I wish to respond to the September 4 letter “On the Decline of Psychotherapy,” which was so critical of psychotherapy and many practitioners of psychodynamic psychiatry. First, much of the letter seemed to be a personal attack on psychiatrists who do psychotherapy. For example, in this letter we are told, as if it were a fact subscribed by all or nearly all psychodynamic psychotherapists, that “psychoanalytic/psychodynamic psychiatric practitioners regard themselves as the last bastion against the creep of a non-feeling, cold-hearted, high-tech medical world” and“ to these psychiatrists, they are the guardians of humanity in medicine; only a psychiatrist trained in psychodynamic psychotherapy knows how to talk and empathize with patients.” With vaunted language, a generalization has been made to masquerade as a factual claim.
I was trained in a program fairly well balanced with regard to the biological and psychoanalytic perspectives. I have dealt with many psychoanalysts, and all I can say is that I know of few or none who would ascribe to the above sentiment that only they know “how to talk and empathize with patients.”
There may be some arrogant psychoanalytic psychiatrists somewhere holding this view, but there are surely arrogant biological psychiatrists in practice too who would dismiss Freud, Klein, Kohut, and other theorists who have tried to help explain the workings of the mind. In addition, I have observed from my experience working in academia, the private sector, and a government facility that the vast majority of psychiatrists incorporate both biological and psychodynamic aspects into the care they provide.
I do not want to belabor the importance of psychodynamic psychiatry—as a substance abuse psychiatrist, I think I can safely say that the field I work in is heavily biologically based. There is rarely a patient I encounter who can be “fixed” by purely biological or psychoanalytic treatments. Many people benefit from medication, but the best medications cannot work if a patient will not take them because of resistances and motives that must be explored with empathy, tact, and the help of a good theoretical model. Need I mention the fact that much of the scientific medical research supports the conclusion that psychotherapies are generally as effective as medications in many patients?
As a government employee, I do not make a single cent based upon the“ type” of treatment or therapy I offer a patient. I could not disagree more with the comment that “in truth, the only damage done with the decline of psychodynamic psychotherapy by psychiatrists is to the pocketbooks of the practitioners, not to the patients themselves.” Patients would be denied the genuine utility, and even the profound satisfaction, of understanding themselves more fully and being able to explain some of their most valued attitudes, beliefs, prejudices, and, indeed, maybe the entire framework they use to judge their own life experiences. Seems a heavy price to pay even if we do admit that there are some overconfident psychodynamic psychiatrists out there.
JOSEPH D. MARKOWITZ, M.D.
Tampa, Fla.
