Let's regain perspective.
After reading the letter "On the Decline of Psychotherapy" in
the September 4 issue, I thought of several considerations.
In my lectures to medical students, I present them with an analogy. I tell
them that psychiatry can be considered like a forest with many trees;
depending on your training and experience, you focus on a particular tree
disregarding or devaluing the other trees.
Some of my trees: I helped Dr. Walter Freeman to perform transorbital
lobotomies, and in those years, I gave hundreds of ECTs. I trained in child
psychiatry, I am board certified, I spent 13 years at the Washington
Psychoanalytic Institute, and I did hospital psychiatry in the morning and saw
selective patients in the afternoon whom I would treat with psychoanalysis or
Psychiatry went from tree to tree. There were indigestion and
misunderstanding of psychoanalysis. Many doctors went as far as treating
people with schizophrenia with psychoanalysis. The more one knew about
psychoanalysis, the more one knew about its limitations. But the understanding
and assessment of dynamics, ego strength, and so on have enabled me to
evaluate cases in a manner that I could not have done without my
psychoanalytic training. Another of my analogies to the students is that this
type of evaluation is like an X-ray of a fracture, which enables you to see
the magnitude of the fracture but does not cure it.
Progress in psychopharmacology has diminished or almost abolished the use
of psychoanalysis, and I said "almost" because I understand the
pendulum of psychoanalysis is beginning to swing back. I hope that it will not
result in another misunderstanding of psychoanalysis.
The predominate aspect of psychiatry today consists in evaluating the
patient in a 10- to 15-minute framework, eliciting symptoms, making a
diagnosis according to DSM-IV on a phenomenological level,
prescribing accordingly, and then referring to a social worker for
psychotherapy; the insurance pays for it and everybody is happy.
Pharmaceuticals are happy with the present state of affairs. Going back to my
tree analogy, this is to look only at one tree.
To evaluate psychodynamically and to treat accordingly, if the patient is
amenable, takes time, time of training, supervision, and so on. There are many
trees; we should try to see the forest to decide which tree or trees are
applicable to the case: medication alone, medication and psychotherapy, or
ultimately psychoanalysis. When a person needs and can profit from
psychoanalysis and goes through with it, the results are something to behold.
Let's regain perspective.
MANUEL O. HERNANDEZ, M.D.