Hard to Select a Shrink

“You’re distraught, Harry,” were the words S.Q. Lapius greeted me with as he entered my office.

“Why do you say that, Simon?  Just because I threw this sheaf of papers on my desk in disgust and they scattered all over the floor?”

“That was a clue, I must admit,” Lapius said impassively.  “What seems to be the trouble?”

“How the deuce does a doctor choose a psychiatrist?”

“Come Harry, things can’t be that bad.  Take a warm bath.  That will sooth you.”

“Not for me, Simon,” I said with no little exasperation, “for one of my patients.”

“That should be simple, Harry.  Look up psychiatrists in the medical directory, under ‘P’.”

“It’s not that simple, Simon.  An internist is an internist, a surgeon is a surgeon, but a psychiatrist isn’t always the psychiatrist for a given patient.  They differ.  I get varying results, and I can’t figure it out.”

“Too bad, Harry,” he lamented, squinting owl-like through his bifocals.  He placed a cigar into his mouth and said, “You haven’t been keeping up with the literature, I see.”

“How so?”

“The problem is explained in the New England Journal of Medicine the issue of February 15, 1973, an article by one Aaron Lazare.  The trouble is that there are different schools of psychiatry. He lists four particular models by which psychotherapy might be effected: the Medical model; the Psychological model; the Behavioral model and the Social model.”

“I must admit I missed that one, since I’m only up to the 1967 volume of the Journal, but I’ll get to it, I promise.”

“Skip ahead, Harry, it will be worth your while.”

“Will it help me pick the right psychiatrist for the right ‘patient’?”

“Perhaps. At the very least, it will show you what you are up against.  For instance, the Medical model.  Here the physician makes the diagnosis of depression.  Once the diagnosis is made he seeks a medical form of treatment, either drugs or electric shock therapy.

“But if your psychiatrist is oriented to the psychological model he is oriented to treating personality that has been distorted by past experiences and he attempts treatment for emotional traumas the patient suffered as a child. The doctor forms an alliance with the patient so that together they might examine the past, and try to straighten out the distortions once the patient becomes aware of them.

“But then there is the behavioral model, in which the doctor attempts to alter aberrant behavior patterns and doesn’t worry about the prior traumas that caused them.  These doctors use terms like desensitization, reciprocal inhibition, and conditioned avoidance.”

“What do they mean?”

“Beats me.  But the important thing is that the psychiatrist in this model identifies the symptoms of lack of appetite, feelings of helplessness and so forth.  He determines that the symptoms started shortly after the death of her husband who, throughout the marriage had been a continuing source of reinforcement.

“His death is considered ‘a sudden withholding of positive reinforcement of adaptive behavior’.  The treatment consists of reinforcing behavior patterns that are inconsistent with depression and attempting to extinguish depressive behaviors. Here the psychiatrist has to teach the family to reinforce positive behavior patterns.”

I started to say something unpleasant, but Lapius raised his hand pontifically to silence me.  "Not a word until I’ve finished, please.  We have yet to cover the social model.”

I sank back into my swivel chair, defeated.  Lapius continued.  “In the social model the psychiatrist concentrates on how the individual functions in the social system ‘—the type and his ‘connectedness’ to the groups which make up his life space.’  Here the therapy consists of reorganizing the social system in which the patient exists.  Have the patient move out of her daughters house, or go to another town, or change jobs, things of the like.”

“Let’s get back to the original question.  How do I fit my patient to the proper psychiatrist?”

“I guess the only proper way, Harry, is for you to acquaint yourself with the ideologies of the psychiatrists to whom you would refer patients, and then monitor the therapy. If the patient after a reasonable period of time is not improving, suggest, perhaps another mode of treatment.  To do this you must discuss the case with the psychiatrist in advance.”

“I’m confused.”

“Of course, my boy.  Let me help you.  I will treat you with the four modalities.  Knowing something of your background, and having just learned of the problem that besets you, we can dispense with the psychological approach.  For the behavioral, I will urge you not to scatter your papers or get into a huff, it is most uneconomical.

“The social therapy is simple.  We must change your environment.  We do this by repairing to the nearest watering hole.  There, James will take over from me, and supply the medical treatment.”

“Who is James?”

“The bartender.”