In an era in which neuroscience and psychopharmacology have grabbed center stage in American psychiatry, the teaching of psychodynamic concepts in psychotherapy has progressively been squeezed out of the core curriculum in U.S. residency training programs. Nevertheless, many psychiatry residencies retain a significant commitment to training residents in the use of long-term psychotherapy. David Coldberg, chair of the Subcommittee of Psychoanalytic Directors of Residency Training, an offshoot of The American's Committee on University and Medical Education (CUME), estimates that approximately half of all residency programs have some such commitment, with at least 30% having substantially developed programs in the area. A selective survey of these programs illustrates the role that psychoanalysts and psychoanalytic thinking continue to play in the training of American psychiatrists. These residencies are only a few of the many programs in which analysts are actively engaged in teaching and supervision.
The Baylor psychotherapy curriculum begins in the first postgraduate year (PGY-I) with an interviewing seminar jointly taught by a psychoanalyst and the department chair. In the second postgraduate year (PGY-II) two didactic experiences are provided concurrently over the first six months. One is an introduction to psychotherapy case conference, which residents refer to as the “empathy seminar.” This course helps residents identify and enhance their empathic abilities, learn to follow the patients associations, and recognize early manifestations of transference and resistance through structured exercises. The other seminar follows ten weeks of basic readings in psychotherapy with another ten featuring a videotaped demonstration of a long-term psychotherapy conducted by a supervising and training analyst from the Houston-Galveston Institute. At the conclusion of the experiential seminar, residents are assigned their first two psychotherapy cases.
The PGY-II psychopathology seminar is also taught from a psychodynamic perspective, with Gabbard's Psychodynamic Psychiatry in Clinical Practice the assigned text. In PGY-III residents increase their outpatient psychotherapy case load to six. They also attend a six-month seminar on individual psychotherapy led by a training analyst from Houston-Galveston. Finally, in the fourth year of training, residents attend a seminar on brief psychotherapy followed by an advanced seminar on psychotherapy. They continue with six psychotherapy cases while adding brief psychotherapy patients as well.
The Medical College of Wisconsin integrates psychoanalytic concepts throughout its four-year curriculum. Of the four training and supervising analysts in Milwaukee, three are full-time faculty, and the fourth, while not full-time, is heavily involved in residency education. One of the training analysts teaches an introduction to psychodynamics in the first postgraduate year. In PGY-II residents spend half their time at the Psychotherapy Center; designed specifically for outpatient therapy, it boasts superior soundproofing and its own records to ensure confidentiality. Residents are expected to carry ten or so cases in once-a-week exploratory psychotherapy. Two psychoanalytically trained or dynamically oriented supervisors are assigned to each resident. The focus is on intensive supervision of selected cases. Residents in the second year also take two yearlong seminars taught by training and supervising analysts. One is a developmentally oriented introduction to dynamic concepts and their application to the psychotherapeutic process; the other is an ongoing clinical seminar covering such basic issues as assessment, fees, transference, countertransference, and resistance.
In PGY-III and PGY-IV residents continue with selected cases of psychoanalytic psychotherapy. They are also expected to have some experience with more intensive psychotherapy conducted two or three times weekly. These cases continue to be supervised by a psychoanalytic or dynamically oriented psychotherapist. A training and supervising analyst teaches a seminar that takes up issues covered in the second year, now at a more advanced level with more sophisticated readings. The strong influence of psychoanalytic thinking in the residency is related to the presence of analysts in key administrative posts within the department, including the director of medical student education in psychiatry, the department co-chair, the vice chair responsible for clinical care throughout the department, and the chief psychiatrist at the Psychotherapy Center. The director of residency education is an analytic candidate.
Psychoanalytic concepts are at the core of the curriculum at the Karl Menninger School of Psychiatry, largely because of its intimate relationship with the Topeka Institute for Psychoanalysis, a department within the Menninger Clinic. The faculty of the Topeka Institute serves also as faculty within the School of Psychiatry. Residents are encouraged to pursue psychoanalytic training, and the Institute offers a sliding fee schedule to candidates in training. In the first postgraduate year a 26-week seminar, Introduction to Classical Psychoanalytic Theory, is required. The PGY-II didactic curriculum includes courses in psychodynamic psychiatry, long-term psychodynamic psychotherapy, diagnostic interviewing, and psychotherapy case selection. In addition to the didactic curriculum, residents must conduct individual psychotherapy during the second postgraduate year, with anywhere from two to four patients seen from one to three times per week under the supervision of faculty.
The PGY-III didactic curriculum at Menninger includes basics in child psychotherapy, topics in psychoanalytic psychotherapy (an advanced seminar that addresses psychotherapeutic work with narcissistic, borderline, and psychotic patients), a continuous case seminar, and group psychotherapy. At this stage five to ten hours of psychotherapy are required per week. In their final year, residents continue their psychotherapy case load while taking seminars in ego psychology and object relations theory, brief psychotherapy, and family and marital therapy. Throughout the four years, a majority of residents elect either personal analysis or a training analysis.
At Sheppard-Pratt, psychodynamic thinking and psychotherapy training are integral to the entire residency program. In past years a major activity of residents was long-term psychotherapy of inpatients. However, drastically reduced lengths of stay in the hospital, the result of aggressive utilization review by managed care and insurance companies over the past five years, have made training in psychodynamic psychotherapy a predominantly outpatient venture. In the first postgraduate year, residents take a six-month course covering the basics of psychodynamic theory, psychodynamic therapy, and normal development from a psychodynamic perspective. In the second year, residents begin to see long-term outpatients in dynamic psychotherapy under individual supervision. They are required to see five ongoing cases once or twice a week. The didactic curriculum includes a weekly seminar including a six-month survey of the various psychotherapies, followed by six months devoted to an in-depth understanding of object relations theory and the psychodynamic treatment of more severely disturbed patients.
PGY-III residents have their clinical assignments in an outpatient setting and continue with their long-term psychotherapy cases while adding at least five hours of short-term psychotherapy. They also co-lead a group and begin work with
Jon K. Meyer, James W. Lomax, Donald R. Ross, Martin M. Klapheke, and William H. Sledge contributed to this article.
child and adolescent outpatients in individual psychotherapy (a minimum of two cases is required). Didactic courses in PGY-III include a yearlong seminar devoted to advanced psychodynamic psychotherapy, a continuing case conference of an outpatient, an experiential group (which does not report to the training director), a nine-month weekly course in group psychotherapy, and a monthly seminar on family therapy. The majority of residents elect to continue seeing psychotherapy outpatients during their fourth postgraduate year.
At Yale the psychotherapy curriculum begins with a six-week interviewing seminar during the first half of PGY-II. The seminar involves either direct observation or videotaping of the residents, and they also observe a faculty member conducting psychiatric interviews. Second-year residents also attend a seminar on the psychological basis of psychiatry and a course that focuses on the practical issues in developing a therapeutic alliance and beginning a long-term psychotherapy process. In the second half of PGY-II each resident is expected to pick up one outpatient in psychoanalytic psychotherapy under the supervision of a faculty member, who typically is an analyst. By the end of PGY-II the residents have picked up a second patient as well.
In the third postgraduate year residents attend a yearlong individual psychotherapy course as well as seminars on group and family therapy. Each resident is expected to see five or six patients in ongoing individual therapy and two in brief therapy, and to have some experience in group psychotherapy and family therapy. PGY-IV at Yale involves a wide variety of electives. Some residents have up to 25 hours per week of psychotherapy experience and attend elective seminars on the psychotherapy of borderline patients, psychotherapy research, or introductory psychoanalysis (an extension-division type of course conducted by the Western New England Institute). Occasionally, other courses are offered that involve the psychotherapy of psychotic patients and multiple personality disorder. Finally, the Western New England Institute sponsors a departmental grand rounds each year focusing on a psychoanalytic topic.
As this sampling of programs suggests, psychoanalytic thinking is alive and well in many of the outstanding American residency programs. Residents themselves hunger for teaching that will help them understand their patients. The limitations of an exclusively pharmacological approach to treatment become apparent very early in a residency. Indeed, in some settings analysts who previously were banished from biologically oriented departments have been asked to rejoin the faculty because of persistent demands by residents for a more balanced education.
While it may be tempting to blame biological psychiatrists for the declining role of psychoanalytic teaching in psychiatry residencies, analysts must reflect on their own contribution. Many analysts have withdrawn from academic settings to devote their time to psychoanalytic practice and the activities of their institute. Yet psychoanalytic thinking remains a vital part of the training of psychiatrists, even in the “decade of the brain,” and analysts abandon academic training programs at their peril. If analysts do not involve themselves in teaching, others will willingly take their place.