In the 1970s and 1980s many psychiatric residency programs were riddled by splits. Faculty and programs were identified as psychoanalytic or psychobiologically oriented. The third edition of the Diagnostic and Statistic Manual (DSM III) published in 1980, marked a change from a psychodynamic understanding of the patient and illness, to an emphasis on neo-Kraeplinian descriptive diagnosis. Psychiatric training followed suit, with a shift to a descriptive behavioral model at the expense of a psychoanalytically oriented one. This polarization between mind and brain was further fueled by the insurance industry with the advent of managed care in the 1980s. Managed care heavily favored the use of medications and brief formulaic therapies, which were clearly economically preferable.
The American Psychoanalytic Association has been working on ways to reintroduce psychoanalytic and psychodynamic theory and practice into residencies, and individual analysts have found ways to do this too.
Despite the development of “core competencies” for psychiatric residencies, which include psychodynamic psychotherapy, many graduating residents do not feel prepared to engage in psychodynamic treatment. As a result, training programs have offered fellowships in psychotherapy, and many psychoanalytic institutes have developed psychotherapy training programs to augment residency training. The American Psychoanalytic Association has been working on ways to reintroduce psychoanalytic and psychodynamic theory and practice into residencies, and individual analysts have found ways to do this too.
Kathryn Zerbe is professor of psychiatry at Oregon Health and Science University (OHSU), the only medical school in the state. She also serves as the vice-chair of psychotherapy; there was no such title or position when she arrived from the Menninger Clinic in 2001. Zerbe was recruited to OHSU to serve on the faculty of obstetrics and gynecology, having occupied the Jack Aaron Chair in Psychiatric Education and Women's Mental Health at the Menninger Clinic. Once she arrived she became a beacon for psychiatric residents, who approached her for curbside consults seeking a psychodynamic understanding of their patients. The residents had an intuitive sense that something was lacking and that they understood their patients' brains better than their minds. She responded by initiating an evening seminar for senior residents to discuss process and to help them develop a deeper understanding of their patients and psychotherapy, co-run with a psychodynamically oriented psychiatrist, Kelli Holloway.
By 2002, changes in the Department of Psychiatry presented her with the opportunity to become a vice-chair of psychotherapy, a position she helped design, bringing psychoanalytic concepts back into the mainstream of the residency. Her efforts were soon rewarded with a teaching award in 2003, which was again bestowed in 2004 and 2005. Zerbe has worked closely with other analysts, including Gerald Fogel (a founding faculty member of the Oregon Psychoanalytic Institute) and Donald Rosen, director of residency training at OHSU. Finding that residents were inhibited by the medical model, which prizes the “right” answer, she used case conference and texts (e.g., Freud and Beyond, by Mitchell and Black) to instill a psychotherapeutic model which extends beyond the traditional medical model.
Zerbe has co-run seminars with Nancy Winters, a psychiatrist with expertise in cognitive and interpersonal therapies, and used the occasion to compare and contrast how one formulates what ails the patient, and how one then addresses it. This dovetails with encouraging residents to risk being “wrong” in what they say to a patient. She has emphasized that getting to understand the patient (which includes making mistakes or asking the wrong question) can be curative in and of itself. This helps introduce the use of transference and countertransference into the heart of the treatment. The introduction of a psychotherapy track in the outpatient service, along with a self-pay option for patients, has proven a great success, attracting a wide variety of patients interested in psychoanalytic psychotherapy including university students. She developed a summer elective on dream work for fourth-year residents. It is fully subscribed.
In addition to serving on the full-time faculty at OSHU, Zerbe is also a supervising and training analyst at the Oregon Psychoanalytic Institute. Zerbe believes that the involvement of analysts in many aspects of psychiatric training at OHSU has helped stir interest among psychiatrists. Several former residents and clinical and full-time faculty are in full analytic training.
The psychiatric residency at George Washington University Medical Center has long enjoyed strong training in psychodynamic psychotherapy. A confluence of events has further strengthened this aspect of the program.
Janis G. Chester, M.D., a psychotherapist associate, serves on the Psychotherapy Task Force and the Committee on Government Relations and Insurance.
When Jeffrey Akman assumed chairmanship of the Department of Psychiatry, he had to address the fact that the faculty lost money by treating patients covered by managed care insurance plans. He made a bold move, and negotiated with the university CEO for an exception to be made for his faculty; they would no longer contract with managed care. The faculty would instead negotiate fees with their patients in a traditional private practice model. As a result, the department made a financial comeback and set an example for its trainees. The doctor-patient relationship and therapeutic alliance were shown to be alive and well. Thinking and acting along those lines was rewarded. This business decision had another secondary effect on the residents. When the faculty held managed care contracts, only the uninsured patient was eligible for treatment in the resident clinic. Once the contracts were abandoned, all patients could be seen by residents in the outpatient clinic, using a sliding scale payment model. This affords the residents the opportunity to treat a broad array of patients with many diagnoses. Treatment is not dictated or limited by insurance company criteria.
A few years later, the Department of Psychiatry and the Washington Psychoanalytic Institute made another bold move. They entered into an affiliation agreement which brought psychoanalysts back to mainstream medicine. The analysts have fortified their role in teaching and supervising residents and medical students. Psychoanalysts supervise and teach residents starting in the second year of training. Faculty appointments are facilitated by the affiliation, leading to a larger pool of analysts available for teaching, supervision, and seminars. When Washington Psychoanalytic sold its headquarters and needed an interim home, George Washington University made space available for offices and classes. The affiliation was further supported by offering qualified residents the opportunity to begin psychoanalytic training during their senior year of residency. The supervision and clinical work at the Washington Psychoanalytic Institute is credited toward their residency requirements. Stephen Rosenblum, a supervising and training analyst at the Washington Psychoanalytic Institute, helped to shepherd the affiliation and continues to serve as the liaison between the two entities. According to James Griffith, the residency training director at George Washington University, psychoanalysts were important to the residency before the affiliation in a more intangible way. He recalls that the analysts were always able to keep the needs and the uniqueness of the patient in perspective, despite the vagaries of competing theories and the undue influence of third-party payers.