I was shocked to read Dr. Henry A. Nasrallah’s “Shattering dogmas” (From the Editor, Current Psychiatry, January 2011, p. 12-16), in which he referred to an aspect of doctor-patient boundaries as a dogmatic holdover from the “primordial phase of psychiatry (aka psychoanalysis)… “ If a psychopharmacologist chooses to monitor blood pressure or check for cogwheeling, no psychoanalytically oriented psychiatrist would object. Your “dogma” is a caricature that reflects poorly on a genuine appreciation of sound psychological treatment. A lot of money is wasted on acute repeat hospitalization after ineffective treatment of axis II patients by biologically oriented psychiatrists. All reductionism deprives patients of ideal care. Referring to psychoanalytic principles with derision is in itself “primordial. “ There has never been a time when the relational aspects of human development have been established so incontrovertibly nor has any psychoanalyst ever chastised a colleague who chooses to use a sphygmomanometer. Context counts. Brain maturation, gene-environment interactions, early life stress, attachment disorders, mirror neurons, resilience, etc. have emerged in support of psychoanalytic perspectives— including the judicious absence of careless physical contact in a complex, intense relational treatment. Boundary violations still are malpractice and clinically astute discipline is not dogma. Perhaps you’ll clarify your point.
Sara Hartley, MD
Alta Bates Summit Medical Center
University of California, Berkeley and University of California,
San Francisco Joint Medical Program
Dr. Nasrallah responds
The term “primordial” is not an insult, because it refers to the early phase of development. Consider the primordial phases of internal medicine and surgery, which now are regarded as archaic (even dangerous) but a necessary step in the evolution of modern surgery or internal medicine. Unquestionably, psychoanalysis is the foundation of modern psychiatry, and it dominated our field for decades, although it was more theoretical than evidence-based. Psychoanalysis provided a valuable construct to understand human behavior. However, like other branches of medicine, psychiatry evolved and advances in neuroscience moved psychiatry into an eclectic medical model that emphasizes rapid treatment with medications combined with short-term psychotherapies for most mental disorders. Psychoanalysis and medical models both are criticized as being imperfect, but both have the same objective: to rapidly relieve our patients’ suffering and to help them regain their social and vocational functioning. And by the way, axis II patients rarely are admitted to a hospital unless they make a serious suicide attempt. Various types of psychotherapy help partially, but numerous studies show a benefit from selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, mood stabilizers, or atypical antipsychotics in various personality disorders. It would be dogmatic to believe that axis II disorders cannot benefit from biologic modalities, just as it would be dogmatic to believe that schizophrenia should be treated with drugs only without psychosocial therapies.
Henry A. Nasrallah, MD