Biopsychosocial Psychiatry

To the Editor: In their piece, Glen O. Gabbard, M.D., and Jerald Kay, M.D. (1), correctly pointed out the need for more empirical evidence to guide decisions about when and how to combine psychotherapies with pharmacotherapies. Their assertion, however, that “dividing treatment between a psychiatrist-prescriber and a nonpsychiatrist psychotherapist” can be seen as “a tacit endorsement of Cartesian dualism” (p. 1959) belies a misunderstanding of what dualism is and how it can be combated. It is likely that their misconception is shared by many who see the distinction between psychotherapy and pharmacotherapy as congruent with that between the mind and brain. While they accurately pointed out that “Psychotherapy must work by its impact on the brain” (p. 1959), they did not recognize that that is precisely why divided treatment and dualism, despite superficial resemblances, have no relation to each other. It is the belief that psychotherapies treat the mind while pharmacotherapies treat the brain—not the way such treatments may be delivered in practice—that is dualistic. Moreover, when the psychotherapy involved is behavior therapy, it is largely observable, third-person, non-introspection-based (i.e., nonmental) phenomena that are of interest. And when the pharmacotherapist spends his or her time with a patient inquiring about moods, perceptions, thoughts, and the like, he or she is entering the first-person subjective world that Drs. Gabbard and Kay referred to as “mind.” (The absence of constructs such as ego defense, transference, and resistance from such a pharmacotherapist’s thinking and work makes that point no less true!)

There are many reasons why having more than one clinician (psychiatrist and psychotherapist, orthopedic surgeon and physical therapist, etc.) involved in the care of a patient may be desirable or even necessary. As Drs. Gabbard and Kay discussed, there may be countervailing reasons why such arrangements should not be employed in particular instances. We need to learn more about the conditions under which combined treatments are superior to monotherapies and about the circumstances in which the benefits of dividing labor among professionals with different training, talents, and interests may be outweighed by the drawbacks of such practices. Inquiries into those important questions, however, should not be encumbered by the misconception (that Drs. Gabbard and Kay rightly exposed) that “Psychotherapy is a treatment for ‘psychologically based’ disorders, while ‘brain-based’ disorders should be treated with medication” (p. 1959) nor by the misconception that dividing the provision of such treatments is a reflection of Cartesian dualism.