The Psychiatrist as Psychotherapist – a Tale From “The Golden Age of Psychiatry”

In a prior blog posting entitled “The Psychiatrist as Psychotherapist” there was a reference to the privilege of being trained during “The Golden Age of Psychiatry.”As the following story illustrates, This Golden Age had a somewhat turbulent beginning…

When I completed my medical school education at Georgetown in 1975, and prior to beginning residency training at the psychoanalytically-oriented program at Tufts New England Medical Center in Boston, I traveled to London to learn about the emerging and exciting field of psychopharmacology. This was a conscious decision to round out my education and become exposed to new ideas that I would not receive in Boston, as the Tufts program focused on providing some of the top psychoanalysts in the country teaching residents how to perform intensive psychotherapy of hospitalized patients as well as outpatients. As the Tufts program lacked a psychopharmacologic curriculum, I felt that I needed to go to London.

Upon arriving I was surprised to learn that there was a severe dichotomy between the teachings of the psychopharmacologists, and those of the psychoanalysts. In short, not only did they vehemently disagree as to the origin and treatment of serious emotional problems, there appeared to be a lack of respect for or synthesis of differing points of view.
Nonetheless, I was there to learn about how medications could assist in restoring the brain’s emotional functioning, and I excitedly engaged with my professors at England’s Maudsley Hospital and Institute of Psychiatry, who were pioneers in the research and clinical use of medications to treat emotional disorders. It was a wonderful experience that I treasure to this day.

Now flash forward several months to the beginning of my residency training at Tufts. I was in my first month of the program, and I was on weekend emergency call at the New England Medical Center emergency room. A nineteen year old young man came in who was in a highly agitated manic state. Armed with my newfound European knowledge about the use of Lithium to treat Manic Depressive Psychosis (later renamed Bipolar Disorder), I admitted him to our inpatient unit and confidently placed him on Lithium. I was really proud of myself. That feeling of pride would turn out to be very short-lived.

On Monday I received an urgent call from the Director of Residency Training at Tufts, who insisted upon seeing me immediately. Nervously entering his office (he was a world famous psychoanalyst), he sat me down and proceeded to rake me over the coals for placing my patient on this “unknown” and “dangerous” substance, Lithium, which I had no right to do, particularly since I hadn’t discussed it with my supervisor (who as a social worker could not advise me on prescribing any medication, so I didn’t see much sense in that requirement).

I was crushed, and when he dismissed me from his office I was convinced that he would terminate me from the program. Shaken by the experience, and looking for an immediate reality check and some support, I went to see one of my supervisors (also a world famous psychoanalyst, with a kindly demeanor) and asked him whether I would be terminated, and what I needed to do to restore my good graces with the Director. My supervisor patiently listened as I described my experiences in London, and what I had learned that I simply tried to apply to my poor manic patient to alleviate his suffering. The supervisor told me that he would intervene with the Director on my behalf, and asked if I could provide him some articles on “that Lithium medication” as he was curious about it. (Interestingly, Lithium was first used to treat patients in Australia by John Cade in 1949 , and this was 1975, one year after the FDA had approved it for use in the United States, so it was not as if I was some wild-eyed radical psychiatrist).

Relieved, I left his office and was not bounced out of the program. I provided him two articles on the use of Lithium, and we discussed how the Lithium, combined with my seeing my manic patient five times per week in intensive therapy, worked together to help him. Two years later Tufts brought in a new Department Chairman- trained as both a psychoanalyst and a psychopharmacologist. I went from being the radical first year resident to being selected as Chief Resident in my third year, and a member of the medical school faculty the following year.

The Golden Age was underway.

Of course what was interpreted as a reckless and a bold move by me at that moment in history is now routine practice, and today treating a manic patient with psychotherapy alone would be considered malpractice. The Biopsychosocial Model of psychiatry is in full bloom – integrating a number of knowledge bases and databases to optimize the care of our patients.

It was my great privilege to go to London to learn psychopharmacology, and an even greater privilege to train in psychotherapy under the tutelage of top psychoanalysts in Boston. I feel grateful for these experiences every day, and remember with fondness and humor my turbulent initiation into The Golden Age of Psychiatry.

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