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Dr. Kubie states a training problem of first importance when he reminds us that the psychiatry resident is exposed immediately to clinical responsibilities for which he has little preparation. With this, your discussant is fully in agreement.1,2,3 For the obvious fact is usually overlooked, that five or six years of medical school and internship provide intensive training in clinical and preclinical medicine, but little training and experience in those psychological observations which are basic in psychiatry. This should be recognized as fundamental in planning a residency program. It never is.
Yet I am not in agreement with some of the proposals which Dr. Kubie derives from this major premise. Thus, Dr. Kubie thinks of a series of conflicts while the individual is developing that lead to more and more complex neurotic symptomatology whose breakdown produces psychosis. But I conceive of healthy, neurotic, and psychotic modes of thought and adaptation as active in the personalities of all individuals at all stages of development;4 breakdown of neurotic adjustment is indeed important in the outbreak of some psychoses, but I do not consider it primary in all.
Secondly, Dr. Kubie thinks that because the newness and incomprehensibility of psychotic thought for the beginner in psychiatry is so difficult, his training program should be reformed by providing several years of experience with psychoneurotic patients before he begins to tackle psychotic cases. My own experience is that while some students do much better at first with neurotic patients, there is also a goodly percentage of beginners who feel more at home, more “objective” and more interested at first with psychotics. Indeed the lives of senior American analysts of our generation show their interest in psychiatry had first been awakened by learning to understand a delusion or hallucination by the study of the patient's mental content. My own opinion as to whether it is better to begin with neurotic or in-patient c