10. the psychologist's contribution to the training of psychiatrists
TRANSCRIPT
SYMPOSIUM, 1946
10. THE PSYCHOLOGIST'S CONTRIBUTION TO THETRAINING OF PSYCHIATRISTS
MORRIS KRUGMAN, PH.D.
Bureau of Child Guidance, Board of Education, New York City
T H E fact that a psychologist is invited by a group of psychiatrists tojoin in a discussion of the training of psychiatrists speaks volume" for
the developing relationship between psychiatry and psychology. It was notso many years ago that the psychiatrist's major contact with clinical psychology was through a four or five page appendix on mental testing, in verysmall type, at the back of the standard textbook on psychiatry. This usuallyconsisted of single tests from each age level of the 1905 Binet. I do not meanto imply that clinical psychology was mistreated by psychiatry, and thatthis has now been corrected. On the contrary, the fault lay more with psychologists who, for many years, were content to work with their brassinstruments, their rats, their mazes, and, somewhat later, with intelligencetests and statistics. Not that these are unimportant; they playa vital rolein research. They have, in the main, however, until relatively recently prevented the psychologist from learning about the behavior of human beings.
It is ironic for a psychologist to speak of training, not only of psychiatristsbut of anybody, since he is usually subjected to the worst possible trainingfor the practice of his own profession. By and large, the offerings of departments of psychology in the graduate schools of the major universities prepare students for the practice of psychology about as well as the first coursein psychiatry at medical school prepares for the practice of psychiatry, orthe undergraduate course in sociology prepares for social work. This is, ofcourse, an exaggeration to make a point, but it is not much of an exaggeration. The head of the graduate psychology department of one of our largestuniversities actually said to me that it is not the business of a graduate schoolin a university to teach anything that has anything to do with the practicalapplication of knowledge. This is a typical attitude in our higher institutionsof learning. In spite of this handicap, clinical psychology has developedtremendously because many psychologists have, in recent years, brokenaway from the restraints of their early training. They have succeeded inrelegating sense perception and minute measurement of isolated phenomenato their proper places in the scheme of things, and to proceed from a stultifying, static concept of personality and behavior to a more functional anddynamic view. I present this rather long-winded explanation only because Ibelieve that all three fields of orthopsychiatry-psychiatry, psychology, and
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social work-have tended toward closer working relationships because eachof them has developed in this direction.
Getting down finally to specifics, what are the contributions of the psychologist to the training of psychiatrists? To begin with, the psychiatristin-training needs an awareness of the psychologist's contribution to theclinical study. The psychologist's tools for measuring verbal and nonverbalintelligence, educational achievement, aptitudes, interests, and personalityfactors should become familiar to the student psychiatrist, not for purposesof administration, but for general information, so that he may be conversantwith the various types of psychological tests, their special uses, and the clinical interpretation of the results. He should learn to read a psychologicalreport and draw from it significant data and reject the inconsequential. Fromthe psychologist's description of the patient's behavior during the test situation, from the manner of attack on different types of mental functions, fromspontaneous comments, from the content of the responses, and from theattitudes displayed, much useful material and many leads for the psychiatricstudy can be obtained by the psychiatrist who learns to read the languageof the psychological examination.
In the training of psychiatrists, one of the obstacles to overcome is thealmost universal tendency of new psychiatrists to attempt to do everything.The opinion of the social worker is apt to be belittled; the pediatrician'sor neurologist's opinion on physical factors not taken seriously, or perhapscompletely disregarded; the psychologist's report in the case conference forgotten, or allowed a minute or two after all decisions on treatment have beenmade. I have seen psychiatrists in case conferences ask the psychologistsome time during the conference for the patient's IQ, accept that figure asthough it were some magic code that explained everything about the patient,and neither asked nor expected another word of explanation or elaboration.The young psychiatrist should become conversant with the pitfalls of theIQas such; with the analysis offunctions on the intelligence test; the qualitative evaluation of quantitative results; possibilities of differential diagnosisfrom psychological tests; the characteristic functioning of the variously disturbed, as the severely disturbed emotionally, the psychopaths, the psychotics, the organic involvements, and the others. The various deteriorationindices, for example, developed in recent years, are nothing more than fragments of intelligence tests in which the different elements show differentrates of loss when mental functions deteriorate.
To develop respect for his contribution to the case study, however, thepsychologist must demonstrate his worth. He must produce a psychologicalstudy that is not so limited and stereotyped that all subjects appear to comeout of the same mold. The psychological study must be a rounded, dynamic,meaningful study of the individual's particular characteristics and problems.
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Experience with a large number of psychiatrists operating in the child guidance framework has shown that the inexperienced psychiatrist is frequentlythreatened by competence on the part of staff members of the other professions, while the more experienced and the more competent the psychiatrist, the more does he welcome the other contributions to the case study.Apropos of this, an extremely able psychiatrist recently said, "We knowlittle enough as it is about what makes the human being tick. We certainlycan't afford to ignore any clues, hints, or ideas from whatever source." Thatis one of the important attitudes to develop in the young psychiatrist. Anoutgrowth of such an attitude is the improved use of psychologists by thepsychiatrist. As child guidance and mental hygiene clinics are organized today, the psychiatrist is usually the administrative officer and chief of staff.It is therefore important that in his training he learn to make the best useof the staff usually associated with such clinics.
When we discuss the work of the psychologist, the first things that cometo mind are intelligence and educational tests. There are numerous areas,however, which overlap to such an extent that it is frequently impossibleto say whether the psychologist or the psychiatrist is most concerned. Theuse of parts of the intelligence test battery for a deterioration scale has already been mentioned. Wide discrepancies between verbal and performancetests frequently characteristic of those with cortical involvements constituteanother example. Still others are: the measurement of aptitudes and interestsand their relation to personality, to motivations, drives, and emotionalvalues; the measurement of basic abilities, such as reading, writing, speech,number concepts, artistic abilities and manual dexterity, and the discrepancies between these abilities and actual function or failure to function atcapacity. Reading disabilities in particular are of interest to both professionsbecause they are so common and require different approaches in treatmentdepending upon the type of disability. Much depends upon whether we aredealing with a generalized educational disability or a special reading disability; whether the special disability is due to cortical anomalies, such ascortical word blindness, strephosymbolia, the various aphasic conditions,and the like, which can be uncovered in the careful psychological examination. Indications may be for neurological study, the aphasic status, or theelectroencephalographic study; or there may be affective factors which require psychiatric study. The same is true of speech and motor disturbances.The psychiatrist and psychologist are both involved in these.
The child's adjustment to school, and the adult's adjustment to a vocationconstitute another common area. By and large, the psychologist is likely tobe the better informed on schools and vocations. Problems of school adjustment or maladjustment, choice of school or course, vocational opportunities,resources for special types like the mentally retarded, the gifted, those with
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special abilities or disabilities, the disturbed, the delinquent, those withphysical or sensory defects, and many others, are usually turned over to thepsychologist when psychologists and psychiatrists work together, althoughjoint efforts may be necessary. In the main, the psychologist is the educational specialist of the clinic team. One further point in connection with theschool. As a rule, the new psychiatrist becomes so completely involved inthe problems of his patient that he sometimes neglects to allow for thesituations in the large classroom. Some balance between the patient's needsand the realities of the classroom situation must be struck, and the psychologist should be of help in the psychiatrist's orientation in this respect.
The next item is a double-edged sword, and has both positive and negativeaspects for the training of psychiatrists. I refer to the use of personality testsby the psychologist, particularly projective techniques, of which the mostcommon are the Rorschach and the Thematic Apperception Test. Althoughoriginally a psychiatric tool, the Rorschach has become more and more atechnique of the psychologist. Many psychiatrists prefer to have the Rorschach administered and interpreted by the psychologist, even though theyare adept at it themselves. The psychiatrist-in-training should not only learnabout this test and its uses and abuses, but should also become familiar withsome of the technical details of the method in order to be competent to judgeits use by others. What happens too often, is the young psychiatrist's greatdependence upon the psychologist's Rorschach interpretation. Instead ofusing it as a supplementary technique, it is often used as a psychiatric study,which it does not pretend to be. This trend needs to be reversed, and thetraining period of the psychiatrist is the time in which to do it.
Therapy is, of course, the most important function of the psychiatrist.There are areas of therapy, however, which can be entrusted to the socialworker and to the psychologist, and the psychiatrist-in-training should learnto discern these. Reading and other educational disabilities, speech disturbances, some types of motor disturbances, and emotional disturbances whichare not too deeply rooted and can be alleviated by supportive methods, aresome of the types that are usually treated by the psychologist, occasionallywith concomitant psychotherapy by the psychiatrist. This kind of workingrelationship, as well as the case conference at which the treatment plan isworked out, is important in the psychiatrist's training.
Psychiatry is becoming increasingly interested in research. The psychiatrist's education seldom includes training in research, while the psychologist'straining does. Research method, statistics, and the objective approach, bothin research and in diagnosis, are fields in which the psychologist has someresponsibility to convey the essentials to the young psychiatrist. The psychologist, on the other hand, is usually weak in the dynamic approach, whichshould serve as a balance to too great objectivity.
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The functions of the psychiatrist, mentioned or implied in this discussioncan be roughly classified in four categories: diagnosis, treatment, researchand administration. In discusing the role of the psychologist in the trainingof psychiatrists, the psychologist's part in these functions may have beermagnified by virtue of being placed under a microscope for purposes of dis.cussion. In actual practice there is seldom any difficulty about defining thefunctions of the two in working together. In spite of considerable overlappingof function, there is nevertheless a remarkably clear-cut differentiationoperating in each individual case. In our organization, for example, in thepast fifteen years, perhaps thirty psychiatrists and sixty psychologists haveat different times worked together with a minimum of friction. Each respectsthe other's contribution to study and treatment and each learns from theother. Participation in training is mutual. If, in this discussion, only thepsychologist's part was emphasized, it was because that was the specificassignment.