Drs. Kay and Gabbard Reply

To the Editor: We welcome the opportunity to respond to the important points raised by Drs. Waterman and Batra, Lissak, and Grunebaum. First, Drs. Waterman and Batra are concerned that we obfuscated the issue of dualism by suggesting that split treatment (in which a psychiatrist might provide pharmacological treatment and a nonmedical mental health professional might provide psychotherapy) is not representative of a Cartesian-based practice model. They argue that the provision of such services is unrelated to a dualistic approach. Although a two-person model of treatment may certainly be implemented in a way that eschews dualism, it is, in fact, this split treatment model that has led clinicians and the general public to reify an artificial separation of mind and brain. As Drs. Waterman and Batra acknowledge, we are fully aware that psychotherapy should not be artificially relegated to “disorders of the mind” or “psychologically based disorders.” However, we feel that a split treatment approach forces clinicians to adopt a conceptual model that strengthens the mind-brain split rather than dissolving the mind-brain barrier. We wish to note also that there is emerging evidence that psychotherapy and psychopharmacology may be affecting the same or similar neural pathways (1).

Dr. Lissak has had difficulty finding mentors and teachers who are proficient in combining psychotherapy and pharmacotherapy. We noted in our article that integrated treatment is neglected in many training programs, and we hope that situation will improve now that it is mandated as one of the core competencies. But we strongly disagree that the two approaches are incompatible. Many of us combine them every day and teach our residents a systematic approach to integrated treatment.

Dr. Grunebaum appeals to us as clinician educators not to dismiss the social characteristics of our patients. We believe he is right that educators often give short shrift to the social context of our patients. Both of us have written about the centrality of family interventions in the treatment of schizophrenia, bipolar disorder, and some cases of severe depression. We concur with his citations in the literature to that effect. We believe that attention to family, marital, and ethnocultural considerations are vital to the effective treatment of our patients.