Friday, January 7, 2011

Osteopathic Psychiatry: It's Time to Smell the Roses

Medical Students and physician review a techni...

In August of this past year, the House of Delegates of the American Osteopathic Association passed a resolution supporting the use of osteopathic manipulative medicine (OMM) for the treatment of psychiatric and neurological patients. In some circles, this might be viewed as a controversial decision and for non-medical readers, I need to explain why.

To begin with, we're not really talking about neurological patients since OMM has long been used in their treatment. With psychiatric patients, however, it's another matter. You see, psychiatry has traditionally been the one medical discipline in which practitioners, apart from a polite handshake, generally tried to  refrain from touching patients as a matter of principle. Psychiatric relationships are already complicated due to their subject matter, why risk complicating them further by introducing physical contact into the mix?

Not all psychiatric writers agree, however. Irvin Yalom, MD, for example, argues physical contact shouldn't be rigorously avoided; rather, when touch has been appropriate, the next step is to talk about its meaning for the patient (The Gift of Therapy, 2003). There is a wise saying, Everything is grist for the therapy mill, which means everything that takes place between doctor and patient should be discussed as a natural part of the patient's psychotherapy. But OMM involves more than placing a comforting hand on the shoulder of a grieving patient, which is why the decision to employ it has the potential to generate controversy. From my perspective, the issue has as much to do with history as with theory.

The practice of psychiatry as it's usually conceived can be traced to the work of individuals who were adherents, so to speak, of The Indiana Jones School of Psychiatry, i.e. they made it up as they went along. That's legitimate, by the way, when you're quite literally going where no one else has gone before. You sort of have to find your own way because there isn't anyone who's done what you're about to and can advise you to take up a hobby instead, or better yet, just get a dog.

In those days, psychotherapy was the psychiatrist's primary, if not only, tool -- it would be years before lithium became the first psychiatric medication on the scene. I studied under a psychiatrist who completed her training prior the advent of psychiatric medications and I asked her what that was like. She said being thrust into a ward filled to the brim with actively psychotic patients with nothing to use but psychotherapy was a hopeless endeavor, but as they had nothing else, what else could they do? 

According to the pioneers in the field (Jung, Freud, and others), the cure to neurosis was found in the resolution of the transference (the idea that a therapist unconsciously reminds a patient of another key figure in their lives, a parent for example, and by working through their feelings toward the therapist, they are actually working through painful feelings toward the parent; past and present meet in the transference). I can't say that psychiatrists and patients didn't ever touch because there are records to the contrary; it just wasn't a formal element in the process because it was feared touch might interfere with resolving the transference. The relationship between patient and doctor, therefore, was primarily cerebral and words were relied upon to render it incarnate in flesh and blood.
For the most part, the osteopathic community has focused its interests on the application of OMM to promote wellness and treat physical illness, especially in the context of primary care medicine. There are references to its use with psychiatric patients in the literature, but these are few and far between. Many, if not most, osteopathic (D.O.) psychiatrists have been trained in the traditional hands-off model and hence, experience a natural reticence about using touch to any great extent as a treatment modality.

Now, here's the problem. If osteopathic medicine represents a similar but also different approach to medical practice, it only makes sense that osteopathic psychiatry should represent a similar but also different approach to the treatment of psychiatric illness. As long as our methods are identical, however, it's kind of hard to see how anyone can point out a distinction between us and our MD colleagues. If you want to claim your degree confers a measure of "something else," it's only fair to ask what that might be.

In response, many have been inclined to say, we're interested in the whole person. But here's where I run headlong into my own experience. I've trained side by side with M.D. psychiatric residents and witnessed how much they care about their patients. They may not use the mind-body-spirit terminology that is the heart and soul of osteopathic medicine, but they care and that's what matters above all. What I'm getting at is, whatever differences exist between us, they have to be real, measurable, and not based solely on a well-worded principle, as critical as it may be to osteopathic identity (see Mission Impossible, 2/5/2014).

I realize I may be treading on thin ice and not all my osteopathic colleagues are going to be comfortable with the prospect of introducing therapeutic touch into the psychiatric mix. But times change. Physicians can undergo sub-specialty training in alternative medicine. The diagnosis and treatment of psychosomatic illness has its own subdivision within the American Psychiatric Association. The landscape of psychiatry is becoming far richer and far more complex than our forefathers and mothers could ever have imagined when they invented the talking cure. I think the House of Delegates is telling us it's time we woke up and smelled the roses.

(A follow-up essay may be found here)

(Public Domain image via Wikipedia)


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