestige and power; psychiatry is a natural outgrowth of medicine, the culmination of the development of the healing art, derived from all sources, incorporating all that is evidently useful to treat the needs of a total human organism. It is not a compendium of maneuvers to befuddle the mind or to replace one myth with another, or to talk a patient out of his imaginings, or to tranquilize him until the vis medica trix na turae takes over.

How Nonmedical Psychotherapy Is Sold Because many psychiatrists do not seem to appreciate thoroughly what psychiatry is (this problem and its resolution are developed later), it is not surprising that the public does not know what psychiatry is. Nonmedical therapists seize upon this opportunity, drawing attention only to what psychiatry seems to be and to what psychiatrists seem to do.

Consumerism By appealing to the concept of free will (of which they may never again make mention), nonmedical therapists insist that the public be given a choice of therapies and of therapists. The implicit assump271

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tion that the consumer can make an intelligent choice is contradicted by all the evidence of consumer behavior in the marketplace. Psychiatrists do not yet advertise; the public buys advertised products (2). An apparently, but not necessarily, more rational approach would be to open the question to empirical study. For example, California’s LantermanPet&-Short Act requires the county mental health programs to institute cost-effectiveness studies. If one is concerned with the cost-effectiveness of therapies in producing quick, quick, quick relief of anxiety or depression, certainly the matrix should include bars, racetracks, and massage parlors. But there are larger issues than symptom relief. For example, during World War II, I initiated what was probably the first attempt to measure the effects of group psychotherapy (3). Using the Minnesota Multiphasic Personality Inventory, my co-author and I discovered that the members of my group showed more improvement than did the members of my supervisor’s group. Did this embarrassing datum suggest that I was a better therapist than he? Or, since my pay was lower than his, did my work have a lower cost/effectiveness ratio? And, if we had been in a competitive situation, should I be hired rather than he or should I be the preferred contractor for the delivery of mental health services? Instead of answering immediately, I note the following: 1. He had taught me to conduct group psycho-

therapy. 2. He continued to supervise my work. 3. He was there to back me up if a clinical crisis occurred, whether through my error or not. 4. He was responsible for the care of the patients with whom I worked. 5. He maintained a favorable milieu in which I could function. Taking these considerations into account, I can only say, let us not be naive about costeffectiveness. The apparent objectivity and simplicity of the concept mask its inability to measure the most important factors in practice. The Reductive

Error

Some psychiatrists wear glasses, some smoke a pipe or a cigar, some wear tweed jackets, some put their patients on the couch, some reflect on what the patient says or answer a question with silence or 272

with another question. Some psychiatrists may conduct family or marital therapy or practice deconditioning or hypnosis or psychoanalysis-and, of course, so may other people who are not psychiatrists. It is the general thesis of nonmedical therapists that they can do all the things that psychiatrists can do except prescribe drugs. It is certainly true that, collectively, they can; but without having received the training that physicians receive and without being able to accept total responsibility, nonmedical therapists are clearly not justified in seeking hospital staff membership or in contracting to provide therapy except by medical referral or under medical supervision. The lay public (which includes the press and legislators) is told that certain people can do many of the things that psychiatrists can do and therefore should be treated on an equivalent basis. This is a case of pars pro toto, which is an error in logic. Further, psychiatry is more than the sum of its parts: To be a psychiatrist is more than to have completed all of the individual courses leading to graduation, even as the good feeling that accompanies having passed one’s Boards is greater than would be justified by any “real” difference it makes in one’s life. A proper philosophy for a psychiatrist to have is: I am prepared to do whatever needs to be done, or to see that is is taken care of, and to make sure that it has been handled.

How Psychiatrists Yield Their Advantage After having completed medical school, and usually some sort of internship, many psychiatrists do not seem to realize what they have accomplished and where they stand at that point. They have received our culture’s basic training in the ultimate responsibility that one living person can take for another, yet they often appear to behave as though they had completed a mere required prerequisite course to their upcoming training in drug-assisted psychotherapy. Of course each individual has a choice as to how much responsibility he will accept and how he cares to exercise it, but he should be aware of the choice he is making and the point at which he is making it. Would a physician knowingly enter a field of specialization in which he will be in direct competition with not only clinical psychologists, psychiatric social workers, and pastoral counselors, but also a seemingly endless variety of inadequately trained or untrained “therapists” including representatives of cults such as Scientology? It may be argued that this is not the case.

Psychiatry, Primary Care, and Medical Primacy

Perhaps not yet, but it soon will be unless a basic reorientation occurs in psychiatry. The decision to become a psychiatrist may have been made before one entered medical school. But the problem is essentially the same: Would a student become a physician in order to become a psychiatrist in order to compete with, et cetera, . . . ? And the problem for psychiatry persists: Is it worth anyone’s time and expense to go into psychiatry merely to be empowered to prescribe medication? In many minds the answer will be “no.” And this presages bleak days for psychiatry. Can the situation be altered? Perhaps, but to treat it, it must be properly diagnosed. In my opinion, the unfortunate position of psychiatry results from the displacement of the medical model by two other models: the psychoanalytic model and the public relations model.

The Psychoanalytic

Model

As Freud so ably argued, “Psycho-analysis is not a specialized branch of medicine. I cannot see how it is possible to dispute this. Psycho-analysis is a part of psychology; not of medical psychology in the old sense, not of psychology of morbid processes, but simply of psychology” (4). I am aware of no evidence that he ever changed his mind. Freud accepted, however, that “the application of analysis to the treatment of patients. . . must be content to be accepted as a specialized branch of medicine. . . . and to submit to the rules laid down for all therapeutic methods. I recognize that that is so; I admit it. I only want to feel sure that the therapy will not destroy the science.” In his determination to preserve the science and not permit it “to be swallowed up by medicine and to find its last resting-place in a text-book of psychiatry under the heading ‘Methods of Treatment,’ alongside of procedures such as hypnotic suggestion, autosuggestion, and persuasion, which, born from our ignorance, have to thank the laziness and cowardice of mankind for their shortlived effects. . . ” (5), Freud insisted that medical training not be required for psychoanalysts, indeed that there be no specific prerequisites for training in a psychoanalytic polyclinic or institute. As physicians,-we must insist that all therapies must “submit to the rules laid down for all therapeutic methods,” primary among which is the principle of treatment of patients by the physician

or directly under his supervision. This principle, which may be termed “medical primacy,” is in clear contrast to the psychoanalytic model, which is not medical and has its authority structure outside of Freud subjugation of medicine. resisted psychoanalysis to medicine and welcomed the development of separate training institutes with a That nonmedical allegiances. system of psychoanalysts have sought prominent positions within medicine is no indication of their acceptance of medical primacy, but should be more accurately recognized as the invasiveness of the psychoanalytic model into the medical organism. Psychiatry is well infiltrated, if not dominated, by psychoanalysts, and virtually all psychotherapy is psychoanalytically oriented. The problem for psychiatry resulting from its infiltration by psychoanalysts has nothing whatever to do with the relevance of psychoanalytic theory or with the therapeutic efficacy of psychoanalysis. The problem is that one does not have to be a physician to be a psychoanalyst, and the more psychiatry identifies with the psychoanalytic model, the more it is replaceable by nonmedical psychoanalysis.

The Public Relations Model Physicians and scientists are expected by their colleagues to present their findings in medical and scientific journals. The media are open to anyone who is sufficiently entertaining. There is no reason to believe that physicians will be more entertaining than nonphysicians; hence, when physicians resort to the media to publicize themselves, they are competing with all comers. This should be obvious to all. Psychiatry cheapens itself in another way: by embracing techniques, schools, or cults that have become prominent through media exposure. There may be utility for psychiatry in certain aspects of transcendental meditation, transactional analysis, behavior therapy, or sex therapy, but for psychiatry to adopt these movements en bloc is to reduce psychiatry to a collage of maneuvers that can be accomplished equally well by nonpsychiatric prestidigitators. Even if the public demands these modalities, we should not stock them, but we should produce finer products under our own label.

Total Care, Primary Care, Psychiatric Care How may the ideal of total care be translated, via primary care, into psychiatric care? An already 273

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familiar answer to this question is through continuing medical education, especially through education of general practitioners or family practitioners by psychiatrists or by psychoanalysts, as in the well-known Balint groups (6). But only a small number of psychiatrists may be employed in this manner. On the other hand, it is not likely that many psychiatrists will wish to become general practitioners. There is, however, a general or family practice of psychiatry that includes the use of psychotropic drugs and hospitalization when necessary, and also includes psychoanalysis or intensive psychotherapy, couple, sex, and family therapy, hypnosis and behavior therapy, the use of suggestion, imagery, biofeedback, and progressive relaxation, or whatever modality is appropriate to the situation. Fink and Oken (7) have ably defined and presented the case for general psychiatry as a primary care specialty, noting that it well meets Alpert and Charney’s criteria (8) of first-contact medicine, longitudinal responsibility, and an integrationist function as well as Petersdorf’s defining terms (9), which include the above while emphasizing the personalized relationship of doctor and patient. Fink and Oken pragmatically acknowledge, however, the need for formal, i.e., governmental, recognition of general psychiatry to render de jure what is already de facto. More ingenuously, I will assume that what should be is, and will offer three cases as examples of how the general psychiatrist functions as primary care specialist.

Case 1 A 30-year-old married mother of three had been hospitalized for schizophrenia and was receiving followup care when her husband changed jobs, requiring an interstate move. They immediately joined a church, and their minister made the psychiatric referral. The primary patient was maintained on psychotropic drugs, which had to be changed a number of times; psychotherapy with supportive, uncovering and integrative goals was undertaken, as was marital and sex counselling. The patient’s husband was seen in intensive individual psychotherapy for his own neurotic and characterologic problems, and, on one occasion when he was about to be fired, an interview with his boss saved his job. Their oldest son was treated for enuresis. Affective elements began to appear in the primary patient, and she was treated with lithium with dramatic results. In his third year of college the oldest son had a hypomanic episode, successfully and quickly treated by lithium. He had another episode

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following graduation and was again treated with lithium (he prefers not to be on maintenance therapy). The patient and her husband have since been divorced, and she has had several psychotic episodes principally of a hysterical nature; these were ultimately terminated, and she functions effectively as a nurse, albeit on maintenance lithium. The youngest daughter currently suffers from headaches; the psychiatrist is integrating the medical evaluation of her condition as part of an ongoing longitudinal care process that has already gone on for 12 years. Midway in this period the patient’s husband sought the services of a nonmedical therapist for her; she received megavitamin therapy and psychotherapy of an unspecified type. A flagrant psychotic state resulted, and the primary care psychiatrist was again called upon; hospitalization was required. The continuity of care has not again been broken.

Case 2 A brilliant electronics engineer of schizoid temperament developed a brain abcess as a result of uncontrolled juvenile diabetes. He became psychotic and was referred initially for differential diagnosis, the process of which became so intriguing that he was retained for therapy. When the psychosis (an acute brain syndrome) cleared, the patient showed, in addition to his characterologic problems, an intense phobic reaction based on a single focal epileptic attack probably resulting from the formation of scar tissue at the operative site. His phobia was successfully treated, but his diabetes remained uncontrolled, with almost continuous glycosuria and increasing impotence. Even before his untimely death, at 49, of a heart attack, his wife had become the primary patient. She had for years suffered from increased intraocular pressure, which proved to be psychogenic and responded to psychotherapy; unfortunately, one retina had already been severely damaged by choroiditis. A very intelligent, childless woman with hysterical personality, her communicative disorder was so marked that, when I was on vacation, she was hospitalized by another psychiatrist as a schizophrenic. Following this hospitalization, I encouraged her into intensive psychotherapy, and she has become “a good analytic patient.” Although extremely shy, sexually naive, and with marked feelings of inferiority, she has learned to express her feelings and conduct her life with considerable rationality. She has entered into a relationship with a widower, who is now in treatment with me for premature ejaculation. For about 10 years, the patient has suffered from urinary retention. Because of her communicative difficulty, doctors have tended to dismiss her as a crank. It has become the psychiatrist’s role to find good specialty care for this patient and to interpret her complaints to other physicians.

Psychiatry,

Case

3

A 34-year-old mother of six presented the problem of her oldest son, 16, her second child, who was belligerent, truant from school, suspected of taking drugs, and had threatened suicide. After a few sessions with the son and one with his parents, it became evident that there were serious problems with the two older daughters as well, and it was agreed that family therapy would be undertaken with the parents and all six children. Before the first family session could take place, the father was hospitalized with a spinal cord injury; he had sought to prevent the oldest daughter’s boyfriend from visiting her and had been shot and crushed against a tree by the fleeing assailant’s automobile. For the next 4% years, the father, now paraplegic, was plagued with urinary infections, leading to hypertension and loss of a kidney. The mother now became functional head of the household, and she and five of the children required massive psychiatric support. Nine months after originally scheduled, the first family session took place, but without the older daughter, who was now living with her boyfriend, whom she later married. Only partial reconciliation with that daughter has now been achieved. A considerable number of problems have been dealt with-medical, vocational, sexual, and ethical, as well as primarily intrapsychic.

Primary Care, and Medical Primacy

tion is the way the psychiatrist handles the countertransference. If he is reasonably objective and manages not to “take sides,” any problems that arise become no more than grist for the mill. While a husband may resent his wife’s transference feelings toward a male therapist, there is an equal and opposite feeling on his wife’s part with respect to an empathy between the same therapist and her husband. In practice, these difficulties are analyzable and should not be thought of as obstacles to treatment, but rather as nuclei of the treatment process. The therapist’s concern is ultimately with the understanding of process in the individual, the couple, and the family, and extends readily to family process involving other physicians. It has been suggested in this paper that a major objection to primary care by psychiatrists may come from psychiatrists themselves. There is no doubt that the orientation toward practice that is here recommended is demanding, time-consuming, and often frustrating. It may not be attractive to all. Nevertheless, it does offer what it promised: an area of practice that is uniquely the province of the psychiatrist.

References Comment There

can be little doubt

psychiatrist

has served

that in the cited cases, as primary

the

care physician.

In addition to breadth and continuity of care, there has also been intensive analysis of the psychodynamics of primary and secondary patients. It is the author’s contention that this care could have been provided only by a physician, and only by a psychiatrist. It is also evident that this care could not have been provided within the traditional psychoanalytic model, but this is not tantamount to saying that the care could not have been provided by a psychoanalyst. It is reasonable to raise questions about dependency, transference, and countertransference in situations where the psychiatrist accepts such extensive responsibility. Obviously, dependency is great, but it is not pathological dependency, inasmuch as it is not inappropriate to the exigencies of the particular life circumstances. While any one of the patients is being seen intensively, transference phenomena occur. How serious is the problem of parallel or competitive feelings of several family members toward a lone therapist? A major factor determining the answer to this hypothetical ques-

1. Boring EG: A History of Experimental Psychology. New York and London, D. Appleton-Century Co. Inc., 1929, p. 410 2. Page IH: Does it really pay to advertise? Mod Medicine 44:8-16, 1976 3. Rashkis HA, Shaskan DA: The effects of group psychotherapy on personality inventory scores. Am J Orthopsychiatry 16345-349, 1946 4. Freud S: The question of lay analysis. Postscript SE 20:251-258, 1927 5. Freud S: The question of lay analysis. SE 20:177-250, 1927 6. Balint M: The Doctor, His Patient and the Illness. New York, International Universities Press, Inc., 1957 7. Fink I’J, Oken D: The role of sychiatry as a primary care specialty. Arch Gen Psyc Riatry 33:998-1003,1976 8. Alpert JJ, Charney E: The Education of Physicians for Primary Care, publication (HRA) 74-3113. Washington, D.C., U.S. Dept. of Health, Education, and Welfare, 1973 9. Petersdorf RG: Issues in primary care: The academic perspective. J Med Educ 50 (Suppl):5-13, 1975

Direct reprint requests to: Harold A. Rashkis, M.D. Elkins Park House Elkins Park, PA 19117

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