Viederman: How did you decide to become a psychoanalyst?
MacKinnon: When I started my psychiatric residency in 1951, psychoanalysis was at the height of its popularity. The most intellectually stimulating teachers were analysts. If one was interested in the mind and its inner workings and wanted to seriously think about what one did and what it meant, one sought psychoanalytic training. The writings of Freud and other analysts offered deeper insights into human behavior. Much has changed today, yet in some ways I believe that is still true. What I hope to accomplish these next five years is to persuade an increasing number of people that psychoanalysis is still relevant and that our future is a bright one. Toward that end, psychoanalysis will continue to broaden understanding of the human mind and the ways in which it functions.
We compete for time in the resident's education today because there is a much broader body of knowledge that competes for the resident's attention. Today's resident receives only an introduction to psychoanalytic thought, and many residency programs have almost lost contact with psychoanalytic ideas altogether. Many alternative theories that residents are trying to learn, such as cognitive and behavioral approaches, can be examined and understood from a psychoanalytic vantage point. Wherever something happens between a patient and a doctor, psychoanalysis provides a rich perspective on the meaning of the interaction, irrespective of the interviewer's theoretical orientation.
I do not believe that it will be the behavioral or the cognitive therapist who will succeed in tying together an understanding of all the patient material and different clinical approaches to which residents are exposed. Psychoanalysis offers the most complete theory we have of human behavior and of the mind. It is my view that in due time psychoanalytic understanding will encompass all of these other disciplines and will provide a unified model of the mind. Behavioral and cognitive techniques won't be defined as psychoanalytic therapy, but they will be defined as techniques that can be understood through a psychoanalytic model of the mind.
One of our major challenges it to teach psychiatric residents that psychoanalytic training, per se, is still relevant to their clinical psychiatric work. Psychoanalysts are no longer defined by how many hours they spend treating patients on the couch four or five time a week but rather by how they understand all of their patients, including those in supportive therapies and analytic psychotherapies. Timewise, formal psychoanalysis might be only a portion of their work week, but the psychoanalytic frame of reference will influence how they conduct a consultation, do liaison work with other medical specialties, teach students, understand literature and art, etc.
Viederman: What you are saying is that psychoanalytic education broadens one's understanding of all aspects of the relationship between psychiatrist and patient, as well as one's general understanding of human behavior.
MacKinnon: Absolutely, and of oneself as well. Psychoanalytic theory is in the process of expansion and it is being influenced by contributions from neurobiology, cognitive psychology, and social learning theory that broaden our understanding of human behavior. These developments show that psychoanalysts will not become “organ specialists” with a frame of reference that focuses only on unconscious mental life. Psychoanalytic theory can contribute a greater understanding of the mechanisms of health and of the homeostatic means by which it is preserved.
Viederman: You're optimistic about how this might be accomplished.
MacKinnon: I think one of the things that make psychoanalysis exciting for young people is the idea of new research being done. By that, I mean new research that's relevant and understandable to nonanalysts as well as the psychoanalytic community. Much of past and current analytic research has focused on case reports and the study of psychoanalytic process. This always leads to more data than the researchers can manage, and projects tend to get bogged down. Further, critiques of research methodology have left the broader scientific community dissatisfied with such efforts. If we initiate smaller projects that will not attempt to solve all problems in one massive study, we have a better chance of producing research the rest of the field will respect.
Viederman: Roger, are you saying that process research isn't valuable?
MacKinnon: No, I'm not saying it isn't valuable, but I am saying that what we need right now is some prospective outcome research that demonstrates that psychoanalysis is effective. To accomplish that you need valid and reliable instruments of measurement that will be respected by the scientific community. Validity and reliability studies are essential preparatory steps to measuring both clinical outcome and analytic outcome. This is work that psychoanalysts are not traditionally trained to do, and I think we have to reach outside of psychoanalysis proper to find the people with the research knowledge, training, and skills who can help us in doing work that will produce the kind of information we are seeking.
Viederman: So one aspect of your research plan is to initiate a team effort.
MacKinnon: First you must have a team, and you need research scientists who are sympathetic to what we do, as well as being aware of the research problems with which psychoanalysts have struggled previously. This is one of the advantages Columbia enjoys as part of a major department of psychiatry in which research is a prominent mission, and where there are people who have the skills to develop the instruments and to do the validity and reliability studies that provide assurance that we are measuring what we think we're measuring and that can achieve results reproducible by other groups.
Viederman: What have you actually done to implement this research?
MacKinnon: Well, we have a research Advisory Committee that is quite eclectic and of a heterogeneous scientific background. We have several analysts on the committee, three with extensive research backgrounds: Herb Schlesinger, Otto Kernberg, and John Oldham. Myron Hofer is a renowned biological researcher with an interest in psychodynamic psychiatry. Bob Spitzer and Andy Shodol have agreed to help us and are devoting serious time to this endeavor. We meet regularly, we have a work group, and they are reviewing the research that is currently going on. The chair of this committee is Steve Roose, who in addition to being an analytic graduate with an active analytic practice is Chief of the Depression Research Unit and Co-Director of the Late Life Depression Research Clinic. Other members are Wayne Myers, an experienced analyst with a longstanding interest in psychoanalytic
research, and Sam Perry, who has an extensive research background as well as a psychoanalytic practice and is now Associate Chairman for Research in the Cornell Department of Psychiatry.
Viederman: You have a good committee here. Now, what have you commissioned them to do?
MacKinnon: We are trying to stimulate interest in research and we have several initiatives. Steve Roose is also a member of the Curriculum Committee, so we just completed a review of the curriculum to see where critical thinking can be more sharply focused. I believe that research can be stimulated by more scholarly examination of the underlying concepts and observations upon which our fundamental hypotheses are built. We can teach how to examine data. We are working toward one or more prospective outcome studies, but first we must plan the steps we need to take in order to mount such a major undertaking. We must systematically evaluate all the instruments currently available to determine their strengths and weaknesses. We would also be interested in developing an inter-institute project for our final study once some of the preparatory work is completed. Prospective psychoanalytic outcome studies will take a long time, as we have to follow a significant number of cases.
Viederman: I gather, then, that you believe psychoanalysis requires special instruments of measurement?
MacKinnon: I believe it does, and we may have to develop our own. But I don't think psychoanalysts can develop them by themselves any more than can research psychiatrists lacking psychoanalytic knowledge. This is truly an area in which we need to cooperate.
Viederman: Have you any specific plans to encourage a research atmosphere?
MacKinnon: Well, one of the things we have planned is to introduce research seminars, two or three times a year, for the entire student body and all faculty who are interested. The seminars would provide an opportunity for researchers to present work in progress. We are not the only institute to recognize the timeliness and importance of this effort. Judy Kantrowitz in Boston is doing interesting studies on the subject of the patient/analyst match. she is studying how similarities and differences of cultural background and life experience of the patient and the analyst influence outcome. The Chicago Psychoanalytic Institute has just completed a survey of all institutes of The American and collated a catalogue of every project currently underway in this country. The incentive for students and younger colleagues would be expert consultation, criticism, and help that would improve their analytic work. As you know, the first thing I did as director at Columbia was to form a curriculum study group—Arnold Cooper, Roy Schafer, Otto Kernberg, and yourself—to consider the ideal psychoanalytic curriculum for the Nineties. The committee has extensive experience in psychoanalytic education, and its report is currently being reviewed by our faculty and student body. The current Curriculum is largely a product of ten years of devoted work and continuing refinement by Helen Meyers. She has reviewed the Cooper report in great detail and has made many helpful suggestions and recommendations. All of this is being taken under advisement by our new curriculum committee, chaired by Betsy Auchincloss. The committee has agreed that research is a vital part of the future of psychoanalysis. Although we have concluded that a research mentality is best taught through individual courses and not simply through a course in research methodology, there is no reason we shouldn't offer a separate elective course in research techniques for any who are interested. Nevertheless, the idea of critical thinking is something that really has to transcend all the courses, as that is the principle on which all research rests.
Viederman: What do you hope to accomplish with this emphasis?
“Psychoanalytic theory can contribute a greater understanding of the mechanisms of health and of the homeostatic means by which it is preserved.”
MacKinnon: I hope to encourage more young people to be interested in psychoanalytic training and research. The most experienced researchers on our committee feel that new ideas and inspiration come from young people, and that we must encourage and support them. The senior researchers will teach them what they need to know about methodology and special techniques as they go along. Another idea is to form a Psychoanalytic Journal Club for candidates, with a senior researcher as leader, to help them understand how to read a research paper from a critical point of view.
Viederman: What are the financial demands of this research?
MacKinnon: Actually, at the beginning they will not be that great. We will need money to hire a statistician. Fortunately, we have free consultation from experts in the Department of Psychiatry, and we have 40 candidates and 150 active faculty members, with more faculty added every year. All of these faculty members want to do something that will make a difference. When they originally came into psychiatry most of them said, “I'd like to do a little teaching, a little practice, and a little research.” This is one of the few areas where anyone can actually do “a little” research, although they can't design it. The actual designers have to have a more significant commitment and greater expertise. Nevertheless, others can participate in a more limited way, and a number will want to do that. Those who want to acquire analytic experience might accept lower-fee referrals of analyzable patients who might become part of the study cohort.
Viederman: So one way to reawaken interest in psychoanalysis is to stimulate research. Are there other ways?
MacKinnon: We have just initiated a Psychotherapy Division designed to compensate for the many residency programs that today offer little or no teaching of psychodynamics or experience in psychoanalytically oriented psychotherapy. I think we can do a service, both to the field of psychiatry and to ourselves, by offering extension courses to people after their residencies. Don Meyers, who chairs our Extension Division, has asked our most exciting and committed teachers to put together a one-year curriculum in which the theory of behavior and the clinical theory of psychoanalytically oriented psychotherapy is taught. Each psychiatrist will have the choice of one or two individual supervisors for cases seen in private practice. It is our anticipation that the enthusiasm this generates will lead to a decision, in some, to seek further training in psychoanalysis. It will certainly help the others to become more enlightened in their clinical work and in their attitude toward psychoanalysis. I view this in a dual way. I think if you are performing a service to the professional community, and you do it effectively, a certain number of people will identify with you and will want to become a member of your group. Among the larger group who do not go on for psychoanalytic training, many will eventually hold jobs of importance in departments of psychiatry and will be in a position to decide whether to include dynamic psychiatry in their programs. Some years ago I was assigning analytic psychotherapy supervisors to psychiatric residents at Columbia, and one of the chief residents, who was helping me do this, asked, with regard to one of our residents who was an experienced neurobiologist, “Why are you giving him one of our best analytic supervisors?” I replied, “That is exactly why I am giving him Dr. X, because he will probably be a department chairman and it will be in his hands whether or not there is any
dynamic psychiatry in his department.“ Everyone we influence in a positive way has an opportunity to do something for psychoanalysis in return.
Viederman: Will this new program be open to psychologists?
MacKinnon: We have just started to train psychologists at the Psychoanalytic Center. There are some psychologists who otherwise qualify for psychoanalytic training but lack experience in one of the areas we require. It is for this group of psychologists who have applied for full training at Columbia that we will offer remedial programs.
Viederman: On that note, could you outline the requirements for training psychologists and how they were arrived at?
MacKinnon: Well, first we looked at the requirements for psychiatric residency training as put forth by the American Board of Psychiatry and Neurology. They require training in six major areas. We thought that if psychologists had training in those same six areas, and had been taught in an accredited internship over a two-year period in the presence of psychiatric residents, there would be every reason to expect them to be at the same level as our psychiatrist candidates. Preliminary reports from our teachers confirm our hypothesis. In addition, some psychologist candidates have special expertise our psychiatric candidates lack, and I expect that that will enrich the field.
Viederman: You obviously feel that we should strive to maintain our connections with psychiatry and medicine.
MacKinnon: We need to strengthen our connections with psychiatry, because that is where most of our future trainees and research workers are to be found. I believe that the key processes in career choice are identification and intellectual interest. I have seen many applicants whose experience in medical school or during residency stimulated their interest by providing them an opportunity to watch psychoanalysts at work, to listen to their description of treatments, and to appreciate the level of insight provided. Psychoanalysts, particularly M.D. psychoanalysts, must devote more time, interest, and energy to the teaching of medical students and residents. Psychoanalytic mentors should be chosen carefully, and the availability of these relationships could be programmatically structured, though serendipity obviously plays a role. One can have an important influence as a mentor at critical periods in education. This influence can last a lifetime, and identification plays an important role. This is one of the few residencies in the country where someone in my position works with residents intensively for three consecutive years. In addition, I am an active participant on the selection committee for residents for our program. I wouldn't dream of giving this activity up now that I am Director of the Psychoanalytic Center. The vast majority of our residents who apply for analytic training apply only to Columbia. This clearly speaks of an experience in the Department. They receive long-term, analytically oriented therapy supervision beginning in their first year, with a case they are ale to follow for the entire three years. It is the only program in the country, to the best of my knowledge, that does this. I want them to have the awareness of intrapsychic life and conflict, in the context of longitudinal experience with patients early in their training. The vast majority of our supervisors are graduates of our own Psychoanalytic Center. This experience has a profound effect on the residents. Psychoanalysts must be visible if they are to make a favorable impression on those they hope will joint them in a commitment to psychoanalysis.