Rapid and dramatic changes in psychiatry have caused many analysts to wonder if there is any place left for them in psychiatric residency training. Despite some evidence and claims to the contrary, an unrelenting process seems at work removing “the mind” and the practice of psychotherapy from psychiatry. Dynamic psychotherapy and psychoanalytic concepts seem almost to have been singled out for exclusion.
Although some might consider this view a paranoid fantasy, it is one openly held by many psychiatrists and analysts familiar with current realities. Is the relationship truly over between psychoanalysis and American psychiatry? As we move toward a redefinition of the latter, is there a future for analytic knowledge and psychodynamic psychotherapy?
These are important and fundamental questions for those of us who believe an ongoing connection between psychoanalysis and psychiatry is vital to both disciplines. Many analysts are in a position to influence the process of change and to find new ways to reinvigorate the bond between the two fields. This is a defining moment for those not yet ready to let the alliance between psychoanalysis and psychiatry pass into history.
There are a number of factors in the widening gap between psychiatry and psychoanalysis, among them (1) the ascendancy of a standardized symptom-cluster diagnostic system combined with more effective and diverse psychopharmacological treatments; (2) an increasing demand that treatment effectiveness be demonstrated through controlled studies; (3) a paradigm shift within psychiatry from the psychosocial to the biological; (4) general confusion (even within psychiatry) concerning what constitutes dynamic psychotherapy, adequate training, and the circumstances in which this treatment should be utilized; (5) an explosion of models of psychotherapy, with no organized attempt to understand or control the process; (6) the demonstrated effectiveness, in clinical studies, of models of psychotherapy that are not psychodynamic; (7) economic, political, and social forces that demand brief and less costly treatments; (8) a general tendency toward change, with rejection of the previously dominant model, together with the great difficulty of employing complex models in clinical work; (9) the continued dominance of Cartesian thinking and the difficulties encountered in constructing a unified mind/brain model; and (10) cultural shifts that are generally antiintellectual and oriented toward action, immediate gratification, and simply defined, demonstrable results.
These issues have emerged since a time—the 1950s and 1960s—when psychoanalysis was the dominant force in psychiatry. While psychoanalysis offered much and lent American psychiatry a certain legitimacy, even then there were problems: (1) psychoanalysis, as an explanatory model and as a treatment, was vastly oversold and idealized; (2) some analysts were elitist, arrogant, and monolithic, which provoked attacks by those who were excluded or who had legitimate reasons to pursue other approaches; (3) the psychiatrist/analyst was perceived as being far removed from the medical model; (4) theories were emphasized that could not be “proven,” and a difficult and awkward vocabulary was insisted on; (5) the treatment of less disturbed, more affluent patients led to a sense that psychiatry was neglecting patients with severe and chronic illness. For two decades the American Psychoanalytic Association has been slow to collaborate with the evolving field of psychiatry. A more curious and disturbing fact is that many analysts in prominent positions within psychiatry have been publicly silent on this growing rift between the two fields. A deeper understanding of these issues can help inform strategies. This is not a time, however, for antagonism, defensiveness, or despair. It is important to work vigorously now in a positive spirit of collaboration if we are to be successful.
Analysts still remain well positioned to keep mutual, interactive growth alive in both fields through the training of future psychiatrists. This work begins in medical school, but its cornerstone must be psychiatric residency training. In spite of what often seem insurmountable problems, there are reasons to summon our best effort in this area. The outcome will substantially affect the future of both fields and has profound consequences for patients and their families. There are still many analysts involved in psychiatric education, and many residency training directors and chairs of psychiatry departments wish to continue a psychodynamic tradition. Many current leaders of AADPRT (the American Association of Directors of Psychiatric Residency Training) are themselves analysts or analytically informed psychiatrists. Indeed, six of its last ten presidents have been analysts.
Analysts must continue to involve themselves in the teaching of dynamic psychotherapy; this is the foundation for learning psychoanalytic applications in clinical psychiatric work. Analysts remain the most highly regarded group of psychotherapy supervisors, a fact that can be useful in gaining further footholds in psychiatric education. Some change in expectations and a better-defined pedagogic focus are needed, and departments of psychiatry must work to provide residents suitable patients with whom to learn dynamic psychotherapy. Instruction should include brief dynamic psychotherapy and the skilled combination of psychotherapy and pharmacotherapy.
In addition to supervision, there are a number of ways in which analysts can become more influential teachers in residency programs. Essential here is a willingness to be open, curious, creative, and collaborative. Teaching needs to be integrated within current practice realities. This requires keeping up with advances in psychiatry and experimenting with combined approaches. As analysts we are able to recognize pertinent manifestations of unconscious conflicts, work with transference and countertransference in the clinical situation, explore the impact of an illness, and examine the interplay among symptoms, dynamic issues, character, and context for each individual patient. We do not treat diagnoses but rather people who are sick. Everyone is unique. When analysts can describe what they see and can demonstrate the essential data they use in making inferences and drawing conclusions, residents learn to appreciate the analytic perspective in their work.
Once these general principles are followed, analysts can become highly valued educators in a variety of new settings—inpatient and consultation-liaison services, emergency rooms, crisis clinics—and in the ongoing management of patients with chronic and persistent mental illness.
David Goldberg, M.D., is chair of the American Association of Directors of Psychiatric Residency Training.
The best place to begin during residency is on the first-year inpatient service. In the midst of a rapid-turnover, diagnosis-discharge environment, there may seem no place for “analytic” teaching. However, someone willing to sit down without a DSM-IV agenda and listen to a patient, to ask questions that follow the patient's lead, and to talk about experience has much to offer neophyte clinicians. It is an important time for demonstrating and imprinting a broad approach to clinical care. Residents are often greatly relieved to talk about their own responses to psychoses, depression, and the interactions they are inevitably drawn into with their patients. Throughout the course of training, opportunities continually arise for analysts to teach. The combination of interviewing, clinical discussions, psychotherapy supervision, and seminars can be as rich and varied as the training director, teachers, students, and time will allow.
A subcommittee comprising analytic directors of psychiatric residency programs is currently working with CUME (The American's Committee on University and Medical Education) to find ways to support analysts who teach psychiatric residents and to develop effective educational strategies. While an organized approach is necessary, the future is in the hands of individuals who remain involved in teaching and who search for ways to keep psychiatrists and analysts talking with one another. The subcommittee is preparing a presentation for The American's fall meeting.