Psychoanalysis prevailed in psychiatry training not so long ago. The expulsion of psychoanalysts from academic psychiatry over the past quarter-century has been detrimental to psychodynamic therapy training in residency. At this time of advances in neuroscience and the dominance of biological psychiatry, it is time to take stock of psychotherapy training.
Psychoanalysts in academic psychiatry enjoyed academic glory and power after World War II, but in the 1970s that grip began to weaken. Psychoanalysis didn't cure all ills, and new treatment methods and medications were being discovered. Community psychiatry and the de-institutionalization of patients held promise for the hundreds of thousands of patients chronically hospitalized in sometimes despicable conditions.
It is true that de-institutionalization and the later advent of atypical antipsychotic medication breathed new life into countless previously forsaken patients. Yet the unfortunate by-products of inadequate housing and outpatient/rehabilitation services, and increased homelessness for the chronically mentally ill, are reminders of the limits of promises.
As community psychiatry waned in the 1980s, biological psychiatry became king. New medications were discovered, treating a broader range of psychiatric disorders than ever before. Madison Avenue advertising and vast profits for the pharmaceutical industry, as well as the force of managed care, influenced this shift. Psychoanalytic training was no longer a prerequisite for becoming department chair. As biological psychiatry gained dominance, psychopharmacologists seized the keys to power in academia; slowly but surely, psychoanalysts either were expelled or left. Psychoanalysts who had supervised in the emergency room, on inpatient units, and in the general hospital disappeared from residencies. New requirements for courses in psychopharmacology, cross-cultural psychiatry, and managed care eroded time previously spent teaching psychotherapy. In the public's eye, by the 1990s, Prozac and its many cousins appeared to hold the promise of curing all woes and even changing personality, without so much as a visit to a psychiatrist.
So where are we now? Is academic psychiatry devoid of psychoanalytic teaching? Do residents even learn psychodynamic psychotherapy?
The steady erosion of psychotherapy training has left many residency graduates uninformed and unskilled in providing psychotherapy. Applicants to the APsaA Fellowship Program are hungry to learn about psychoanalysis, an indicator of the paucity of resources available in many programs. However, many residents expect only to prescribe medication, and they see no need to learn psychotherapy. Senior examiners at the psychiatry board examinations, themselves well-schooled in psychotherapy, often lament this change as they examine board candidates who do not understand that symptoms may have arisen in the context of a life event and that the life event is meaningful to the patient.
To address the threat of losing the psychotherapist in the identity of a psychiatrist, in 1996 the American Psychiatric Association (APA) established the Commission on Psychotherapy by Psychiatrists, which has refocused the lens on psychotherapy education and revitalized psychotherapy. The commission has published data on the efficacy of psychotherapy and conducted several educational programs well attended by residency training directors and educators [see “APA Acts to Keep the Psyche in Psychiatry,” TAP 35/1].
I recently conducted a survey of directors of psychiatry residency training regarding psychodynamic psychotherapy training. The responses revealed that although all programs offer some training, interpretation of the very general requirements of the Residency Review Committee, the agency that accredits residencies nationwide, is extremely variable. Training program content remains under the control of the chair, training director, and residency education committee at each program. Only a handful of training directors in the United States are psychoanalysts, and some cities have no psychoanalysts in the vicinity, limiting resources for residencies to draw from.
On the low end in psychodynamic training, residents may treat as few as two patients for up to one year maximum in weekly psychodynamic psychotherapy, supervised by a psychodynamically informed psychiatrist, and receive a total of only twenty-four hours of didactic courses. On the rare high end, residents may treat three or four patients weekly for one year, another three or four for two years, and one for almost three, with two or three hours of supervision weekly by psychoanalysts for two and a half years. In these programs, residents receive up to 200 hours of didactic courses on psychodynamic psychotherapy. In only a couple of these high-end programs do residents regularly see some patients twice per week.
Enter competencies and the Outcome Project of the Accreditation Council for Graduate Medical Education (ACGME). Competencies are the latest buzzword in education, from elementary to graduate level. These are the specific knowledge, skills, and attitudes necessary to demonstrate capability in a given subject, discipline, or profession. Competency-based education shifts the educational focus from teaching to outcome and assessment of outcome. The ACGME and its Residency Review Committee announced that all residencies by January 2001 must begin to demonstrate competency in six core areas deemed essential for all medical specialties: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.
Psychiatry is the first specialty also required to develop specialty-specific competencies.
Lisa A. Mellman, M.D., is an associate clinical professor of psychiatry at Columbia University College of Physicians and Surgeons, associate director of the psychiatry residency at Columbia, and a faculty member of Columbia's Psychoanalytic Center. She chairs the APsaA's Fellowship Committee. To obtain the list of AADPRT competencies for psychodynamic psychotherapy, e-mail her at .
Residencies must demonstrate that residents are developing competency in five psychotherapies: supportive, psychodynamic, brief, cognitive behavioral, and combined psychopharmacology and psychotherapy.
Until now, residencies were required to provide selected courses and clinical experiences for residents, like selections at a buffet meal where many dishes are sampled. In fact, as psychiatric knowledge has expanded, the number of required courses and experiences has also increased. Residents attended class and participated in rotations, but without detailed assessment of what they were actually learning and the skills they were acquiring. Psychotherapy education in particular was poorly delineated and assessed.
Returning to the food analogy, until now residents might have put several entrees and vegetables on their plates but really only digested dessert. Suddenly, residencies are required to assess what their residents are eating, how it is metabolized, and what nutrients (knowledge and skills) are actually retained. This shift to educational outcomes has stirred up the field, as strengths and deficiencies are suddenly apparent in each residency program.
The prospects for improved psychotherapy training are significant. Educators must rethink how to teach psychotherapy and how to measure what residents learn. Psychotherapy education, including psychodynamic therapy, is suddenly front and center, with great potential for enhanced teaching and a rapprochement with psychoanalysis.
To address this new change, several organizations formed task forces in 2000. The organization of psychiatry training directors, the American Association of Directors of Psychiatry Residency Training (AADPRT), established a Task Force on Competency, as did the APA. The Academy of Child and Adolescent Psychiatry had already begun drafting core competencies for child and adolescent psychiatry in 1999. The following year, a “quad” group with representation from the Residency Review Committee, the American Board of Psychiatry and Neurology, AADPRT, and various residencies developed sample core competencies, which AADPRT disseminated to the field. The AADPRT task force, with assistance from experts in each psychotherapy modality, then developed sample competencies for each of the required psychotherapies.
Now training directors of psychiatry residency programs are determining how to use these competencies, including how to assess whether residents are indeed developing the requisite knowledge, skills, and attitudes, and developing remediation plans when they fall short. Old methods for assessment including supervisor evaluation, oral examinations, and chart review will continue, and new methods need to be created. For example, Linda Mullen, Robert Glick, and Ronald Rieder at Columbia developed and validated a psychodynamic psychotherapy multiple-choice test, which has been administered to almost 1,000 residents across the country.
This is an exciting time for psychoanalysis and residency education. Psychoanalysts can again play a key role in psychotherapy education, the identity of a psychiatrist as a psychotherapist, and the future of psychoanalysis within academic psychiatry. They can bring excitement and knowledge of psychoanalysis to residents and reinvigorate interest in psychodynamic and psychoanalytic education.