What distinguishes psychiatrists from psychologists, social workers and counselors?

Psychiatrists are physicians who specialize in the branch of medicine called psychiatry. After medical school psychiatrists do a four-year residency in psychiatry. In this day and age, many psychiatrists do not do psychotherapy. Their practice is much more like the practice of an internist who may see thirty or more patients a day. The treatment emphasis is medication. A much smaller number of psychiatrists like myself are primarily psychotherapists.

The majority of psychotherapy is done by psychologists, social workers and counselors. They are not able to prescribe medication and routinely refer their clients to psychiatrists for medication. This arrangement is a split treatment with one person doing the psychotherapy and the other doing the medication treatment.

Psychiatrists have considerably more formal training in patient care than do psychologists, social workers and counselors. Medical students spend at least two full years in direct patient care under supervision of more senior physicians. Psychiatry residency training adds another four years of supervised, direct patient care. As a psychoanalyst, I had an additional five years of supervised training. The amount of supervised, direct patient care varies for psychologists depending on the program. Two to three years of direct patient care under supervision is the average. A Masters in social work is a two-year program in which time is divided between classroom studies and direct client care. Despite differences in formal training, non-psychiatric therapists can be excellent psychotherapists while some psychiatrists could be mediocre psychotherapists.

What are the common medical-psychiatric problems you treat?

The discomfort and pain of depression and/or anxiety drives the call for help. The typical reasons for the distress center around problems in relationships and work. For teenagers, the pain or struggle centers around social experience and school. The other relationship that motivates treatment is the relationship with oneself. Problems of self-esteem are very common and sometimes take center stage. Behavioral problems are also common. In such cases, people often come to therapy at the insistence of others like a spouse, employer or family member. Common behavioral problems are substance abuse, anger outbursts, infidelity, school refusal, and sexual impulsiveness.

Another common problem is persistent physical pain and or dysfunction. These types of physical distress can cause secondary emotional reactions. Also, stress in its’ many forms impacts bodily function. Certain parts of the body and bodily systems are particularly effected by emotional reactions. And, most of us have specific parts of the body that are vulnerable to stress. Some people are prone to headaches while others get back or neck pain, joint pain, muscles stiffness or skin irritations. The most common system affected by emotions is the entire gastro-intestinal track. When depressed or anxious people overeat and under eat. Constipation, hemorrhoids, indigestion, bloating, acid reflux, and so-called irritable bowel syndrome are common symptoms often strongly related to emotional experience.

How long does treatment take?

Duration depends on the problem being treated. Most often, people begin treatment because of distress experienced most commonly as some degree of depression, anxiety or a combination. The “pain” that has finally brought the person to the doctor is often lessened within a few sessions or even in the first session. For some people, the immediate reduction of symptoms is the only goal. Therapy can stop and if the problem occurs, then another brief treatment can be used to “cure” the symptom. This model of treatment is the dominant model in primary care medicine as practiced by internists, family medicine practitioners and the old school GP (general practitioner). Treatment of depression or anxiety is then no different than treatment for pneumonia, rash, acute back pain, or joint swelling.

Most often, the symptoms in some form have occurred at other times in the person’s life. Treatment can then be redirected to this recurrent symptom with the goal of preventing the repeating experience. This treatment typically takes longer. The symptoms are just a manifestation of more fundamental problems of the overall “system”. For those interested in getting at the system leading to recurrent problems, more sessions are required. One approach I use is an intensive treatment process of anywhere from 12-30 sessions. Frequency of session could be 1-3 times a week.

Some problems are less acute, more longstanding and more complicated. The most common example is problem in relationships. How we function in and experience relationships are the most important factors in our adaptation to life because relationships are so pervasive in our lives. Intimacy, friendships, work and family all involve relationship experiences.

Another common relationship crucial to how you function in and experience the world is your relationship with yourself. Self-critical thinking is frequently present, otherwise known as being hard on yourself, expecting much of yourself, and all too often, thinking you are falling short of your expectations. Related to this relationship is the relationship with your body. Dissatisfaction with your body and the often related attempt to distance yourself from your body greatly interferes with effectiveness and pleasure.

Treatment for relationship problems takes however long it takes. Consider trying to change the way you walk, your posture, the volume and speed of your speech and how fast and how much you eat. These personal “ways” are strongly embedded and changing these mindbody patterns can take time. People vary in their availability for change and time may be required to help you simply become more available. Once available then changes can begin to occur. Or, simply becoming more available for change may be the single most important change you can make.

What is your philosophy about medication?

I am conservative when it comes to medication and use it sparingly. A few people I have treated over the years have absolutely needed medication. Attempts to go off of medication resulted in predictable symptoms of depression or losing touch with reality. The latter is called psychosis. Most of the people I work with can be treated without medication. At least, that is my opinion. I am sure if seen by the majority of psychiatrists practicing across the country, most of the people I see would be prescribed medication.

Antidepressant medication is the most frequently prescribed medication. In absolute numbers, internists and family doctors account for more antidepressant prescriptions than prescriptions given by psychiatrists. To be sure, some people need and respond well to medication. I prefer other avenues if at all possible and many alternative pathways exist. And, medications have side effects. A common side effect of antidepressant medication is emotional numbing manifesting for some in the inability to feel sadness or actually cry. This side effect interferes with a primary goal of my work in various contexts – feeling more or simply the ability to feel with greater range and intensity.

Do you focus more on disease or health?

I work to help people function most effectively and feel more pleasure in living. For various reasons, we experience obstacles in the pursuit of these two fundamental and interrelated goals. In the end, we are all trying to adapt to the world most effectively. Problems of adaptation are sometimes labeled as disease. The point at which discomforts or limitations become “disease” is arbitrary. I prefer to think about health as a continuum or spectrum. So, we are less healthy, healthy and very healthy. The goal is to move further to the right on the spectrum to more and more healthy. Rather than consider something to be “wrong” with you, I prefer to consider your limitations and strengths, that which facilitates and that which interferes with more effective adaptation.

Disease is typically considered to be bad and something to be eradicated. Certainly some illness is life threatening and needs to be aggressively treated. However, most people suffer from chronic aches, pains and discomforts that are more difficult to categorize as specific disease. As well, the symptoms are not life-threatening but can certainly be a real hindrance to living. Symptoms can also be thought of as messages and indicators of something needing attention. The symptoms of so-called disease are your mindbody feedback system alerting you to something amiss. Symptoms are valuable information that can lead to true alteration in your adaptation to living. My focus is on effective and pleasured living rather than disease.

Do you collaborate with other medical or alternative healing providers?

In the spirit of a more holistic approach, I collaborate with other health and wellness practitioners when indicated.

How are body and mind connected?

The study of psychology is a study of feeling, thinking and behavior. All behavior is physical and manifested through some bodily process. Single cells in your body are “behaving” at all times as are your gastro-intestinal, circulatory, respiratory and musculo-skeletal systems. The brain and nervous system are the drivers of behavior. Thoughts and feelings are commonly considered to be mental rather than physical. But thoughts and feelings can’t be experienced or registered without the brain. Neurons have to fire and neurotransmitters (chemicals in brain cells) have to act in order for you to think and feel. In that regard, feelings and thoughts or “mind” are physically based. “Mind” is bodily.

Feelings are always experienced physically. You know you are angry or sad or excited or scared because of physical sensations. Also, we can identify feelings in others through simple observation because feelings are manifested physically/behaviorally – tears, frowns, smiles, downcast eyes, slowed speech, “look” of terror, etc. Common language also reflects understanding of the connection of mind and body and feelings and behavior. Examples include, so and so is a “pain in the neck”, gut feelings, heartfelt, “falling” in love or being “swept” off your feet, or “takes my breathe away”.

Feelings, thoughts and behavior are interconnected. Exercise can produce feelings of well-being and calm. Simply breathing in a certain way induces feelings of calm. Feeling calm or happy can result in relaxed musculature and more effective athletic performance/behavior. Thinking well of yourself can produce calm as well as a more upright and “proud” posture. Conversely, thinking less of yourself can result in a more slouched and protected posture and feeling of shame.

Are you a mental coach for athletes?

Because mental or psychology includes thoughts, feelings and behavior, I redefine “mental” as including the physical. In that regard I am a mindbody coach. I have special expertise in the “mental game”, meaning the common understanding of mental coaching; emphasis on feelings and thoughts and the effect of both on athletic performance. However, my coaching also incorporates the physical aspects of sports without focusing on details of technique.

What distinguishes your approach to golf from traditional sports psychologists and swing instructors?

Sports psychologists and swing instructors typically focus on either the mental or physical aspects of golf. I focus on both or more specifically the interrelationship of thoughts, feelings and behavior. In golf, the behavior of greatest interest is the swing. Your swing, like your walk, the volume and speed of speech, your way of communicating and your style of dress reflects who you are as a person. The swing is not some isolated movement but connected to you – all of you. Your way of playing golf as in course management and the spirit of your play is also a reflection of your “way”.

As a physician, psychiatrist and athlete, I have the training and experience to fluidly shift attention back and forth to you and specific golf skills. One potential benefit of this multidimensional approach is you can learn about and develop your golf game by learning about and developing yourself. You can also learn about and develop yourself by learning about and developing your golf game and specifically how you interact with the club and swing.

The swing is the central element in the activity of golf. Consequently, I pay attention not only to your thoughts and feelings but your physical self as manifested in your swing and more generally, how you move and interact. I do so without focusing on technical – this is right, that is wrong – swing details. I connect the mind and body through emphasis on feel, instinct, the senses, the spirit of play, and pleasure.

As is true of all my work, my aim is helping golfers feel more pleasure in the experience and play more effectively. The most distinguishing and game changing aspect of my approach is – Pleasure Leads, Effectiveness Follows. Most golfers believe the reverse: Pleasure in the game is a result of playing more effectively. Unfortunately, many golfers find effectiveness fleeting and/or experience frustration in their pursuit of effectiveness. The result is absence of consistent pleasure in the game.