The University of North Carolina-Duke University Psychoanalytic Education Program developed as a psychoanalytic institute in the early 1960s. Its original faculty and candidates had close ties to both universities' departments of psychiatry. Over time the affiliations loosened, and now the institute has minimal administrative connection to the universities. Although many members of the local psychoanalytic society continued to supervise psychiatry residents over the program's thirty-some years, participation in psychotherapy education at the psychiatry residencies gradually declined. By 1996, few supervisors for psychotherapy at UNC were members of the local analytic society.
In 1996, concurrent with the move into a newly constructed hospital, the UNC psychiatry chairman restructured the psychiatry clinics: less time devoted to psychotherapy, more time for supportive care and medication management. While still a candidate, I was asked to design improvements to long-term psychotherapy — a traditionally valued component of the residency — despite the reduction in time spent with such patients. I sought input from the local analytic community to bolster the supervisory experience.
Today the residents at UNC receive the vast majority of their supervision from experienced psychoanalytic clinicians. Today there are more than thirty residents who begin psychotherapy clinic in their second year; almost all are supervised by at least one analyst or candidate, and many have two analytic supervisors. Most of the other supervisors are respected non-analyst members of the analytic society or psychiatry faculty with many years of supervisory experience. All the supervisors who are not on the university staff have adjunct faculty appointments.
The curriculum for the psychotherapy clinic initially emphasizes psychodynamic concepts as a framework for integrating other psychotherapy models, such as cognitive behavioral therapy (CBT), which is taught late in the second year. The third-year seminar focuses more on developmental models and case conferences.
Throughout the clinic, residents maintain four hours weekly of psychotherapy with two to four patients, receiving two hours of supervision for these patients, who are referred from the more general psychiatry clinic or UNC student psychological services. Most patients pay a reduced fee. Treatment courses of more than 100 hours are not unusual. The residents' competence is assessed from a required case write-up, six to nine pages long, modeled on case summaries written for certification by the APsaA.
“While some residents at first express anxiety and intimidation when exposed to analytic concepts and clinicians, most easily overcome these barriers and enjoy an area of psychiatry they might initially have thought arcane or frivolous.”
Third- and fourth-year residents also see patients in CBT and other brief therapies; they have less time remaining in their training to start long-term cases. Faculty psychologists with expertise in CBT supervise some of this brief work.
The generous donation of time by local analytic clinicians has stimulated several UNC residents to pursue analytic training. Some begin their training while still residents. Resident attendance at scientific meetings of the society has dramatically increased. While some residents at first express anxiety and intimidation when exposed to analytic concepts and clinicians, most easily overcome these barriers and enjoy an area of psychiatry they might initially have thought arcane or frivolous. Although only a few pursue careers that include much psychotherapy, all the residents develop a working familiarity with psychodynamic concepts and become intelligent referral sources for analysts and psychodynamic therapists.
There are problems with this supervisor arrangement. Residents must drive to the offices of supervisors, limiting the geographic area from which supervisors can be drawn. Another problem is the clinic's lack of integration with the psychoanalytic referral service run by the society. Although a few callers to that service have ultimately been referred into the psychotherapy clinic at UNC, the clinic has generated no analytic cases for candidates or other psychoanalysts, except for the cases converted to analysis by residents entering analytic training.
A key to this program (and probably others like it) is the strong support of the chair and training directors of the residency. Not all administrators appreciate and welcome psychoanalytic concepts and therapies into the academic setting. Many of the general trends in academic psychiatry continue to emphasize neuroscience and biological psychiatry. As an analyst “on the inside,” I have been positioned well to help re-establish connections between the institute/society and its former close partner, the department of psychiatry.
Analysts' and candidates' participation in this supervisory program demonstrates an abiding dedication to our local psychoanalytic enterprise. We all hope to reap the benefits in good will, candidates, referrals, and participation in the society for years to come.
Burton Hutto, M.D., is an assistant professor of psychiatry at the University of North Carolina and a teaching analyst for the UNC-Duke Psychoanalytic Education Program. He directs the psychotherapy education program for the psychiatry residency at UNC.