The double life of a psychiatrist: role changes between hospital and office.

There is a tension in the life of a psychiatrist who combines inpatient work with the practice of outpatient psychotherapy. The tension is not a new one, but it was once more easily ignored and did not actively interfere with a young psychiatrist gaining comfort with his or her skills as a psychotherapist. A decade ago, the socially dominant (if erroneous) image of a psychiatrist was someone who practiced psychotherapy. It was seen as the core of what a psychiatrist did. If a psychiatrist was interested in psychotherapy, he might wonder how other activities affected this core identity, but the goal of defining a professional identity around the practice of psychotherapy was relatively straight-forward. The situation is very different today. The change is due largely to two related factors: the major advances in biological psychiatry and the dramatic increase in nonpsychiatrist psychotherapists. Most psychiatric residents today either see their primary identity as based clearly on biological treatment, or else they are left feeling a bit confused. Being a psychotherapist no longer seems central to being a psychiatrist. The practice of psychotherapy therefore no longer provides a clear sense of professional identity. Yet many psychiatric residents are interested in psychotherapy and will be doing it throughout their careers. The question of how to do so comfortably while pursuing other psychiatric activities has a renewed urgency. A first step is to clarify the nature of the tension.