Fluorescent lights cast a harsh glare over the seminar table around which sit 10 psychiatry residents, surrounded by coffee cups, notes, palmtops, and handouts. The psychoanalyst professor who teaches basic psychodynamic psychotherapy has piqued the residents' interest, helping them see conflicts and compromises, repeated relationships, and strangled affects, where there had been confusion and irrationality. The residents' understanding of deeper dynamics is building, and most are more and more curious. Then, one resident who has been quiet for several meetings says, “This is definitely interesting, but it is not evidence-based like CBT; it's just so subjective.” Is this a knowledge deficit on the part of the resident, resistance to the affects stimulated by the case discussion, or a consequence of our teaching technique? How can we meet this challenge?
The Residency Subcommittee of the Committee on University and Medical Education developed a two-year agenda to address the educational need expressed in the all-too-common vignette above. Psychiatry residents are often interested in psychoanalytic theory, and certainly in psychodynamic psychotherapy technique, but they are caught in the headwind against the treatment, the result of widespread perception that cognitive therapy has been proved to be more efficacious for most problems.
The charge of our committee is to facilitate the relationship between psychoanalysis and psychiatry training in medical schools and residencies. After a period of declining interest in psychiatry departments in the ‘80s and early ‘90s, there has been a notable increase in interest in psychotherapy among psychiatry residents nationally. This is attributable to several factors, including the American Council on Graduate Medical Education's mandate to ensure competency in psychotherapy upon graduation from residency, the increased interest in all areas of psychiatry among medical students, and the sense that this is one of the last places left in medicine where relationships are seen as important. Our committee includes a number of senior medical and residency educators and has increased its membership, reaching out to psychotherapy researchers as well.
Psychiatry residents are often interested in psychoanalytic theory, and certainly in psychodynamic psychotherapy technique, but they are caught in the headwind against the treatment, the result of widespread perception that cognitive therapy has been proved to be more efficacious for most problems.
We are aware that the evidence base of psychodynamic psychotherapy is a focus of substantial research activity in a number of major academic centers, and that there is a very active scientific and political controversy over its effectiveness. A committee at the American Psychiatric Association is charged with studying this question, and it is also a focus of dialogue among members of the American Psychological Association's Division 39 Section 6. Embedded in this larger controversy is the question of whether the traditional techniques for evaluating the evidence base of a medical treatment are appropriate for studying and evaluating psychodynamic psychotherapy. The American Psychological Association's Presidential Task Force developed Guidelines for Evidence-Based Practice, which include a variety of types of data, not just randomized controlled trials. But, we are also aware that the existing evidence base is more substantial than most psychodynamic therapists believe, and this information needs to be more widely appreciated by trainees and practitioners alike.
The committee developed plans to create and disseminate new educational materials to be used in medical school and residency designed to increase awareness of psychodynamic psychotherapy as a valuable treatment modality. We saw our role as helping to translate existing research findings into educational tools that would highlight important theoretical and technical literature and expose residents to the substantial database about psychodynamic psychotherapy's effectiveness and the methodologic issues involved in studying it.
The committee started by collaboratively creating an updated psychodynamic psychotherapy reading list. Beginning with several existing reading lists, Elizabeth Auchincloss and I consulted with committee members and other colleagues about those articles seen as most useful for students and polled APsaA members about which Freud articles would be most valuable for trainees to read. The resulting reading list was completed in two formats, one referred to as the “essentials” (), targeting medical students and most residents, and the other “complete” (), for those residents with a deeper interest. The references are organized under the rubrics of theory, development, psychopathology, assessment, and treatment, as well as case descriptions, classic Freud papers,
Richard Summers, M.D., is clinical associate professor of psychiatry and associate director of education for residency training at the University of Pennsylvania, and a member of the faculty of the Psychoanalytic Center of Philadelphia.
and new directions in psychodynamic psychotherapy. The reading lists were widely publicized to medical school and residency training programs and are also published on the American Association of Directors of Psychiatry Residency Training Web site at .
Our committee, especially Ray Levy, collaborated with the Committee on Scientific Activities, and with Andrew Gerber and Stuart Ablon, in particular, to create a Web site for the posting and dissemination of teaching tools on the evidence base for psychodynamic psychotherapy. Dedicated to the notion that excellent teaching materials already exist, tailored to specific programs and trainees, we decided to facilitate the sharing of best practices in teaching in this area. The Web site () currently has 13 full syllabi posted by national experts in this area, and more will probably be added soon. We encourage members to visit the site, especially those who are teaching about psychodynamic psychotherapy. Please borrow, edit, share, and use!
We hope that the question posed by the thoughtful resident from our educational vignette above will be moot in the future, having already been covered in an introduction to the psychodynamic psychotherapy course. By including evidence in our education, we can promote broader understanding. Our committee hopes that these new materials will be widely used in settings around the nation and will contribute to training and interest in psychodynamic psychotherapy. Further, we hope to pilot this type of Web-based sharing of best educational practices as a new way of improving our educational techniques and materials.