Psychotherapy by Nonphysicians

To the Editor: In their otherwise very thoughtful article (1), John O. Beahrs, M.D., and Thomas G. Gutheil, M.D., used the terms “medical” or “medicalized” as necessary parts of their definition of psychotherapy in at least three instances. In the first paragraph, they stated, “It [psychotherapy] stands apart from everyday discourse by the extent to which it is defined as a procedure, i.e., medicalized” (p. 4). They then stated, “It has been ratified as a medical procedure by scientific texts, third-party payers, and the law” (p. 4). To imply that the practice of psychotherapy is somehow the exclusive domain of physicians, which is my interpretation of the quoted statements, is gratuitous and insulting to our nonmedical colleagues.

This interpretation simply is not true. Our community has, as have most others, qualified and talented clinical psychologists, psychiatric social workers, and other mental health professionals who are trained in, and excellent practitioners of, the set of procedures collectively known as psychotherapy. Scientific texts about how to practice psychotherapy and how to measure its effectiveness often include nonmedical practitioners; see the works of Carl Rogers and Lester Luborsky. Third-party payers seem to go out of their way not to pay psychiatrists to do psychotherapy, but they often will pay for treatment by nonmedical practitioners. California law recognizes the psychotherapist-patient (or “client”) privilege without stating that the psychotherapist has to be a physician. Physicians have no corner on that particular market and no claim of exclusivity to that piece of turf. The issue of informed consent in psychotherapy is just as germane to nonmedical practitioners of psychotherapy as it is to those with medical degrees. Indeed, the opening of our psychoanalytic training institutes to nonphysicians in recent years guarantees that large numbers of nonphysician psychotherapists will be receiving training at its highest level in the future (something that is, unfortunately, disappearing from many psychiatric residencies, which are now turning out some graduates whose training in psychotherapy is woefully deficient).

Had the authors confined themselves to who should be allowed to practice the procedures known collectively as “psychopharmacology” I would have no quarrel with them. Medical training is indeed a necessary prerequisite for the intelligent practice of psychopharmacology, and even here the issue of informed consent requires the kind of analytical thinking that Drs. Beahrs and Gutheil can furnish us.

I hope to see further articles by the authors on this topic, but I hope that they will be written in a more ecumenical spirit, so that they can be read without invidious implication by all who are engaged in the practice of psychotherapy.