For decades, psychoanalysts were the backbone of teaching and clinical supervision in psychiatric residency programs. Changes in academic psychiatry in the 1970s and 1980s led to the mass exodus (often involuntary) of psychoanalysts from full-time positions in many training programs. The rise of basic and clinical neuroscience research missions in many departments, and the development of new psychopharmacological and other psychotherapeutic interventions, seemed to reinforce the belief that psychoanalysis contributed only marginal knowledge and skills to psychiatric practice. Many analysts felt they no longer could play an important role in psychiatric education, and many gave up even volunteer faculty positions.
An analysis of today's academic environment reveals a situation with new opportunities.
It is well known that the number of U.S. medical school graduates choosing a career in psychiatry has fallen by about 40 percent since the peak recruitment year of 1988. Many explanations have been suggested for this decline, focusing on the economics of psychiatric practice and the restrictions on psychiatrists' scope of practice enforced by the rise of managed care. Some prominent psychiatrists and psychoanalysts believe that this declining interest among medical students shows that the future of psychiatry involves major changes, including a loss of the traditional emphasis on psychotherapy practice. They have concluded that managed care in its present form is here to stay, although this view is contradicted by many public opinion polls, the performance of managed care stocks on Wall Street, and the frenzy of mergers of for-profit companies in a desperate attempt to keep profit margins high.
The fact that some medical schools continue to recruit very high numbers of students into psychiatric careers also fails to support this belief. At the University of Louisville, and previously at the University of Connecticut, I played a key role in developing education programs that led students to choose careers in psychiatry at twice the national average. There is no question that the prospect of working with patients in a psychotherapeutic relationship over time is a key motivator for most of the students with whom I have come into contact over the last 20 years. These students attended school in areas where an insurance company or a large managed care company in the country was based. No one can argue that their choices were made in ignorance of the likely practice or economic environment. This experience of student interest in psychiatry is shared by many senior psychiatric educators around the country and by many on the Committee on University and Medical Education of the American Psychoanalytic Association, of which I am a member.
As President of the American Association of Chairs of Departments of Psychiatry, I am very aware of a major need at both the medical student and residency levels for clinical supervisors in most departments around the country. Many of these departments are chaired by a new generation of leaders committed to training in a comprehensive biopsychosocial approach, who did not preside over academic programs when psychoanalysts left academia in large numbers. These chairs would welcome supervisors and teachers with the expertise of our psychoanalytic colleagues, but the departments are often unsure how to approach people who they feel may carry scars from previous academic involvement.
Overcoming the last decade's loss of psychoanalytic presence in medical schools and residency programs will take time and a concerted effort, but there are a multitude of opportunities. Within the last several years, most medical schools have instituted new “Introduction to Clinical Medicine” courses that address clinical interviewing and assessment, offering a major opportunity for psychoanalysts. Further, the increased emphasis on ambulatory training during the clinical years provides major opportunities for analysts to teach.
There are broad opportunities at the resident training level as well. One of the major concerns of psychiatric residents around the country is the lack of adequate clinical psychotherapy training and training in understanding the body of psychoanalytic knowledge. Thus, the chance to serve as clinical outpatient supervisors, seminar leaders, preceptors for clinical service, or moderators of clinical case conferences give analysts a wide range of teaching options.
How can we take the first steps toward bringing back an analytic presence, so sorely missed, to medical and psychiatric education? First, individual commitments must be made. No organizational efforts will take the place of a decision to volunteer a few hours per week of time to the local medical school's department of psychiatry. When making that individual commitment, take the opportunity to demonstrate how a psychoanalytic way of understanding can contribute to patient care in any clinical setting, with trainees at every level of their education. Don't assume, on the basis of previous teaching experiences, that you can only contribute in an outpatient clinic with senior residents. Some of the best teachers of psychoanalysis of previous decades worked in inpatient or consultation settings.
Individual efforts are the first essential step, but organizational efforts must follow. I have already played an important role in such processes by working to establish the Commission on the Practice of Psychotherapy by Psychiatrists with the APA Board of Trustees. This APA commission, of which I am a member, is chaired by our analyst colleague, Drew Clemens, and includes psychoanalysts Glen Gabbard, Susan Lazar, Bart Blinder, and Jerry Kay in its membership. The work of this group has already returned an important focus on psychotherapy to the APA. As President of the AACDP, I have discussed with the leadership of the chairs group and the American Psychoanalytic Association the value of a joint conference to discuss issues of mutual importance in residency education, as a first step toward greater psychoanalytic input.
If we each make a commitment to medical and psychiatric education now, there can be no limit to the benefits for students and residents within psychiatry and the rest of medicine. The presence of analysts as clinical role models for the next generation of psychiatrists will bring us tremendous satisfaction and help return psychoanalysis to its rightful place in the educational pantheon of tomorrow.
Allan Tasman, M.D., is a professor and chairs the Department of Psychiatry at the University of Louisville. He is currently vice president of the American Psychiatric Association and president of the American Association of Chairs of Departments of Psychiatry. He has served as president of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry. He is a member of The American's Committee on University and Medical Education.