CO\l\It\lCTIO\S
BRiEF
Controversy BY LORRIN
in Medicine M. KORAN,
and
Psychiatry
M.D.
Factual and ethical controversies confront physicians medicine as well as in psychiatry. Jfpsychiatrists can impart a perspective on these controversies and their growth-stimulating
quality
to medical
students
in
and
thereby increase their tolerancefor uncertainty, they will aid them in becoming better physicians and wi//perhaps also remove one reasonfor their disinterest in psychiatry.
the word stems from the Latin roots verand contra, to turn against. Some of my medical students have claimed that they turned against a career in psychiatry because the field is so marked by controversy. They seemed to minimize the extent of controversy in other fields of medicine. Having paid the price of becoming a physician with a specialty, I could only point to the growth-stimulating quality of controversies and refer to the medical controversies that were debated when I was in school. Since the grounds for many of these controversies (e.g., when to give anticoagulants to myocandial infarction patients) have been shifted by new data, my comments about the ubiquity of medical controversy were often seen as quaint but uncompelling. I have attempted, therefore, to refresh my knowledge of controversics in medicine and wish to shame what I have learned with other psychiatrists who teach medical students. Perhaps by being more current, we can provide students with a perspective on controversies in psychiatry that will dissuade them from using this nationalization to avoid the field. CONTROVERSY:
to
“
‘ ‘
facts and values. In psychiatry the etiologies of most disorders are unknown; the exceptions are some forms of mental retardation, some organic brain syndromes, and by definition, the transient situational disturbances. In medicine the etiologies of many diseases are known, particularly those of infectious diseases, nutritional diseases, and diseases due to toxins on trauma. But medicine also confronts widespread diseases of unknown etiology, for example, most forms of cancer, atherosclerosis, most cases of arterial hypertension, diabetes mcllitus, multiple sclerosis, the “collagen” diseases (e.g., systemic lupus emythematosis), glomenuloneph ntis, ulcerative colitis, polycythemia vera, postmenopausal osteoporosis, and rheumatoid arthritis ( I ). The etiology of a host of rarer disorders also remains unknown.
CONTROVERSIES
ABOUT
It is in diagnosis that medicine has most cleanly become a science while psychiatry has remained an ant. The advances in medical diagnosis can be attributed primarily to the development of sensitive and specific laboratory tests that provide repeatable (reliable) data (2). Although it is not widely appreciated by psychiatrists and nonpsychiatric physicians, both medicine and psychiatry lack explicit diagnostic criteria and decision rules for diagnosing many diseases. Feinstein (3) has described the situation in medicine as follows: With
the
rare
and
CONTROVERSIES
ABOUT
rheumatoid exist today for convert various
ETIOLOGY
In medicine, as in psychiatry, controversies etiologies, diagnoses, and treatments and
Dr.
Koran is Director, Undergraduate of Psychiatry and Behavioral York at Stony Brook, Stony Brook, ment
surround involve both
Training in Psychiatry, Science, State University N.Y. I l794.
The
Departof New
author wishes to acknowledge the helpful comments of Drs. Robert Derman, Eli Rubinstein, and Sherman Kieffer, who read this paper in manuscript.
1064
Am J Psychiatry
132:10,
October
1975
DIAGNOSIS
exceptions arthritis, any of the combinations
[history,
physical,
dence
into diagnostic
rheumatic
fever
rigorous classifications and inferences of “clinico-techno-morphic”
criteria that
already
cited
for
no standardiLed
laboratory,
designations.
and
histopathological]
cvi-
(p. 98)
Feinstein goes on to characterize the diagnostic criteria established by authoritative committees for candiovascuIan and pulmonary diseases as “discursive rather than precise” and as lacking definite decision rules. The same criticisms have been leveled at the American Psychiatric Association’s diagnostic manual (4, 5). The efforts of individual psychiatric research teams to remedy these defi-
BRIEF
COMMUNICATIONS
ciencies in psychiatric diagnostic methods have remained primarily local in effect (6, 7). Unfortunately, psychiatric diagnosis depends largely on the psychiatrist’s ability to perceive evanescent behaviors that lack the somatic substantiality and persistence of the ammhythmias, murmurs, hypemnesonances, dullnesses, and masses available to the nonpsychiatnic clinician. On the other hand, even welltrained internists show a surprising degree of disagreement in diagnosing cardiac disease from dcctrocardiognams (8, 9) on physical examination (10), in diagnosing pulmonary emphysema from a physical cxamination (1 1, 12), and in differentiating benign from malignant gastric ulcers on the basis of clinical, X-ray, and laboratory data (13).
need treatment to prevent gradual development of renal damage? 9. Should solitary thyroid nodules be managed mcdically on surgically? 10. What arc the indications for medical versus sumgical treatment in patients with massive pulmonary embolism? The absence of conclusive evidence regarding these questions often results in strong emotions in proponents of each side, much as in the case of psychotherapists of different schools. Additional differences of opinion megarding medical treatments can be appreciated by comparing successive yearly editions of Current Therapy(l7).
CONTROVERSIES
CONTROVERSIES
ABOUT
TREATMENT
The resolution ofcontrovensies regarding treatment mequines data on response rates (benefits) and side effects (risks) in defined populations (indications). In psychiatry adequate data have been accumulated in the past 20 years to justify new pharmacological treatments for schizophmcn ia, man ic-depressive illnesses, endogcnous depnession, and anxiety states (14). In medicine new phanmacological treatments for leukemias, pneumonias, cardiac ammhythmias, and congestive heart failure (to name but a few) have been introduced within the same period (1). Advances in nonphammacological treatments have also been made, e.g., the introduction of behavior thenapies (15), renal dialysis, and cardiopulmonary bypass techniques. However, the indications, contraindications, and risk-benefit ratios of hundreds of therapeutic interventions in medicine and psychiatry remain to be defined. The data and arguments surrounding many controversial medical treatments have been well summarized by Ingelfinger and associates (16). Among the major questions debated are the following: I. Does an intensive exercise program similar to that used in preparing for athletic events decrease recurrences of myocamdial infarction and prolong life in myocandial infarction patients? 2. Does restricted diet and other means of lowering the levels of pre-beta and beta-lipoproteins (including cholestenol) lower the incidence of coronary atherosclerosis? 3. Do attempts to control blood glucose levels help prevent the neumopathic and microangiopathic complications of diabetes? 4. Is a rigidly bland diet necessary to aid the healing of duodenal ulcers? 5. Does aggressive combination chemotherapy of Hodgkin’s disease prolong survival compared with the optimal use of a single drug? 6. What is the optimal dose, dose mate, and field size for radiation therapy in particular stages of Hodgkin’s disease? 7. Do the benefits of long-term administration of admcnal steroids to patients with rheumatoid arthritis on asthma outweigh the risks? 8. Which young women with asymptomatic bacteniunia
ABOUT
VALUES
Regardless of their specialty, all physicians face ethical dilemmas in their practices. Frequently these involve balancing the needs and rights of the individual patient against those of the community. Ethical controversies and dilemmas in psychiatry include the conditions under which civil commitment is warranted (18, 19); the patient’s might to receive treatment (20) or to refuse it (21); and when, if ever, to use psychosurgery to treat functional mental disorders (22). In medicine the dilemmas include whether to withhold treatment from deformed children who would otherwise not survive long aften birth (23); determining the criteria for choosing recipients of organ transplants (24); the patient’s right to be informed about his condition, for example, in the case of a dying patient (25); and when, if ever, to withhold treatment from a dying patient (26). In both medicine and psychiatry, close attention is being given to the issues of informed consent and risk/benefit ratios in human cxpenimentation (27) and confidentiality of patient communications (28).
CONCLUSIONS
Thus factual and ethical controversies confront all physicians. This can be pointed out when students mepmoach us about the extent of psychiatric controversies. More importantly, our students can be helped to recognize that controversy accompanies a healthy intellectual life and stimulates spiritual and intellectual growth. Controvensy is a signpost marking the limits of our understanding and signals frontiers where research is needed. Intelligent controversy is a cutting edge whereby knowledge expands into the territory of ignorance. As Louis Pasteur wrote in The Germ Theory and Its Applications to Medicine and Surgery, I desire Little
temptuous ciple,
judgment and criticism upon all my contributions. of frivolous or prejudiced contradiction, conof that ignorant criticism which doubts on prin-
tolerant
I welcome
has a method motto “More
AmJ
with
open
arms
the
in doubting and whose light.” (29, p. 68)
Psychiatry
132.10,
militant
attack
rule of conduct
October
1975
which
has the
1065
BRIEF
COMMUNICATIONS
If we can convey this to our students and thereby increase their tolerance for uncertainty, we will have aided them in becoming better physicians. Perhaps we will also have removed one rationalization for their disinterest in psychiatry.
REFERENCES I. Beeson
PB, McDermott W: Textbook of Medicine. Philadelphia, WB Saunders Co. 1971, pp 491-510, 959-968, 1066-1083, 1534I 546 2. Vecchio T: Predictive value of a single diagnostic test in unselected populations. N EnglJ Med274:ll7l-1I73, 1966 3. Feinstein AR: Clinical Judgment. Baltimore, Williams & Wilkins
Co. 1968 4. American 5.
6. 7.
8.
Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 2nd ed. Washington, DC, APA, 1968 Jackson B: The revised Diagnostic and Statistical Manual of the American Psychiatric Association. Am J Psychiatry 127:65-73, 1970 Feighner JP, Robins E, Guze 5, et al: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 26:57-63, 1972 Abrams R, Taylor MA: First rank symptoms, severity of illness and treatment response in schizophrenia. Compr Psychiatry 14:353-355, 1973 Gorman P, Calatayud J, Abraham S. et al: Observer variation in interpretation of the electrocardiogram. Med Ann DC 33:97-99,
tilatory function in obstructive lung disease. Ann Intern Med 62:477-485, 1965 13. Wilson WJ, Templeton AW, Turner AH Jr. et al: The computer analysis and diagnosis of gastric ulcers. Radiology 85: 1064 1073, 1965 14. Freedman AM, Kaplan HI, Sadock BJ (eds): Comprehensive Textbook of Psychiatry, 2nd ed, vol 2. Baltimore, Williams & Wilkins Co. 1975, pp 1921-1968, 1982 1986 15. Wolpe J: The Practice of Behavior Therapy. New York, Pergamon Press, l969 16. Ingellinger FJ, Ebert RV, Finland M, et al (eds): Controversy in Internal Medicine II. Philadelphia, WB Saunders Co. l972 I7. Conn HF: Current Therapy. Philadelphia, WB Saunders Co 18. Dershowitz A: Constitutional dimensions of civil commitment, in Drug Use in America, Appendix, vol IV. Edited by the National Commission on Marijuana and Drug Abuse. Washington, DC, US Government Printing Office, 1973, pp 428 --437 19. Ennis BJ: Prisoners of Psychiatry. New York, Harcourt Brace Jovanovich, 1972 20. Robitscher J: Courts, state hospitals, and the right to treatment. Am J Psychiatry 129:298-304, 1972 2 1 Halleck S: Legal and ethical aspects of behavior control. Am J Psychiatry l3l:38I-385, l974 22. Valenstein E: Brain Control. New York, John Wiley & Sons, 1974 23. Motulsku AG: Brave new world’ Science 185:653-663, l974
.
24.
25. 26.
1964
9.
Simonson E, Tuna N, Okamoto N, et al: Diagnostic accuracy of the vectorcardiogram and electrocardiogram. A cooperative study. AmiCardiol 17:829-878, 1966 10. Raftery EB, Holland WW: Examination of the heart: an investigation into variation. Am J Epidemiol 85:438-444, 1967 I 1. Fletcher CM: The clinical diagnosis of pulmonary emphysema. Proc Soc Med 45:577-584, 1952 12. Schneider I, Anderson A Jr Correlation of clinical signs with yen-
1066
Am
J Psychiatry
132:10,
October
1975
27. 28.
29.
Moore
F: Transplant. New York, Simon & Schuster, 972 Fatal illness: should the patient be told? Medical Insight 5(II):2023, 1973 Manning B: Legal and policy issues in the allocation of death, in The Dying Patient. Edited by Brim OG Jr. Freeman HE, Levine S. et al. New York, Russell Sage Foundation, 1970, pp 253-274 Romano J: Reflections on informed consent. Arch Gen Psychiatry 3&.l29-135, 1974 Dubey J: Confidentiality as a requirement of the therapist: technical necessities for absolute privilege in psychotherapy. Am J Psychiatry 131:1093-1096. 1974 Strauss MB (ed): Familiar Medical Quotations. Boston, Little, Brown and Co. 1968
Levy NB:
BRiEF
Controversy BY LORRIN
in Medicine M. KORAN,
and
Psychiatry
M.D.
Factual and ethical controversies confront physicians medicine as well as in psychiatry. Jfpsychiatrists can impart a perspective on these controversies and their growth-stimulating
quality
to medical
students
in
and
thereby increase their tolerancefor uncertainty, they will aid them in becoming better physicians and wi//perhaps also remove one reasonfor their disinterest in psychiatry.
the word stems from the Latin roots verand contra, to turn against. Some of my medical students have claimed that they turned against a career in psychiatry because the field is so marked by controversy. They seemed to minimize the extent of controversy in other fields of medicine. Having paid the price of becoming a physician with a specialty, I could only point to the growth-stimulating quality of controversies and refer to the medical controversies that were debated when I was in school. Since the grounds for many of these controversies (e.g., when to give anticoagulants to myocandial infarction patients) have been shifted by new data, my comments about the ubiquity of medical controversy were often seen as quaint but uncompelling. I have attempted, therefore, to refresh my knowledge of controversics in medicine and wish to shame what I have learned with other psychiatrists who teach medical students. Perhaps by being more current, we can provide students with a perspective on controversies in psychiatry that will dissuade them from using this nationalization to avoid the field. CONTROVERSY:
to
“
‘ ‘
facts and values. In psychiatry the etiologies of most disorders are unknown; the exceptions are some forms of mental retardation, some organic brain syndromes, and by definition, the transient situational disturbances. In medicine the etiologies of many diseases are known, particularly those of infectious diseases, nutritional diseases, and diseases due to toxins on trauma. But medicine also confronts widespread diseases of unknown etiology, for example, most forms of cancer, atherosclerosis, most cases of arterial hypertension, diabetes mcllitus, multiple sclerosis, the “collagen” diseases (e.g., systemic lupus emythematosis), glomenuloneph ntis, ulcerative colitis, polycythemia vera, postmenopausal osteoporosis, and rheumatoid arthritis ( I ). The etiology of a host of rarer disorders also remains unknown.
CONTROVERSIES
ABOUT
It is in diagnosis that medicine has most cleanly become a science while psychiatry has remained an ant. The advances in medical diagnosis can be attributed primarily to the development of sensitive and specific laboratory tests that provide repeatable (reliable) data (2). Although it is not widely appreciated by psychiatrists and nonpsychiatric physicians, both medicine and psychiatry lack explicit diagnostic criteria and decision rules for diagnosing many diseases. Feinstein (3) has described the situation in medicine as follows: With
the
rare
and
CONTROVERSIES
ABOUT
rheumatoid exist today for convert various
ETIOLOGY
In medicine, as in psychiatry, controversies etiologies, diagnoses, and treatments and
Dr.
Koran is Director, Undergraduate of Psychiatry and Behavioral York at Stony Brook, Stony Brook, ment
surround involve both
Training in Psychiatry, Science, State University N.Y. I l794.
The
Departof New
author wishes to acknowledge the helpful comments of Drs. Robert Derman, Eli Rubinstein, and Sherman Kieffer, who read this paper in manuscript.
1064
Am J Psychiatry
132:10,
October
1975
DIAGNOSIS
exceptions arthritis, any of the combinations
[history,
physical,
dence
into diagnostic
rheumatic
fever
rigorous classifications and inferences of “clinico-techno-morphic”
criteria that
already
cited
for
no standardiLed
laboratory,
designations.
and
histopathological]
cvi-
(p. 98)
Feinstein goes on to characterize the diagnostic criteria established by authoritative committees for candiovascuIan and pulmonary diseases as “discursive rather than precise” and as lacking definite decision rules. The same criticisms have been leveled at the American Psychiatric Association’s diagnostic manual (4, 5). The efforts of individual psychiatric research teams to remedy these defi-
BRIEF
COMMUNICATIONS
ciencies in psychiatric diagnostic methods have remained primarily local in effect (6, 7). Unfortunately, psychiatric diagnosis depends largely on the psychiatrist’s ability to perceive evanescent behaviors that lack the somatic substantiality and persistence of the ammhythmias, murmurs, hypemnesonances, dullnesses, and masses available to the nonpsychiatnic clinician. On the other hand, even welltrained internists show a surprising degree of disagreement in diagnosing cardiac disease from dcctrocardiognams (8, 9) on physical examination (10), in diagnosing pulmonary emphysema from a physical cxamination (1 1, 12), and in differentiating benign from malignant gastric ulcers on the basis of clinical, X-ray, and laboratory data (13).
need treatment to prevent gradual development of renal damage? 9. Should solitary thyroid nodules be managed mcdically on surgically? 10. What arc the indications for medical versus sumgical treatment in patients with massive pulmonary embolism? The absence of conclusive evidence regarding these questions often results in strong emotions in proponents of each side, much as in the case of psychotherapists of different schools. Additional differences of opinion megarding medical treatments can be appreciated by comparing successive yearly editions of Current Therapy(l7).
CONTROVERSIES
CONTROVERSIES
ABOUT
TREATMENT
The resolution ofcontrovensies regarding treatment mequines data on response rates (benefits) and side effects (risks) in defined populations (indications). In psychiatry adequate data have been accumulated in the past 20 years to justify new pharmacological treatments for schizophmcn ia, man ic-depressive illnesses, endogcnous depnession, and anxiety states (14). In medicine new phanmacological treatments for leukemias, pneumonias, cardiac ammhythmias, and congestive heart failure (to name but a few) have been introduced within the same period (1). Advances in nonphammacological treatments have also been made, e.g., the introduction of behavior thenapies (15), renal dialysis, and cardiopulmonary bypass techniques. However, the indications, contraindications, and risk-benefit ratios of hundreds of therapeutic interventions in medicine and psychiatry remain to be defined. The data and arguments surrounding many controversial medical treatments have been well summarized by Ingelfinger and associates (16). Among the major questions debated are the following: I. Does an intensive exercise program similar to that used in preparing for athletic events decrease recurrences of myocamdial infarction and prolong life in myocandial infarction patients? 2. Does restricted diet and other means of lowering the levels of pre-beta and beta-lipoproteins (including cholestenol) lower the incidence of coronary atherosclerosis? 3. Do attempts to control blood glucose levels help prevent the neumopathic and microangiopathic complications of diabetes? 4. Is a rigidly bland diet necessary to aid the healing of duodenal ulcers? 5. Does aggressive combination chemotherapy of Hodgkin’s disease prolong survival compared with the optimal use of a single drug? 6. What is the optimal dose, dose mate, and field size for radiation therapy in particular stages of Hodgkin’s disease? 7. Do the benefits of long-term administration of admcnal steroids to patients with rheumatoid arthritis on asthma outweigh the risks? 8. Which young women with asymptomatic bacteniunia
ABOUT
VALUES
Regardless of their specialty, all physicians face ethical dilemmas in their practices. Frequently these involve balancing the needs and rights of the individual patient against those of the community. Ethical controversies and dilemmas in psychiatry include the conditions under which civil commitment is warranted (18, 19); the patient’s might to receive treatment (20) or to refuse it (21); and when, if ever, to use psychosurgery to treat functional mental disorders (22). In medicine the dilemmas include whether to withhold treatment from deformed children who would otherwise not survive long aften birth (23); determining the criteria for choosing recipients of organ transplants (24); the patient’s right to be informed about his condition, for example, in the case of a dying patient (25); and when, if ever, to withhold treatment from a dying patient (26). In both medicine and psychiatry, close attention is being given to the issues of informed consent and risk/benefit ratios in human cxpenimentation (27) and confidentiality of patient communications (28).
CONCLUSIONS
Thus factual and ethical controversies confront all physicians. This can be pointed out when students mepmoach us about the extent of psychiatric controversies. More importantly, our students can be helped to recognize that controversy accompanies a healthy intellectual life and stimulates spiritual and intellectual growth. Controvensy is a signpost marking the limits of our understanding and signals frontiers where research is needed. Intelligent controversy is a cutting edge whereby knowledge expands into the territory of ignorance. As Louis Pasteur wrote in The Germ Theory and Its Applications to Medicine and Surgery, I desire Little
temptuous ciple,
judgment and criticism upon all my contributions. of frivolous or prejudiced contradiction, conof that ignorant criticism which doubts on prin-
tolerant
I welcome
has a method motto “More
AmJ
with
open
arms
the
in doubting and whose light.” (29, p. 68)
Psychiatry
132.10,
militant
attack
rule of conduct
October
1975
which
has the
1065
BRIEF
COMMUNICATIONS
If we can convey this to our students and thereby increase their tolerance for uncertainty, we will have aided them in becoming better physicians. Perhaps we will also have removed one rationalization for their disinterest in psychiatry.
REFERENCES I. Beeson
PB, McDermott W: Textbook of Medicine. Philadelphia, WB Saunders Co. 1971, pp 491-510, 959-968, 1066-1083, 1534I 546 2. Vecchio T: Predictive value of a single diagnostic test in unselected populations. N EnglJ Med274:ll7l-1I73, 1966 3. Feinstein AR: Clinical Judgment. Baltimore, Williams & Wilkins
Co. 1968 4. American 5.
6. 7.
8.
Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 2nd ed. Washington, DC, APA, 1968 Jackson B: The revised Diagnostic and Statistical Manual of the American Psychiatric Association. Am J Psychiatry 127:65-73, 1970 Feighner JP, Robins E, Guze 5, et al: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 26:57-63, 1972 Abrams R, Taylor MA: First rank symptoms, severity of illness and treatment response in schizophrenia. Compr Psychiatry 14:353-355, 1973 Gorman P, Calatayud J, Abraham S. et al: Observer variation in interpretation of the electrocardiogram. Med Ann DC 33:97-99,
tilatory function in obstructive lung disease. Ann Intern Med 62:477-485, 1965 13. Wilson WJ, Templeton AW, Turner AH Jr. et al: The computer analysis and diagnosis of gastric ulcers. Radiology 85: 1064 1073, 1965 14. Freedman AM, Kaplan HI, Sadock BJ (eds): Comprehensive Textbook of Psychiatry, 2nd ed, vol 2. Baltimore, Williams & Wilkins Co. 1975, pp 1921-1968, 1982 1986 15. Wolpe J: The Practice of Behavior Therapy. New York, Pergamon Press, l969 16. Ingellinger FJ, Ebert RV, Finland M, et al (eds): Controversy in Internal Medicine II. Philadelphia, WB Saunders Co. l972 I7. Conn HF: Current Therapy. Philadelphia, WB Saunders Co 18. Dershowitz A: Constitutional dimensions of civil commitment, in Drug Use in America, Appendix, vol IV. Edited by the National Commission on Marijuana and Drug Abuse. Washington, DC, US Government Printing Office, 1973, pp 428 --437 19. Ennis BJ: Prisoners of Psychiatry. New York, Harcourt Brace Jovanovich, 1972 20. Robitscher J: Courts, state hospitals, and the right to treatment. Am J Psychiatry 129:298-304, 1972 2 1 Halleck S: Legal and ethical aspects of behavior control. Am J Psychiatry l3l:38I-385, l974 22. Valenstein E: Brain Control. New York, John Wiley & Sons, 1974 23. Motulsku AG: Brave new world’ Science 185:653-663, l974
.
24.
25. 26.
1964
9.
Simonson E, Tuna N, Okamoto N, et al: Diagnostic accuracy of the vectorcardiogram and electrocardiogram. A cooperative study. AmiCardiol 17:829-878, 1966 10. Raftery EB, Holland WW: Examination of the heart: an investigation into variation. Am J Epidemiol 85:438-444, 1967 I 1. Fletcher CM: The clinical diagnosis of pulmonary emphysema. Proc Soc Med 45:577-584, 1952 12. Schneider I, Anderson A Jr Correlation of clinical signs with yen-
1066
Am
J Psychiatry
132:10,
October
1975
27. 28.
29.
Moore
F: Transplant. New York, Simon & Schuster, 972 Fatal illness: should the patient be told? Medical Insight 5(II):2023, 1973 Manning B: Legal and policy issues in the allocation of death, in The Dying Patient. Edited by Brim OG Jr. Freeman HE, Levine S. et al. New York, Russell Sage Foundation, 1970, pp 253-274 Romano J: Reflections on informed consent. Arch Gen Psychiatry 3&.l29-135, 1974 Dubey J: Confidentiality as a requirement of the therapist: technical necessities for absolute privilege in psychotherapy. Am J Psychiatry 131:1093-1096. 1974 Strauss MB (ed): Familiar Medical Quotations. Boston, Little, Brown and Co. 1968
Levy NB:
