Sir: The manifesto set out by Christodoulou, Fulford and Mezzich, ‘Psychiatry for the person and its conceptual bases’, in their guest editorial for the January issue of International Psychiatry evokes a mixture of excitement and disappointment. Bemoaning the withering of person centredness in modern medicine and psychiatry, and initiating attempts to redress current fragmentation and technological pseudo-solutions cannot but be laudable.
But an empty space lies at the heart of their editorial. There is in fact a long-established branch of psychiatry which fulfils all of the stated goals of the Institutional Program on Psychiatry for the Person (IPPP) established by the World Psy-World Psychiatric Association (WPA). In psychotherapeutic psychiatry (Gabbard et al, 2005) the centrality of personhood is key: strengths and weaknesses are celebrated and worked with; the humanity of the clinician is as important as that of the client; it is collaborative; and personal fulfilment for the client is its overarching aim. A developmental account of how one becomes a person, and how things can go wrong through genetics, environmental failure and intentionality, is a central theoretical project within contemporary psychotherapeutic science (Mayes et al, 2007). But one searches in vain for any mention of psychotherapy in Christodoulou et al’s polemic. There are two passing references to ‘psychological bases’ and ‘psychological … perspectives’. The rest is silence.
The very phrase ‘psychiatry for the person’ contains echoes of Carl Rogers’ ‘person-centred’ counselling. Psychotherapeutic psychiatry, often involving a combination of psychotherapy and pharmacotherapy, uniquely perhaps, is person centred and evidence based. It is often forgotten that the universally accepted meta-analysis within medicine started as a method for evaluation of psychotherapy.
It is perhaps more understandable that psychoanalysis, with its currently controversial empirical base, controversial status and possibly elitist Western cultural bias, is conspicuous by its absence. Nevertheless, does not Freud deserve a mention, alongside Hippocrates and Aristotle and, implicitly, Confucius? Freud celebrated his patients’ personhood, valued their autonomy, promoted recovery and aimed to understand the links between body and mind. His successors, like Balint, pioneered brief therapies and were founders of the very psychosomatic approach which the IPPP endorses.
Perhaps the WPA is understandably frightened of the implications of endorsing psychotherapy, as it might thereby open doors to territorial disputes with clinical psychology, and to the embarrassing fact that, globally, relatively few psychiatric training schemes take psychotherapy seriously (Holmes et al, 2007). Yet these are debates that need to be had if we are to move beyond rhetoric to real change.
Isn’t it time for the WPA to decide where it stands on psychotherapy/psychological therapies, define those it thinks should form a core part of a decent psychiatric service, and insist that relevant psychotherapeutic skills be part of every psychiatrist’s armamentarium?
Jeremy Holmes MD FRCPsych MRCP
Consultant Psychiatrist, North Devon, Visiting Professor of Psychological Therapies, University of Exeter, UK
References
- Gabbard, G., Beck, J. & Holmes, J. (2005) Oxford Textbook of Psychiatry. Oxford University Press. [Google Scholar]
- Holmes, J., Mizen, S. & Jacob, C. (2007) Psychotherapy training for psychiatrists: UK and global perspectives. International Review of Psychiatry, 19, 94–101. [DOI] [PubMed] [Google Scholar]
- Mayes, L., Fonagy, P. & Target, M. (eds) (2007) Developmental Science and Psychoanalysis. Karnac. [Google Scholar]