A resident describes with pleasure her patient's disguised fantasy of self-punishment. Her awareness of the patient's unconscious dynamics has been heightened by a recent discussion, in her residency's Freud Study Group, on Freud's fantasy of having eye surgery the morning after his dream of the botanical monograph.
Earlier, another resident discussed experiencing recurrent feelings of immobility and depression while conducting psychotherapy with an obsessional patient. Moreover, the resident had begun to recognize that his feeling states were a response to a certain kind of provocative anger in this patient. Gradually this awareness of countertransference feelings led the resident to introduce clarifications and then interpretations to his patient. He knew that his own insight was related to analytic case presentations and seminars on transference/countertransference that had been given in his residency program by the teaching analysts of the Albert Einstein Center for Psychoanalysis in Philadelphia. The training of these psychiatric residents, who were clearly delighted with their nascent psychoanalytic knowledge and the power of psychodynamic understanding, was vastly enriched by intensive analytic teaching in their residency program. Too often, however, such training is unavailable. For years, members of The American have struggled with the lessening role of psychoanalysis in psychiatric residencies. Although The American has addressed this problem with such outreach efforts as the Resident Fellowship Program and visiting professorships for psychoanalytically underserved departments, the number of psychiatric residents currently entering analytic institutes as candidates is steadily declining, even while institutes are experiencing increasing enrollment of non-M.D. candidates. Although the reasons for this trend are not entirely clear, it is certainly linked to the decreasing number of U.S. medical students entering psychiatric residencies. Just a few years ago, in 1988, more than 800 U.S. medical school graduates entered such residencies. By 1994 that number had been cut in half.
Today medical students speak openly of psychiatry's loss of allure and, a fortiori, that of psychoanalysis. This loss of attraction may be closely linked to the increasing emphasis, in departments of psychiatry, on managed care models and on biological and nondynamic psychiatric teaching. But these bright, articulate students also speak in depressing tones about the devastating effects of managed care on private practice, adequate patient contact, and the ability to practice long-term psychotherapy. Moreover, in the last year, medical students had become wary of the effects the Clinton Health Security Act—or some version of it—would have had on their ability to practice psychiatry in a satisfying way. Had the act passed, they feared, confidentiality and the patient-physician bond would have been severely threatened. They knew that private care might effectively be precluded by a system of fines for patients seeking such care, and by the act's provision of felony sanctions against physicians practicing outside the system.
While the new ideas associated with the increasing number of non-M.D. candidates are to be applauded, there is also concern about the implications for psychoanalysis if the pool of medical candidates continues to shrink. This trend carries with it the potential loss of the physician analyst's influence in research related to psychobiological aspects of illness, as well as a potentially diminished teaching role for physician analysts in institutes, residencies, and medical schools.
In an effort to address these and other issues concerning psychoanalytic research, patient care, and the teaching of psychodynamics, Paul J. Fink, then chair of the department of psychiatry at the Albert Einstein Medical Center and medical director of the Philadelphia Psychiatric Center (now the Belmont Center for Comprehensive Treatment), discussed with Harold Kolansky the idea of developing a Center for Psychoanalysis that would serve both hospitals. Fink believed that such a center would “attract, encourage, and give recognition to psychoanalysts… as a community of scholars dedicated to teaching residents and medical students.” Kolansky, concurring, accepted directorship of the Center and began at once to recruit faculty.
Albert Einstein Medical Center and the Belmont Center have a combined total of 750 beds, 200 of which are psychiatric. The two hospitals are near each other—only ten minutes apart—and have a combined psychiatric staff of 260. Psychoanalytic teaching in this residency, which has 36 psychiatric residents and geriatric fellows, has always played an important role. In fact, most of the department's chairs, including Paul Sloane, Eli Marcovitz, and both Kolansky and Fink, have been psychoanalysts. In addition, Frederick C. Miller, currently residency training director, is an analyst, as is Herbert Mandell, director of the newly approved child and adolescent psychiatry fellowship.
Although the acting codirectors of the department, Michael J. Vergare and William Dubin, are not psychoanalysts, their skills in dynamic psychiatry and lifelong professional association with analysts assure the continuity of the Center for Psychoanalysis.
The Center had its origin in January 1991, when faculty appointments were offered to training analysts, faculty members, and senior candidates considered strong and innovative teachers in area medical schools and the two local institutes approved by The American. Almost all of these invitations were accepted, and soon a faculty of 55 was assembled, 26 of whom were also child analysts. While Einstein is a teaching affiliate of Temple University, faculty were appointed from other medical schools as well. Faculty engage in classroom teaching of residents, child fellows, and medical students; participate in individual supervision and inpatient rounds and conferences; and provide consultation-liaison services in both the medical and the pediatric departments. To strengthen the Center's psychoanalytic impact within the department, it was essential that it be an integral part of the department's decision-making bodies. Accordingly, the Center's director was appointed to the department's Executive Committee, the Training and Curriculum committees, and the Child Psychiatry Planning Committee.
In addition to the duties already described, many faculty members have been invited to present papers at weekly departmental grand rounds, where they have had large audiences. These presentations have included talks on the influence of psychoanalysis on leadership, biological bridges with psychoanalysis, psychological preparation of children for heart surgery, considerations on the analysis of impotence, long-range studies of psychoanalysis, countertransference with borderline patients, the use of dreams in psychotherapy, and the biological-psychological onset of puberty.
Currently the Center provides 156 seminar hours for residents during their four years, an increase of 30 in the past year. A seminar on the
Harold Kolansky, M.D., is director of the Center for Psychoanalysis, Albert Einstein Medical Center (Philadelphia).
unconscious, conflict, and the dream provides residents their first exposure to the rich and varied presentations of the Center. This informal seminar for PGY-1 residents is conducted in the home of a faculty member, as are the Freud Study Group Seminars. The latter are held monthly throughout the four-year program and concentrate on Freud's writings, case material, and contemporary psychoanalytic views. Other Center offerings include adult and child continuous case conferences, oneway vision observation of a faculty member treating an adult patient, and courses on the neuroses and child development. Faculty members also present their own cases in a regularly scheduled seminar, as well as offering the usual seminars on technique. The richness of this analytic input into the residency program does not preclude ample exposure of residents to biological models, psychopharmacology, family therapy, child psychiatry, geriatric psychiatry, medico-legal aspects of psychiatry, and a host of other subspecialties.
To assure the continuity of themes across the curriculum, the Center's director functions also as a course coordinator, sitting in on most classes. The faculty case presentations allow analysts to provide the residents firsthand analytic experience, offering them clinical insight regarding the early hours, reconstructions, transference-countertransference, dreams, resistance, enactments, and the like. Residents appreciate this close-up view of analytic work. The faculty's gracious expenditure of preparation and teaching time, and their ready availability to residents for informal discussion, all on a voluntary basis, are crucial to the program's success.
In periodic curriculum reviews, the residents have consistently given the Center's courses highest ratings, and have asked for more course time, a request that has been accommodated. In 1993 an analyst faculty member was selected by residents as “best teacher.” In addition, many residents seek psychotherapy or personal analysis, possibly aiding recruitment into analytic institutes.
With the recent approval of Einstein's Child and Adolescent Fellowship, similar teaching roles are anticipated for the 26 child analysts now on faculty. Center faculty are also involved in the teaching of medical students throughout the area.