From the moment Saint Elizabeths Hospital opened its doors in 1855, it began training physicians on how to treat the psychiatrically ill, eight decades before formal residency programs were established. In 1909 William Alanson White (1870-1937) began training future psychiatrists at Saint Elizabeths Hospital in the importance of psychoanalytic concepts.
This psychoanalytic training orientation has remained throughout the last hundred years, through training that became part of Saint Elizabeths's residency programs in the 1930s, through its training U.S. Navy physicians to be psychiatrists in World War II, through the years when psychoanalysis dominated American psychiatric education, and has continued despite the turn toward biological training in many residency programs over the last quarter of a century.
Among the early ones to benefit from Saint Elizabeths's psychoanalytic training was Harry Stack Sullivan (1892-1949). Furthermore, many Saint Elizabeths graduates have become key faculty of the two psychoanalytic training institutions, The Washington Psychoanalytic Institute and the Baltimore Washington Psychoanalytic Institute.
The Washington metropolitan area has five outstanding residency programs in addition to Saint Elizabeths: Howard University, Georgetown University, George Washington University, and Uniform Medical School. By far, most of the psychiatrists in this metropolitan area were trained at Saint Elizabeths, contributing to the Washington Psychiatric Society's (WPS) psychoanalytic orientation. In 1971, for example, the American Psychiatric Association had developed a publication championing the reasonableness of non-discrimination as to national health insurance, but the book was to have an appendix of “fallback” positions of coverage that would not include psychoanalysis. WPS leadership, largely psychoanalysts with ties to Saint Elizabeths, strongly objected and the book underwent an appendectomy.
From the moment Saint Elizabeths Hospital opened its doors in 1855, it began training physicians on how to treat the psychiatrically ill, eight decades before formal residency programs were established.
It is unusual for a residency program to be independent of a university and to be totally dependent on the public dollar. How can it be justified to train psychiatrists in a public setting, treating the most disabled of the psychiatrically ill, and stressing psychoanalytic concepts, when very few of the patients could be seen as ideal psychoanalytic patients? Why should the public taxpayers pay to train physicians in a psychoanalytic-oriented program? Should not the focus be on psychopharmacology? Should not the focus of therapy be on behavioral and cognitive concepts? These were the questions that one of us (RP) faced when he chaired the psychiatry department at Saint Elizabeths for 16 years (1979-1995). Year after year, first NIMH budget officials and later, beginning in 1987, District of Columbia budget officials would demand a justification for our psychoanalytic orientation.
The answers given to the hierarchy to justify this orientation over the decades would be the same answers TAP readers would give today.
First, we would point out that no matter how short the interaction that a physician would have with a patient, transference and countertransference cast their influence. Actually, we would point out, the very short interactions can be overwhelmed with transference, and countertransference feelings can have an enormous impact on the effectiveness of the interaction. The public system of psychiatric care and treatment effectiveness is very dependent on the clinicians' sensitivity to transference and countertransference, even if not a single one of the several thousand patients is in psychoanalysis and only a handful are in psychodynamic psychotherapy.
Second, it was emphasized that regardless of care and treatment being given, history is important. No other major psychiatric approach expects the clinician to obtain the detailed history of the patients that the psychoanalytic orientation expects.
Third, it was emphasized that we want all of our psychiatrists to view each patient as an individual. One of the most winning aspects of psychoanalytic orientation is its avoidance of simplistic reductions. There is a respect for the person that the psychoanalytic orientation requires that we want all psychiatrists to maintain throughout their careers.
Budget folks have a human side. They can understand that the concepts of therapeutic alliance, transference, and countertransference are very important, that unprofessional psychiatrists can severely harm institutions, that a public clinician should acknowledge the importance of the past, and that it is especially key to accept these vulnerable and unlucky citizens as individuals. These values should last another hundred years.
Roger Peele, M.D., is an honorary member of the Baltimore Washington Psychoanalytic Society, chief psychiatrist of Montgomery County, Md., and serves on the faculties of George Washington University, Howard University, and Saint Elizabeths Residency. He treats patients at Mercy Clinic.
Humaira Siddiqi, M.D., is a resident at Saint Elizabeths.