Psychoanalytic Presence in Child Psychiatry Fellowships

Three years ago, I began a fellowship in child and adolescent psychiatry. I had been in practice for four years as a board-certified adult psychiatrist. My main interest was psychoanalytically based psychotherapy, but I also had an active inpatient service, managed medication, consulted to a dual diagnosis unit, and performed ECT. My intention in returning to training was to learn about child development, psychotherapy with children, and medication management in children.

During the first year of my fellowship, I decided to pursue training in both the child and adult psychoanalytic core tracks at a local psychoanalytic institute. Part of the reason for this was that within my child psychiatry fellowship I became aware that the fellowships offered only very limited teaching about therapy and child development.

I began to wonder how other child psychiatry fellows were faring as they tried to understand their child patients from an analytic or dynamic perspective. My concern grew that resources for such learning were limited in the current climate of behaviorism, managed care, emphasis on medication, and reliance on social services.

A Poll of Fellowship Programs

In order to acquire data on this subject, I polled by e-mail twenty-eight child and adolescent psychiatry fellowship programs across the country. I kept the questions simple. Respondents ranged from child fellowship residency directors and chief fellows to the child psychiatry fellows themselves. The best way to present the data is to report how many programs clearly endorsed offering some type of analytic training/exposure to their child psychiatry fellows.

The data are included in the table to the right. An “X” means that fellows were involved with analysts in a particular area of training within a fellowship program.

In 9 of the 28 surveyed programs, fellows have psychoanalysts as supervisors. In some programs, almost all of the fellows have an analytic supervisor. Some programs — the minority—offer no psychoanalytic supervision at all. One program, almost completely behaviorally oriented, has seven out of eight fellows with analytic supervisors and one fellow in training analysis and candidacy. However, this program is extremely unsupportive of psychoanalysis.

In 10 of the 28 surveyed programs, fellows have psychoanalysts as mentors. Mentors are usually thought of as advisors, guides, and advocates. However, mentorship can also subsume some supervisory activities.

In six programs, fellows are involved in some way with their local psychoanalytic institute. This question was meant to cover child psychiatry fellows who were taking coursework from an institute, who were applying for candidacy or already analytic candidates, or who were student associates or psychotherapy associates of the American Psychoanalytic Association.

Sixteen of the 28 fellowships offer lectures by psychoanalysts. This can range from a few weeks of coursework to yearlong seminars. The less quantifiable comments reflected that these didactics were often the favorite course material of the child psychiatry fellows.

Nine of the fellowship programs reported fellows in personal analysis. This is likely to have been under-reported, since it is a more personal topic and fellows may not be willing to reveal this. One program encourages its child psychiatry fellows to be in personal analysis, and one program “had some fellows in psychodynamically oriented psychotherapy.”

Six child fellowship programs reported fellows in psychoanalytic candidacy. This is a rigorous and difficult undertaking. No program polled actually encourages its fellows to become candidates during their fellowship, although one openly encouraged fellows who were interested in psychoanalysis to apply to an analytic institute and to start personal analysis while in the child psychiatry fellowship. One program reported that its graduates often go into psychoanalytic training as candidates after their fellowships.

A Recruiting Opportunity

These data suggest a recruiting opportunity. During a child psychiatry fellowship, the trainee is actively undergoing a tremendous amount of compressed learning, is very curious about the workings of patients' mental functioning, and is open to satisfying learning experiences. The more active and available analysts can be to child psychiatry fellows as supervisors, teachers, and mentors, the more likely analytic training will appear as a viable path.

In addition, psychotherapy associate membership may be a particularly good way to introduce fellows to an analytic atmosphere and analytic colleagues. Supervisors should have brochures describing psychotherapy associate membership on hand for child psychiatry fellows. Psychoanalytic supervisors, mentors, and teachers can direct fellows to the APsaA Web site and mention its literature search capabilities, catalog of teaching tapes, and general information about psychoanalysis.

The APsaA's own fellowship program could be more heavily publicized to child psychiatry fellowships. Supervisors, mentors, and teachers can give brochures and information directly to child psychiatry fellows and put them in touch with current and former fellows of the association.

Child psychiatry fellows would benefit from knowing the names and phone numbers of their local institutes. In this way, a fellow can obtain a list of local psychoanalysts, a descriptive brochure of the institute's core and two-year training programs, and a contact person if needed. Child psychiatry fellows can get on their local institute's mailing list, but they rarely know this is possible.

Most child fellows don't know that the local psychoanalytic institutes have outpatient clinics. Child psychiatry fellows are often told that such clinics and practices no longer exist or are not financially viable. It would be very helpful for fellows to know that institutes have viable community clinics that offer a wide range of services. My impression is that child fellows often regard it a mystery as to where analytic patients come from. Information about community clinics would help fellows understand how the process of analytic or psychodynamic training occurs, how part of an institute functions, and how psychoanalysis is a viable career path.

Overall, I think the data reflected above point to a window of opportunity. It is encouraging that child psychiatry programs and fellows have access locally to psychoanalysts and psychoanalytic institutes as a means to encourage them to pursue an analytic understanding of their patients — and perhaps psychoanalytic training.