To the Editor: Drs. Gabbard and Kay presented the first balanced article describing combined treatment that I have read; however, the question of how to bridge these two modalities—or, rather, communities—remains unaddressed. During psychiatry residency, I constantly struggled to learn how to become a biopsychosocial psychiatrist but found little guidance from either the literature or my mentors. Instead, I learned that the excellent practice of psychopharmacology or psychotherapy, by definition, excludes practice of the other. It is well and good to promote research and teaching in combined treatment, but no faculty exists who can teach what has yet to be created.
I have worked with psychiatrists who are well known in the Los Angeles community on both sides of the fence and even a few who attempt combined treatment. I have adapted my style to reflect the knowledge I garnered from a range of practitioners, but I remain very frustrated. My concern and difficulty with learning combined treatment has left the vast majority of my colleagues and mentors unimpressed. Everyone agrees that the current combined approach is adequate. So I tried to wear two hats in two different settings and learned several things. Both approaches demand relentless focus to eradicate illness and constant alteration in strategy to do so; however, the structural framework for decision making in each is incompatible. As a psychopharmacologist, I assessed symptoms to determine if a patient had reached a threshold for illness, then I treated to decrease symptom severity. As a therapist, I identified behavioral, affective, or cognitive templates that disrupted patients’ lives and tried to alter them through awareness, analysis, education, and exposure. As a biopsychosocial psychiatrist, I saw no way to integrate a threshold model of illness with a template model. The combined practitioners explained how to switch hats in mid-session, but how can one treat patients expertly when combining two incompatible clinical methods? Similarly, why cannot one approach suffice when both approaches aim to treat similar conditions? I beg to differ with Drs. Gabbard and Kay, who compared learning these approaches to understanding that light can be both particle and wave because no such proof exists to force us to compromise. Instead, why not see these approaches as classical physics and quantum mechanics before physicists understood that the theories described the same phenomenon?
I think this article is ahead of the current climate in psychiatry. The field needs to develop effective combined psychopharmacology and psychotherapy before focusing on research and teaching initiatives. The reason residencies do not teach this modality is neither neglect nor lack of faculty but because of a lack of theory and practice. In essence, this article asks psychiatry to adopt a nonexistent aspect of the field. The further elucidation of combined treatment can lead us in search of a third form of practice, one that provides a unified approach to the psychiatric patient, not a second-rate blend of two irreconcilable entities.
