The Physician as Patient: A Clinical Handbook for Mental Health Professionals

Glen Gabbard and Michael Myers have done the mental health and medical communities a great service with The Physician as Patient, which addresses problems faced by physicians who seek mental health treatment. Denial, stigma, and shame compound the realistic concerns physicians have about the impact of this decision on their careers.

The authors open by describing medical culture convincingly. Physicians are predisposed to judge their own performance harshly; these are “A+” individuals who balk at admitting failure. Lengthy training and delayed gratification create special issues for physicians. Genetic predisposition and psychodynamic and environmental factors, combined with a uniquely intense and demanding culture, create stress and may evoke preexisting vulnerabilities.

The middle section of the book breaks down complaints physicians are likely to present with into axis I and II diagnoses, as well as both chemical and nonchemical addictions (the latter including sexual, gambling, and spending addictions). A particularly well-written chapter discusses boundary violations. The authors importantly differentiate between the physician in crisis who possesses a conscience and the much rarer predatory physician whose disruptive behavior is accompanied by neither remorse nor insight. “Lovesickness” and “masochistic surrender” are two conditions the authors treat with compassion.

In evaluating a physician’s capacity to address dysfunctional behavior and change course, the authors consider the concept of mentalization. This idea has gained currency in therapeutic discourse over the last 10 years as a way of conceptualizing object relatedness as a mental phenomenon. Dr. Gabbard has been a pioneer in its application to patients with borderline or personality disorder. Beyond therapists, this may be helpful to human resources departments when considering painful alternatives, such as work improvement plans, referrals to licensing boards or contracted agencies, or termination. The accountable physician who acknowledges responsibility and takes action is more likely to complete a successful work improvement plan than one who externalizes blame or denies problems.

The book’s final section considers psychotherapy as primary or adjunctive treatment. The authors make generally useful and sometimes profound distinctions guiding the decision to recommend cognitive-behavioral therapy versus long-term insight-oriented treatment. They list traits desirable in a long-term psychotherapy patient that aid any evaluation. I was struck by the inclusion of “able to use metaphor” as a desirable trait for the potential psychotherapy patient. This is a brilliant and often assumed but rarely articulated facet of patients able to benefit from therapy, entailing the experience and resolution of transference.

The Physician as Patient will likely serve mainly as a reference volume. Shortcomings include a plethora of quick clinical vignettes with pithy summations. These are far less illuminating than fewer case studies with more longitudinal information might have been. The midsection at times reads too much like DSM-IV, overlapping too broadly with diagnosis in general and raising the question of who is the intended audience. Rather than rehash classifications available in other formats, the authors could have chosen to delve more deeply into some of the content unique to physician culture. The chapter on addictions could be a book in itself. The information in it, though valuable, is compressed to fit this volume’s format and thus less helpful than it might have been.

In discussing the evaluation process, the authors address the dual role of the therapist who must balance physician privacy with public safety. They point out that almost all 50 states now have Physician Health Programs (PHPs), which have arrangements with state licensing boards to monitor physician health and safety. These arrangements differ from state to state.

An “evaluation alliance” is different from a treatment alliance in the type and amount of information that are disclosed. If a physician self-refers or is referred by family or friends, treatment might commence without the upfront understanding of the therapist’s potential dual role. This raises the concern that this volume does not give enough caveats about the possibility of disclosing too much or too little information in a psychiatric evaluation of a physician. Psychiatrists and psychotherapists in each state must familiarize themselves with their states’ specific requirements. Wider education on these matters is obviously needed, and this book raises the question of how to disseminate this awareness.

Overall, The Physician as Patient is a positive contribution to the understanding of the culture of medicine and the forces that lead physicians to seek treatment or avoid it though the need be abundantly clear.