Former Fellow Sandra C. Walker represented the American's Fellowship Program at this January's Midwinter Meeting of the American Association of Directors of Psychiatric Residency Training in Charleston, SC. One year ago, she, Charles P. Fisher, a member of the Fellowship Subcommittee and director of residency training at California Pacific Medical Center/UCSF, and AADPRT executive secretary David A. Goldberg, began discussions about arranging a psychodynamically oriented workshop. Their collaboration produced this year's successful workshop, “Teaching and Learning Psychodynamic Principles in Public Sector Psychiatry.” More than twenty-five residency training directors, psychotherapy training program directors, and chief residents attended. Leader James H. Scully, Jr., former deputy medical director of the APA and newly appointed chair of psychiatry at the University of South Carolina, invited participants to listen to Walker's case presentation from a number of perspectives: the experience of a new trainee in undertaking a challenging case, the crucial role of the supervisor in facilitating both the progress of the case and the clinical development of the resident, and the opportunities to identify and teach specific psychodynamic and psychoanalytic concepts while working with a patient whose illness and social situation raised formidable therapeutic problems. Walker presented her first psychotherapy patient — a suicidal young woman, with DSM-IV diagnoses of major depression, PTSD, and a history of substance abuse whom she met in a county hospital emergency room and treated for more than a year in psychotherapy. Walker described her own experiences as she tried to understand the patient's experience. She showed how supervision with a psychoanalyst, Sandra Connell, a member of the Seattle Institute for Psychoanalysis, helped her tolerate both her experience of the patient and the patient's experience of the therapy. In the supervision, Walker learned about mirroring, containment, the therapeutic frame, transference, and countertransference in a clinically meaningful way.
Walker demonstrated that this patient, despite a great deal of intrapsychic and external chaos, including periods of homelessness, was able to make use of her and to internalize aspects of her ego, resulting in significant reduction of the patient's self-destructive impulses. Walker's collaboration with the multidisciplinary staff of the county hospital inpatient unit helped dilute aspects of the transference/countertransference and thus facilitated the patient's treatment. David I. Joseph, also a Fellowship Subcommittee member and co-leader of the workshop, assisted Walker in preparing the case presentation and contributed to shaping the discussion.
A lively exchange of ideas followed the presentation. Johan Verhulst, University of Washington residency training director and a member of the board of directors of the Seattle Institute for Psychoanalysis, pointed out that Walker's case is typical of many of the patients seen by psychiatric residents on inpatient services. Supervisors may not think of these patients as “good psychotherapy patients,” and the structure of residency training programs may make it difficult for residents to follow such patients through the course of their illness. Several of the workshop participants expressed a desire for supervision of residents by psychoanalysts and for supervising analysts to adapt their skills to teaching residents to do good psychotherapy with the patients they actually see and in the settings where residents actually work. Scully underscored the importance of the supervisor in providing a safe environment in which the resident can explore his or her own reactions to the patient's internal world.
Other participants suggested ways supervisors might become more engaged in the residents' experiences with public-sector patients. These included inviting supervisors to take public hospital-call with supervisees, developing special workshops for supervisors featuring out-of-town speakers who have experience in this sort of work, and providing social opportunities for supervisors, trainees, and residency staff to become better acquainted. David Joseph provided bibliographic references for those who might want to become more familiar with this subject. These included Neil Altman's 1995 book The Analyst in the Inner City, and an article by Sheldon Travin and Harvey Bluestone, “Can the Impossible Profession Help the Impossible Patient: Is Freud Relevant in the South Bronx?” in the Fall 1994 issue of the Journal of the American Academy Of Psychoanalysis. Former Fellows Cynthia Ellis, associate director of residency training, UCSF, and Jodi Halpern, chair of the UCLA Neuropsychiatric Institute Ethics Committee, were also at the meeting. Halpem has just published a book on biomedical ethics and presented a thoughtful and provocative Presidential Forum, “Ethical Issues in Training in an Era of Increased Conflicts of Obligation.” Fisher and Walker are planning a workshop for the 1998 AADPRT Midwinter Meeting in Orlando that will keep both the Fellowship and the value of resident experience with psychodynamic concepts on the minds of AADPRT meeting participants.
Walker's attendance at the AADPRT meeting was financed by the APsaA Fellowship Fund.