the tranquilizers and the antidepressants had even been heard of. These psychiatrists spent their weeks and months in pharmacology courses learning facts about drugs which, except for the sedatives and a small number of amphetamine preparations, they have never used and never will use in their work as psychiatrists. Thus, their knowledge of and experience with the newer drugs stems entirely from their own informal self-educative activities, while their formal training in pharmacology was largely devoted to material having no relevance to their later practice. It is not implied here that formal training in pharmacology is unnecessary, but simply that a brief, concentrated course in what has been termed "psychopharmacology" would be far more to the point than months spent in learning the intricacies of various digitalis preparations, antibiotics, and dozens of other drugs which are of vital importance to the work of the physician dealing with physical illnesses but of no importance to the work of the mental health specialist. Operationally, one certainly does not have to be able to prescribe all drugs in order to prescribe some drugs; institutional rules have already encompassed this fact in regulating the prescribing done by podiatrists, for example. The important questions confronting any professional field serve as good indicators of the underpinnings of knowledge relevant to the field. In the mental health field, there are such questions as these: 1. Is anxiety generated and maintained in a purely reflex fashion (as the behavior therapist would say), as a result of cognitive processes (as the rationalemotive therapist would say), or as a result of conflict between instinctual drives and intrapsychic repressive forces (as the psychoanalyst would say), or by different mechanisms in different situations? 2. To what extent is behavior unalterably determined by infantile and early childhood experiences? How "free," in the existential sense, is man? 3. How much of what we observe in human behavior is attributable to intrapsychic forces and how much to interpersonal influences? What is the interrelationship between the intrapsychic and the interpersonal? 4. What really happens in the various forms of psychotherapy? 5. What is the role of values in the practice of psychotherapy? The questions raised by the coexistence of such diverse practitioners as existential-experiential therapists on the one hand and behavior therapists on the other lead swiftly to questions about the very nature of man. Significantly, however, these like the questions listed above are all questions for the psychologist or the philosopher, not for the anatomist or the physiologist. Even the most reductionistic of the therapeutic approaches, behavior therapy, comes straight from the laboratory of the experimental psychologist. Of the really important questions confronting the mental health field today, only three are not basically questions in psychology, sociology, or ethics: 1. Are there biochemical and/or genetic abnormalities which play a causative role in schizophrenia? 2. Are endogenous depressions really manifestations of physiological malfunction? 3. To what extent does "subclinical" cerebral dysfunction play a part in childhood behavior disorders? The investigation of these questions is properly in the hands of the biochemists, the geneticists, and other researchers; it is beyond the professional scope of the psychiatrist as we usually know him, despite his medical training. And, to repeat, if these conditions should be found to be, let us say, "metabolic diseases," they would cease to be primarily "mental health problems" in the same way that "psychosomatic headaches" cease to be a "mental health problem" when they are discovered to be caused by a brain tumor. The mental health professional, then, is really working in the field of applied psychology in the best sense of that much-misused term-psychology applied to the task of alleviating psychological suffering-with some excursions into the realm of applied psychopharmacology. This is his true operational field no matter what his professional background has been. That jurisdiction over this field should be claimed by a profession whose basic education usually includes not a single course in psychology is, when viewed dispassionately, little short of fantastic. My purpose in this paper is not to propose the details of a curriculum for future mental health professionals, but rather to evaluate the present education of the most influential of these professionals-the psychiatrists--and to suggest a direction for change. Such change must be in a psychological direction if our education is to make sense in terms of the realities of our professional work. > When is some enterprising university going to formulate a curriculum for a School of Mental Health, based on the existing curriculum in clinical psychology and including appropriate additions from other fields (medicine, sociology, social work), and produce graduates whose work can then be compared with that of their more traditionally trained colleagues? It is a dream worth considering. REFERENCES BAHN, A. K., CONWELL, M., & HURLEY, P. Survey of private psychiatric practice. Archives of General Psychiatry, 1965, 12, 295–302. COLBY, K. M. A primer for psychotherapists. New York: Ronald Press, 1951. EISSIER, K. R. Medical orthodoxy and the future of psychoanalysis. New York: International Universities Press, 1965. FRANK, J. D. Persuasion and healing. Baltimore: Johns Hopkins Press, 1961. FREUD, S. The question of lay analysis. (1926) London: Imago, 1947. (1st English ed.) GARDINER, M. A note on accreditation. Bulletin of the Philadelphia Association for Psychoanalysis, 1960, 10, 56–58. GARDINER, M. The seven years of dearth. Bulletin of the Philadelphia Association for Psychoanalysis, 1962, 12, 168–170. GRINKER, R. R., SR., et al. Psychiatric social work: A transactional case book. New York: Basic Books, 1961. HOLLIS, F. Casework: A psychosocial therapy. New York: Random House, 1964. JOSSELYN, I. M. The caseworker as therapist. Journal of Social Casework, 1948, 29, 351-355. KAPLAN, A. H. Social work therapy and psychiatric psychotherapy. Archives of KUBIE, L. S. The pros and cons of a new profession: A doctorate in medical psy- KUBIE, L. S. A school of psychological medicine within the framework of a medical school and university. Journal of Medical Education, 1964, 39, 476–480. LESSE, S. The psychotherapist and apparent remission in depressed suicidal patients. American Journal of Psychotherapy, 1965, 19, 436-444. PINES, M. Training housewives as psychotherapists. Harper's Magazine, 1962, 224, 37-42. SCHOFIELD, W. Psychotherapy: The purchase of friendship. Englewood Cliffs, Prentice-Hall, 1964. SOBEL, R. Role conflict or resistance. American Journal of Psychotherapy, 1964, 18, 25-34. STRUPP, H. H. Psychotherapists in action. New York: Grune & Stratton, 1960. Szasz, T. S. Psychiatry, psychotherapy, and psychology. Archives of General Psychiatry, 1959, 1, 455-463. SZASZ, T. S. The myth of mental illness. New York: Hoeber-Harper, 1961. WARME, G. E. Consulting with aide-therapists. Archives of General Psychiatry, 1965, 13, 432-438. WHEELIS, A. The quest for identity. New York: Norton, 1958. ZILBOORG, G. Mind, medicine, man. New York: Harcourt, Brace, 1943. EXHIBITS D, E, AND F (Medicine, Practice of: Practice of Psychotherapeutics) THOMAS M. KAVANAGH, ATTORNEY GENERAL, STATE OF MICHIGAN Opinion of Attorney General No. 1645, April 22, 1953, analyzed, construed and supplemented. Social workers, psychologists and others dealing with counseling and other non-medical emotional therapy are not practicing medicine in violation of Medical Practice Act; whether clinical psychologist functioning as members of team supervised by psychiatrist is in violation of act, is question of fact determinable in light of specific circumstances. [Opinion No. 2359] JANUARY 20, 1956. Hon. RAYMOND D. DZENDZEL, DEAR SIR: Reference is had to your letter of October 26, 1955, in which you call my attention to an opinion of my predecessor (O.A.G. 1952-54, No. 1645, p. 146. April 22, 1953), ruling that the practice of "psychotherapeutics" constitutes the practice of medicine within the meaning of the Medical Practice Act (Act No. 237, PA 1899, as amended; 338.59, CL 1948; 14.539, Stat. Ann.), which provides in part that: "* * * unless otherwise provided, the term 'practice of medicine' shall mean the actual diagnosing, curing or relieving in any degree, or professing or attempting to diagnose, treat, cure, or relieve any human disease, ailment, defect, or complaint, whether of physical or mental origin, by attendance or by advice, or by prescribing or furnishing any drug, medicine, appliance, manipulation or method. or by any therapeutic agent whatsoever." Elsewhere, the same act requires that physicians and surgeons must be licensed as therein provided (338.51-338.53, CL, Mason's 1954 Supp.; 14.531-14.533, Stat. Ann.), and that the practice of medicine as defined in the section quoted hereinabove by one not licensed is a misdemeanor. (338.57, CL, Mason's 1954 Supp.; 14.537, Stat. Ann.). You point out that Opinion No. 1645, referred to above, has been re-emphasized and intensified by a later ruling, dated November 5, 1953, concerning the status of a civil service appointee in the classification "Medical Technician III." Listed duties include the making of routine physical and mental examinations, assisting with medical treatment and surgery, assisting in autopsies and pathological services, dictating progress reports on medical and surgical patients, and participating in diagnostic staff meetings. The specific question involved in the latter opinion was whether the civil service position was being used to enable unlicensed foreign doctors to circumvent licensure requirements. The ruling was (1) that civil service prescription cannot condone or relieve from the applicability of the Medical Practice Act; and (2) that whether a given individual is "practicing medicine" as defined by the Medical Practice Act is a question of fact, as to which the State Board of Registration in Medicine is best qualified to furnish an answer. In course of this opinion, my predecessor noted that acts in violation of the statute are not rendered legal by the fact of medical supervision. You state that since the issuing of the two rulings hereinabove described, a cloud of doubt has been cast over the legality of long etsablished conduct and practices on the part of social workers, psychologists and visiting teachers. Quoting from your letter: "For a time, some of my constituents * * * eased their doubts by a belief that because they worked under some form of medical supervision, the legality of their employment could not be questioned. This comfort, however, is dispelled by another Attorney General's opinion (that of November 5, 1953, above described) * * *. This opinion, combined with the *** opinion first mentioned, has placed the jobs of professionally trained psychologists and social workers in great jeopardy *. This has been reflected in the increasing difficulty in recruiting personnel." You remind us that: "throughout the state for many years the long established programs and methods employed in public clinics and institutions require the use of trained psychologists, psychiatric social workers and other experts, who are not medical doctors," and that: "without the services of these non-medical experts ***the entire public mental health program would be severely disrupted and handicapped." And, finally, you have supplied us with a number of job descriptions issued by the State Civil Service Commission and by the Wayne County Civil Service Commission for a variety of positions requiring the use of therapeutic and treatment skills in the area of emotional problems. These include clinical psychologists in the Wayne County Mental Health clinic, psychiatric social workers, psychologists, and child psychologists in various public facilities in Wayne County. They also include, at state level, pschiatric social work administrators, corrections youth administrators, consultation center supervisors, psychiatric social workers, child guidance personnel, prison social workers, social case workers, and visiting teachers. You might also have included court marriage counsellors, Friends of the Court, juvenile court workers, child welfare workers, ministers, school teachers, per sonnel directors, and others dealing with emotional problems in a constructive and healing way. Indeed, you might also have added that mothers, close personal friends, neighbors, poets, musicians, lovers, good cooks, and all others by personal with whom the troubled experience amelioration of psychological unease, may be Isaid to be doing therapy in the area of emotional ills and so to be guilty of a misdemeanor in Michigan. The Questions On the basis of the problem as outlined above, you request my opinion with respect to these questions: 1. Is the work currently being performed by skilled, professionally trained psychologists and social workers, as set forth in the civil service descriptions referred to above, legal, or does such work constitute the illegal practice of medicine by unauthorized personnel? 2. Is new legislation needed to sanction such work by trained professional experts who are not physicians but who have the skills required, e.g., by civil service regulation? The Problem Because of the gravity and public importance of the questions you raise, I have instructed my staff to inquire fully into this matter. After due investigation and deliberation, we find that: 1. The current shortage of facilities for mental patients includes not only a shortage of structures for housing such patients in an institutional setting, but also includes a shortage of psychiatrists, psychologists, psychiatric social workers and similar experts essential to the mental health program. This underlines the necessity of clearly determining the proper functions of existing personnel. 2. The relationships between psychology and psychiatry have been and are the subject of careful and profound professional consideration on local, state and national levels, by the organized groups representing these and related professions. These deliberations are still in progress. We note, for example, that in a report entitled Relations with Psychology, issued in 1955 by the American Psychiatric Association, the reporting committee comments: "*** these are questions of public policy; but the public and legislatures cannot wisely resolve these until at least the essential professional questions are resolved within professional circles." 3. The problem of licensing and/or certifying psychologists has been and is receiving considerable attention in all states; existing and recommended legislation appears to be in the nature either of certification (whereby a qualified psychologist by undergoing inquisition as required by the statute is certified as entitled to use the title "psychologist" or "certified psychologist" professionally), or, alternatively, a prohibitive statute forbidding unqualified and/or unlicensed persons to engage in certain activities on pain of penalty as set forth in the statute. The former, or permissive, type is described to us as preferred by members of the various professions concerned. Questions Regarding Statute Premature It is our understanding that members of the profession of psychology in Michigan have not completed their conferences with members of the medical profession and others assisting with the problem. This office is therefore in a position to make a sound decision with regard to the necessity or advisability of a statute governing the practice of psychology, and as to this opinion is reserved pending official advices from those now at work on the problem. Analysis of Previous Opinions The Medical Practice Act has been fully established as a constitutional and necessary exercise of the state police power as applied to the field of public health. See Reetz v. Michigan, 188 U.S. 505 (47 L ed. 563) (1902), upholding 127 Mich 87. At page 508, Mr. Justice Brewer said, in part : "The power of a state to make reasonable provisions for determining the qualifications of those engaging in the practice of medicine and punishing those who attempt to engage therein in default of such statutory provisions, is not open to question.” (Citing cases) And see People v. Carroll, 274 Mich 451 (1936), holding a similar dental practice statute constitutional, where at page 453 the court says: "Regulation of the practice of medicine and dentistry is within the police power of the state," citing People v. Phippin, 70 Mich 6 (1888), wherein a "magnetic healer" was convicted of practicing medicine without a license. There are numerous other cases, both state and national, supporting the right of the state to regulate the privilege of admission to practice medicine. It is thought unnecessary to lengthen this opinion by reviewing them. Basis for Opinion No. 1645 In the light of this doctrine, my predecessor in arriving at the 1953 decision relative to psychotherapeutics, considered that area. In the course of Opinion No. 1645, the following language occurs: "We are advised that psychotherapeutics, psychotherapy, constitutes (1) psychiatry; (2) mental therapeutics, mind-cure, or cure by making mental impressions or suggestions. "Section 14.537, Mich Stat Ann, prohibits the practice of medicine or surgery in this state without a license, and the Attorney General is of the opinion that the practice of psychotherapy comes within the definition of the practice of medicine found in the statute. In the case of Ppcople v. Mulford, 125 N.Y.S. 760 (sic), the treatment of ailments by suggestive therapeutics was held to be the practice of medicine." A reading of the New York case referred to, which decision was rendered in the year 1910, discloses that the defendant treated his patients for physical ailments by treatment consisting entirely of the laying on of hands, manipulation, breathing, and rubbing his hands together, which method of treatment he designated as "suggestive therapeutics." Thus the case governs treatment of a physical ailment by influencing the mind. The opinion might well also have cited the Michigan case of People v. Phippin, noted hereinabove, which had already established that persons attempting to cure physical ailments by suggestion, “mind cure," or similar activities, are in the area of medical practice and must be licensed. To the extent that psychotherapeutics involves this kind of activity-purporting to cure a physical ailment by "making mental impressions or suggestions," the opinion of my predessor is soundly based and is a correct statement of the law. The opinion does not purport to govern any situation other than the one just described. Psychology, Social Work, Psychotherapeutics Defined In light of the questions you now raise, it seems necessary to inquire further into the nature and function of psychotherapeutics, other than and in addition to the practices as above defined. Since psychotherapeutics is one of several functions performed by psychologists, we may appropriately begin by turning to the definition of psychology. According to Webster's International Dictionary, psychology is: "that science which treats of the mind (of man or other organisms) in any of its aspects; systematic knowledge and investigation of the phenomena of consciousness and behavior; the study of the organism and its activities, considering it as an individual whole, especially in relation to its physical and social environment.” Social work is defined in the same reference work as "any activity designed to promote social welfare, especially organized philanthropic assistance of the sick, destitute, or unfortunate." Psychiatric social work is defined as “social work with cases of mental dis order." According to the current (1955) report (entitled Findings) of the Commission on Psychology of the Conference of Psychotherapy and Counseling of the New York Academy of Science, there are 13,000 members of the profession of psychology at this time. Of this number, 5,000 are working in clinical areas, half in academic work (teaching or research), others in hospitals, churches, schools, correctional institutions. About 400 are practicing psychotherapy as private counselors. The same source notes that "Psychotherapy, historically, has fallen in the realms of religion, philosophy and education." "During the last decades of the 19th century, American psychologists concentrated on the experimental, objective study of behavior, hence the accent on research methods and techniques in training and professional work * Applied psychology, the report points out, then developed as the attempt to use |