Why Psychodynamic Psychotherapy?

 

I am not averse to top ten lists and came up with 8-points initially but easily found another two.  I have had a few posts over the past year based on my experience in a psychotherapy seminar that I coteach with several experienced instructors.  We meet 2 hours a week – every week over the course of the year.  The first hour is a didactic based on the Cabaniss text Psychodynamic Psychotherapy: A clinical manual. (2).   Over the course of the year, we cover every bullet point and entering into this later than my colleagues – I have been impressed with the level of discussion from both the faculty and residents.  The second hour each week is dedicated to the discussion of specific cases.  Different perspectives are encouraged.  I have made note of when I got an idea for a post here from participation in that seminar.  This teaching format was carefully designed over the course of many years by the instructors who were there long before I joined.  They also describe it as a format where clear improvements can be observed in the residents practicing the techniques.  

Several issues come up when psychotherapy training is discussed for psychiatrists. Over the years it has been a hot political issue.  As previously noted – many people like to characterize the history of psychiatry in an oversimplified manner.  The original asylum psychiatrists had little more than moral treatment of Pinel and Tuke.  That was followed by a period of brain based descriptive asylum psychiatry focused on neuropathology and phenomenology.  That was followed by a period of psychoanalysis and psychodynamic psychiatry.  And finally biological psychiatry starting in about the mid-20^th century with advancements in somatic treatments.

That is the timeline that is typically used to describe American psychiatry – but things are always more complicated.  I trained in the 1980s when departments were often split between the psychotherapy staff and biological psychiatry staff – but the split was really an illusion.  The residents were trained in both. I trained with some of the top biological psychiatrists in the country and they also did psychodynamic formulations and psychotherapy.  During my 3 years of residency, I was supervised for an hour for every hour of psychotherapy I provided every week in addition to the training seminars in psychotherapy.   

At the national level experts in psychotherapy have always worked and published in parallel to the biological psychiatrists and neuroscience-based psychiatrists.  The reality is that you cannot practice psychiatry well without being able to integrate the medical, biological, and the psychotherapy dimensions of the field. 

A general psychotherapeutic approach to the patient is required in psychiatry for several reasons. All medical students learn diagnostic interviewing beginning in the first year of medical school. The basic principles are empathy and open-ended questions.  There is not much content about immediate problems in the interview, how to discuss difficult topics, how (or why) to expand on the phenomenology, and what to do about your personal reactions to the patient.  In a previous post I have discussed this as a reason why supportive psychotherapy is the clinical language of psychiatry.

The evaluation in psychiatry is very often an intervention point. It is not possible to interview the patient in a crisis and have them return at a later date to address the crisis.  Talking and psychotherapeutic interventions are the mainstay of crisis intervention. The psychiatrist needs to assist the patient in resolving the crisis.  These crises can happen at any point in time – even in patients who have been doing well for years.  A psychiatrist always needs to be prepared to do crisis intervention at any point in time and that involves good psychotherapeutic skills. 

Psychotherapy is the treatment of choice for many disorders.  It has been used for decades to treat severe personality disorders and the consensus lately is that it is the preferred treatment over medication in some of those scenarios.  The landscape can be confusing because branded and manualized therapies are often used in clinical trials and even though they can get equivalent results.  It is probably safe to say that psychodynamic psychotherapists used to shifting from supportive to interpretative modes see much of what they do in these psychotherapy manuals and trials.

The therapeutic alliance is most explicitly discussed in psychodynamic psychotherapy. It has been written about for decades and is important in all aspects of individualized psychiatric care.  In training it is also discussed as an important anchor point for clarifying the treatment process during periods of conflict or impasse.

Treatment setting is an important aspect of psychiatric care.  In acute care settings, the patient population is selected based on problem severity, lack of response to other therapies, need for additional modalities, and team-based care.  Transference and countertransference is complicated by the fact that it is now occurring at the team and institutional level.  Any psychiatrist working in that setting needs to be able to figure that out and intervene before there are any major problems and assist the team in managing reactions to specific patients and families.

Most of the suggested guidelines for psychotherapy training in residency are competency based rather than based on time.  The reality of training is that there is a shortage of staffing for any centrally recommended training program.  Programs are left to their own devices to provide training in this area. An untapped resource in many areas are retired psychiatrists and therapists who might be willing to volunteer to continue teaching.  That has been my role in this seminar and I find it highly rewarding. 

Training in psychodynamics and all of its theorists also provides and important historical context for the profession.  How were the original concepts modified over the years? Are some of these approaches and concepts (attachment theory, interpersonal psychotherapy, existential psychotherapy, infant psychotherapy, self-psychology, etc) still useful today? 

The most significant aspect of psychodynamic psychotherapy is the unique focus on consciousness. Unless you read about consciousness research explicitly this is the only place where that occurs.  I mentioned last week that when I attended medical school the emphasis was on objectivity and classifying people according to their disease and how well it could be characterized and whether those findings could be replicated. You do not have to be particularly bright to see the shortcoming of this approach.  No two people with asthma, brain tumors, or anemia are alike even after saying they have the same disease.  Their physical state, the way they think about it, their response to treatment, and the way they interact with you as their doctor is unique. In figuring out how to help them with whatever their psychiatric problem is – a diagnosis is only part of the story.  It requires thinking about who they are and why they might be reacting to things the way they do – a formulation.

Finally, and probably most importantly – psychodynamic training prepares the psychiatrist for what is ahead.  The first 5-10 years in practice is a potential minefield.  In today’s practice environment – psychiatrists are often overworked, seeing many people with severe medical and psychiatric problems who also have potentially severe interpersonal problems. Those problems are generally focused on aggression, sexuality, power dynamics like money and autonomy.  There is a general negativity about psychiatry in the press and on social media – largely from people promoting their own interests.  All of that can result in highly stressful situations in practice – especially if there are no colleagues around for consultation.  A psychiatrist can develop anxiety about some of these problems in practice and what can be done about them.  Although the issue has not been studied in the literature – my speculation is that psychiatrists trained in psychodynamics – especially if these topics have been explicitly discussed in training are more prepared to solve them in an effective way than psychiatrists without that exposure.  A typical way this issue is approached is to suggest rules that should not be violated.  Understanding what is happening at an emotional level is probably a better approach.

Reducing the mystery of psychotherapy and having a good idea of how it works is a clear goal. There have been times in my studies where the interventions seemed vague and which interventions were useful was not clear.  I can recall a few highlights over the course of my career that were very enlightening.  The first was a seminar with Otto Kernberg, MD about 30 years ago.  He provided the clearest definitions of the three basic intervention in psychoanalysis and psychodynamics that I have heard.  He described them as, clarification, confrontation and interpretation.  Clarification in this case is communicating the therapists empathic understanding of the patients experiences over time at the conscious and preconscious level.  Confrontation is not the usual adversarial sense, but is used to point out inconsistences or patterns in the patient’s narrative that may have escaped their attention.  In the seminar I attended, Kernberg pointed out that many people may be holding these inconsistencies outside of their awareness and the confrontation serves bring things together in a consistent narrative.  Finally, the interpretation connects patient's conscious experience and unconscious defenses, wishes, or conflicts.  Learning how to do that involves both reading about the theory and basic cases as well as seminar discussions with input from faculty and residents.   

Many consider the interpretation to be the mysterious part of psychodynamics and the secret handshake of this kind of psychotherapy.  It becomes more intuitive with a specific frame for psychodynamic therapy.  The two best examples I can think of are Interpersonal Psychotherapy and the Psychodynamic Life Narrative.  In the first case, Klerman and Weissman used psychodynamic principles to design a manualized therapy for depression.  It was subsequently applied to substance use disorders. Viederman designed the life narrative approach for crisis intervention in college students.  Both therapies are formulation based and designed to be used on a short-term basis.

The flexibility to go from an uncovering or transference based psychodynamic psychotherapy (TFP) to a supportive one is a critical skill.  There are people who will do better with supportive therapy and others who do well with TFP but in a crisis will do better with a supportive approach.  There is a broad range of flexibility in psychodynamic psychotherapy with supportive interventions that are identical to therapies taught separately as cognitive behavioral therapy, and behavioral therapy.  It also provides a framework for existential psychotherapy.     

Mechanisms of change in psychotherapy are written about broadly across therapies and specifically for psychodynamic psychotherapy.  It is safe to say that psychodynamic psychotherapy is more focused on the relationship with the therapist and the central role of emotions and insight. 

That is my brief commentary on the importance of psychodynamics and psychodynamic therapies in psychiatry.  There are many clinical trials for specific conditions that show psychodynamic therapy is effective. Some of those trials are 40 years old at this point.  We have many branded therapies advertised for specific conditions with features that overlap both supportive and psychodynamic psychotherapy adding further support to the claim it is a good approach to teaching psychiatrists.  When I look at the training recommendations for psychiatrists –  if you are running a training program and look at the three choices – psychodynamic psychotherapy should be preferred.  It covers two of the three types of therapy, has a rich history of involvement by psychiatrists at the clinical and theoretical level, and probably provides trainees with a better model for analyzing problems that occur in their future practices.

 

George Dawson, MD, DFAPA  

 

 

References:

 

1:  Kernberg OF.  Severe Personality Disorder: Psychotherapeutic Strategies.  Yale University Press; New Haven; 1984: 381 pp.  

2:  Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES.  Interpersonal Psychotherapy of Depression.  Basic Books, Inc; New York; 1984: 255 pp.

3: Viederman M. The Psychodynamic Life Narrative. Psychiatry. 1983 Aug;46(3):236-246. PubMed PMID: 27719516.

4:  Holly A Swartz.  Interpersonal Psychotherapy (IPT) for depressed adults: Indications, theoretical foundation, general concepts, and efficacy. In: UpToDate, Roy-Byrne P (Ed), UpToDate, Waltham, MA, 2018.  Accessed February 17, 2018.

5:  Wampold BE. How important are the common factors in psychotherapy? An update. World Psychiatry. 2015 Oct;14(3):270-7. doi: 10.1002/wps.20238. PMID: 26407772; PMCID: PMC4592639.

6:  Høglend P, Hagtvet K. Change mechanisms in psychotherapy: Both improved insight and improved affective awareness are necessary. J Consult Clin Psychol. 2019 Apr;87(4):332-344. doi: 10.1037/ccp0000381. Epub 2019 Jan 10. PMID: 30628797.

7:  Churchill R, Moore THM, Davies P, Caldwell D, Jones H, Lewis G, Hunot V. Psychodynamic therapies versus other psychological therapies for depression. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD008706. DOI: 10.1002/14651858.CD008706. Accessed 12 May 2026.

8:  Høglend P. Exploration of the patient-therapist relationship in psychotherapy. Am J Psychiatry. 2014 Oct;171(10):1056-66. doi: 10.1176/appi.ajp.2014.14010121. PMID: 25017093.

9:  Nakamura K, Iwakabe S, Heim N. Connecting in-session corrective emotional experiences with postsession therapeutic changes: A systematic case study. Psychotherapy (Chic). 2022 Mar;59(1):63-73. doi: 10.1037/pst0000369. Epub 2021 Jul 22. PMID: 34291996.

10:  Abbass AA, Kisely SR, Town JM, Leichsenring F, Driessen E, De Maat S, Gerber A, Dekker J, Rabung S, Rusalovska S, Crowe E. Short‐term psychodynamic psychotherapies for common mental disorders. Cochrane Database of Systematic Reviews 2014, Issue 7. Art. No.: CD004687. DOI: 10.1002/14651858.CD004687.pub4. Accessed 12 May 2026.

11:  Perry JC, Bond M. Change in defense mechanisms during long-term dynamic psychotherapy and five-year outcome. Am J Psychiatry. 2012 Sep;169(9):916-25. doi: 10.1176/appi.ajp.2012.11091403. PMID: 22885667.

12: Babl A, Grosse Holtforth M, Perry JC, Schneider N, Dommann E, Heer S, Stähli A, Aeschbacher N, Eggel M, Eggenberg J, Sonntag M, Berger T, Caspar F. Comparison and change of defense mechanisms over the course of psychotherapy in patients with depression or anxiety disorder: Evidence from a randomized controlled trial. J Affect Disord. 2019 Jun 1;252:212-220. doi: 10.1016/j.jad.2019.04.021. Epub 2019 Apr 8. PMID: 30986736.

13:   Yakeley J. Psychoanalysis in modern mental health practice. Lancet Psychiatry. 2018 May;5(5):443-450. doi: 10.1016/S2215-0366(18)30052-X. Epub 2018 Mar 21. PMID: 29574047.

14:  Blatt SJ, Behrends RS. Internalization, separation-individuation, and the nature of therapeutic action. Int J Psychoanal. 1987;68 ( Pt 2):279-97. PMID: 3583573.

Minnesota Continues A Flawed Approach To Serious Mental Illness And Aggression

I was shocked to see this article posted on a CBS web site.  I was shocked because I was completely unaware  that such a law existed.  I was shocked because Minnesota has fairly well documented problems in their state hospital system.  The state security hospital has had numerous problems with containing violence and aggression and there is no evidence that situation has been resolved.  There are very few specialized units in hospitals in the state that could potentially deal with the problems of violence and aggressive patients.  There has been no effort to modify the limited infrastructure in the state that has been the result of managed care-like rationing over the past 20 years.

The story is a lot more involved than suggested by the news article.  When I read it I contacted my state legislators and asked for clarification primarily by pointing me to where the "12 hour rule" existed in the State Statutes.  The Minnesota State Statutes are generally easy to search but I could not find it.  My state Senator got back to me and suggested that this is the rule in 253B.10 PROCEDURES UPON COMMITMENT.  Chapter 253 is the civil commitment statute and reading through this chapter suggests that transfers from jail to state mental hospitals have to be adjudicated as mentally ill by civil commitment.  Other pathways include being found not guilty by reason of mental illness, and for examination or determination of competency to proceed to trial.  Apart from the time constraint, that part of the statute does not materially alter patient flow to state hospitals.  The statute gets more interesting with the following subdivision:

Subd. 4. Private treatment.

Patients or other responsible persons are required to pay the necessary charges for patients committed or transferred to private treatment facilities. Private treatment facilities may not refuse to accept a committed person solely based on the person's court-ordered status. Insurers must provide treatment and services as ordered by the court under section 253B.045, subdivision 6, or as required under chapter 62M. 

Private facilities refuse to accept court ordered and committed patients all of the time just based on the fact that severe mental illness cannot be treated on an 8 day DRG payment that in reality is treated like a 4 or 5 day length of stay.

The article itself focuses on Anoka Metro Regional Treatment Center.  That is a state operated psychiatric facility just north of the Minneapolis-St. Paul area.  If the intent of the legislature is to alleviate crowding in jails, the writing of a statute will not do that.  If I had to estimate, the majority of inmates in county jails with significant mental illness and addiction problems are not committed and do not meet the forensic criteria suggested in the statute.  The article also illustrates the ambivalence that the state government has toward state run hospitals.  Not too long ago, the legislature wanted to close this hospital down.  Many states have adopted the managed care rationing model to mental illness.  They reasoned that the best way to "save" money is to close down state-run hospitals and clinics.  I have no doubt that the state would close it down if possible but it occupies too central a role in the civil commitment process.  There is instead a detailed political process to manage the hospital (see first reference).  That document is current, 114 pages long with 41 references to "jail" and 37 references to "aggression".  It acknowledges the role of the state in treating aggressive patients with mental illnesses. 

I have no way of knowing if any of the patients mentioned in this article requested transfer to a private hospital.  I would consider any hospital in the state that is outside of the state hospital system to be a private hospital because at this point they are all parts of private health care systems.  Only a fraction of community hospitals in the state have psychiatric units and a smaller portion of those are equipped to treat violent or aggressive patients.

I have tried to elaborate on this blog the type of structure necessary to treat people who are violent and aggressive as a result of mental illness. Any time that correctional populations are considered, the problem is more complicated than mental illness or not.  There are many individuals with sociopathy or personalities that are anti-authoritarian and with a tendency to criminal behavior.  At the extreme end a variant of psychopathy has been described where criminal tendencies, combined with a lack of empathy leads to an individual who is potentially more dangerous.  Those individuals often have a history of repeated violence against others and a pattern of planned violence as way of life.  The associated issues are that patients who are predominately personality disordered criminals are better taken care of within the correctional system.  Patients with primary mental illness who are incarcerated for non-violent crimes or violent crimes that occur only an episode of discrete mental illness are probably better treated in a mental health setting - especially if that is a continuation of their ongoing care.  Those statements are generally true because the personality disordered mentally ill will demonstrate a pattern of threatening other patients and staff with physical violence.  They may also exploit more vulnerable patients and try to intimidate them into giving them money, information, or personal favors that they can use to their advantage.  Those behaviors are goal driven, reinforced by a life of crime, and not likely to change as a result of any psychiatric intervention.

The article states that 146 inmates have been transferred from Minnesota jails to state hospitals since July 2013.  There is an eye witness account of what has occurred and a description of some of the injuries to staff including facial fractures and a torn shoulder tendon as the direct result of assaults on staff.  There is also the following statement from the affected staff person:

 And though she agrees there are other factors behind the rise in workplace injuries — a hesitance to use force against potentially abusive patients chief among them — she said she and her co-workers believe the 48-hour rule is largely responsible.

The issue of the use of physical force in psychiatric hospitals was also the primary cause of the upheaval in the previously cited problems at the Minnesota Security Hospital. A change in administration occurred to address the issue of patient injuries due to physical interventions. According to news reports that and the associated administrative measures were associated with an increase in staff injuries. We are left with the impression that there have been no effective interventions to prevent patient and staff injuries in state hospitals and the problem of aggression in these facilities has been poorly addressed. Organized psychiatry in the state has been silent on these issues.

The bottom line in this article is that it illustrates that Minnesota politicians and bureaucrats have no understanding of what is required to treat people with mental illness and aggressive behavior.  Their misunderstanding is significant and it occurs at multiple levels.  First, they have no understanding that the current system of mental health care is based on a system of rationing designed to provide minimal to no mental health care.  That all starts with hospital systems that have been rationed to the point that there are often no detectable changes in the mental health of the people admitted compared with the people discharged.  Psychiatric care in rationed hospitals is designed to limit treatment to a brief period or reimbursement.  Second, they have a track record of using mental health jargon to come up with their own diagnostic category of "sexual psychopaths" that can be used for indefinite confinement of sex offenders.  This categorization allows for diversion away from a correctional system that is apparently unable to confine sex offenders to the satisfaction of politicians and their constituents.  Third, the state managed security hospital has had a number of problems in the past few years including the mass resignation of psychiatry staff and an increasing number of injuries to hospital staff.  Fourth, Deputy Human Services Commissioner Anne Barry is quoted in the article. She was also quoted in previous articles about the Security Hospital. She attributes the problem to unintended consequences. To me that suggests a complete misunderstanding of psychiatric services in the state of Minnesota. Any psychiatrist in this state, especially if they work on an inpatient unit would be able to predict this problem. Commissioner Barry has also been quoted in the articles about the Security Hospital (see below)  Fifth, the direct quote by State Sen. Kathy Sheran also illustrates a misunderstanding of the problem. The idea that state hospitals are holding large numbers of people who don't need to be there is longstanding political rhetoric. In the absence of environments that can assist severely disabled individuals the default environments are hospitals. It is glib to say that people should no longer be a hospital when they have no safe place to live outside the of the hospital. As a reviewer of hospital admissions and lengths of stay, the presence of acute symptoms is typically used to mark who should be in a hospital. Chronic severe psychiatric disorders have a number of problems with cognition and functional capacity that lead to an inability to care for self independently of acute symptoms.  The associated political problem is a lack of funding for community based programs to resolve the problem.  As I have previously posted in many cases these community based programs that are inadequately equipped to contain aggression place both patients and staff at higher risk.

I qualify this post with the same qualifications I have put on previous posts on the topic on state run facilities.  The only source of information I have on this issue has been the press and legislative reports on mental health services in correctional facilities and at Anoka.  Media reporting of psychiatric issues and services leaves a lot to be desired and typically vacillates between blaming psychiatrists for all of the problems and tragic cases that result from a lack of services.  The only corroboration in this article seems to be the reaction of state politicians to it.  We have seen similar reactions to these issues in the press.  Unless there are some outright denials about the scope of the problem, something needs to be done.  The last thing we need is a state run Task Force or Commission investigating  itself.  The second to last thing we need is consultants hired by the state to write another report.  At this point, I don't even think that a review of the incidents is possible.

Any hospital in the state should be required to prospectively flag records based on violence, aggression and whether they were transferred from the correctional system.  All of the staff in those cases should make a recording of their perceptions of the antecedents, intervention and why it failed or succeeded, and the outcome.  Those cases should be reviewed on a weekly or monthly basis by psychiatrists with experience in treating severe mental illnesses and aggression.  That panel of psychiatrists should be carefully screened for conflict of interests, especially any financial conflicts of interest with the State or any other entities responsible for providing the treatment in question.

It is time to solve this problem.  Having the problems analyzed time after time by the same people who do not understand the problem and who can not possibly come up with a solution has not worked in the past 5 years and it will not work in the future.  Instead we have a state official charged with solving the problem saying that fewer psychiatrists makes sense and psychiatric expertise at the systems level is not needed as the system continues to collapse.  The system of state hospital care for patients with serious mental illnesses and aggression may not be salvageable at this point without realistic backing by the state.

A key part of the miscalculation appears to be casting psychiatrists in the role of generic technicians.  Of course these technicians would not have any understanding of patient centered care or a therapeutic alliance despite the fact that they have been writing about it for over a 50 years.  This accomplishes two goals at least at the rhetorical level.  It makes it seem like untrained administrators can address systemic issues of violence and aggression.  It also makes it seem like the only thing psychiatrists can do it prescribe medications - often to "stable" people.  Far too many errors have been made and public statements on the issues are consistent with a lack of appreciation of the problem and a complete lack of appreciation that psychiatrists are the only people professionally trained to provide this level of care.  This is by no means only limited to state systems.  These attitudes are prevalent in any hospital or clinic that is under the direction of a managed care system.

Will the problem of aggression in people with severe mental illness be addressed by arbitrary rules on patient flow and a treatment program that is flowing down from politicians and bureaucrats?  Will the problem be solved by a consensus of stakeholders?  Will the problem be addressed by new age jargon and philosophy?

I don't think so.


George Dawson, MD, DFAPA

Refs:

Minnesota Department of Human Services - Direct Care and Treatment. Plan for the Anoka Metro Regional Treatment Center. Direct Care and Treatment and Chemical and Mental Health Services Administrations. February 18, 2014

From the above document:  "Jails also count on AMRTC to take people whose criminal behavior is determined to be the result of mental illness (a new law requires that AMRTC accept referrals from jails within 48 hours of referral). Because of insufficient capacity in the service system, there are lengthy waiting lists for AMRTC beds"  (p 61).

Supplementary 1:  A previous quote from Commissioner Barry: "DHS officials say the facility no longer needs as many psychiatrists because many of the patients are stable and only require psychiatric visits once every three months. In addition, Barry said, the importance of psychiatrists at the facility has lessened over the years. Psychiatrists are just one part of the treatment team, she said. Nurses and psychologists also play an important role in patient care, and in many cases, advanced practice nurses can handle many of the tasks that used to be the responsibility of the psychiatrists, she said."

Supplementary 2:  I was unable to find any statute that described this 48 hr transfer rule.  I have asked my state representatives for assistance since it may not be a statute.  Corrected as of 12/9/2014 with the statute posted above.

Supplementary 3:  If you currently work in a non-state funded psychiatric unit and have received these transfers from correctional facilities please post your experience in the comments section below.  Feel free to post them anonymously and in a way that does not indirectly identify you or the facility that you work at.

Suggested Changes to Psychiatric Residency Programs

I received an e-mail two weeks ago that asked for my suggestions on immediately reforming residency programs for psychiatry.  I had the experience of completing my residency in two different university based programs.  My residency occurred at the height of the controversy between the self described biological psychiatrists and the psychotherapists and psychoanalysts.  Although I have never seen it written about there was open animosity between the groups at times.  A biological psychiatrist back in the day might make a statement like: "I don't do talk therapy".  A psychotherapy oriented psychiatrist might refer to the biological types as "Dial twisters" referring to an approach that suggested excessive biological reductionism.  Apparently neither group had read Kandel's seminal article in the New England Journal of Medicine four years earlier and how plasticity can be affected by talking, medications, and of course other experiences.

Several years ago, I attended an anniversary of the University of Wisconsin Department of Psychiatry, the program I eventually completed my residency at.  Thomas Insel, MD was one of the invited speakers.   He outlined a revolutionary approach to educating psychiatry residents that involved a joint 2 year neuroscience internship with residents from neurology and neurosurgery.  He did not provide any details.  When I sent him a follow up e-mail two years later, he said it would probably not happen on his watch.  I can easily build on that theme.  I think that a two year program focused on basic and clinical neuroscience remains a good approach.  The current approach to getting the relevant information is haphazard at best.  It depends on lectures in neuroscience being interspersed with clinical rotations of varying quality and to a large extent it depends on the faculty.  How many faculty are there and how many of them are expected to produce managed care style billings or "productivity" rather than high quality teaching.

A comprehensive and integrated approach that will teach state of the art neuroscience and provide the relevant training in neurology and medicine is possible.  There are many obvious areas for improvement.  Residents often spend their time on clinical rotations of minimal relevance for psychiatrists.  I can recall learning ICU medicine and needing to familiarize myself with various tasks (Swan-Ganz catheters, central lines, ventilator settings, dopamine drips, balloon pumps) that I would never use again.  I needed to be seeing hundreds of people with heart disease, arrhythmias, hypertension, diabetes, other endocrine disorders and neurological disorders.  I saw many of those people when they were hospitalized, but seeing these folks in ambulatory care settings designed to enhance the learning experience for a psychiatrist would provide a better experience.   The process should probably start earlier in the fourth year of medical school.  Prospective psychiatrists should be focused on electives in neurology, medicine, and neurosurgery rather than psychiatry.

The teaching of psychiatry needs to address the practical concerns about diagnosis and treatment but also philosophical concerns.  Residents need to be familiar with the antipsychiatry philosophy and the existing literature that refutes it.  Residents need to know about the issue of the validity and reliability of psychiatric diagnoses and how that is established.  There is actually a rich history of how that came about but it could easily be summarized in one seminar.  One of the features that I was interested in when I was interviewing for residency positions was whether or not the program supplied a reading list.  There were surprisingly few that did.  This subject area would be a good example of required reading that is necessary to bring any prospective resident up to speed.

A good model to illustrate the difference between a neuroscience based approach as opposed to a symptoms based approach is American Society of Addiction Medicine (ASAM) definition of addiction on their web site.  Unlike the DSM collection of symptoms designed to pick a group of statistical outliers,  the ASAM definition correlates known addictive behaviors with brain substrates or systems.  Both of the standard texts in the field by Lowinson and Ruiz and the ASAM text by Ries, Feillin, Miller, and Saitz are chock full of neuroscience as it applies to addiction.  When I teach those lectures, I generally am talking about how medications work in addiction at that level but also how psychological and social factors work at the level of neurobiology.  I have not seen the DSM5 at this time, but I do think that it is time to move past defining every possible substance of abuse and associated syndrome and incorporating neuroscience.  Especially when the neuroscience in this case has been around for 50 years.   Residency programs need to teach that level of detail.

Psychiatrists need to maintain superior communication skills relative to other physicians and that means getting a good basic experience in interviewing and psychotherapy techniques.  At the same time - the psychiatrist of the future needs to be able to order and interpret tests including ECGs and MRI scans.  That wide skill base taxes every faculty except the very largest academic departments.  In the Internet age, there is really no reason that every residency program should not have access to the same standardized PowerPoints, lectures, and didactic material.  The ASCP Model Psychopharmacology Program is an excellent example of what is possible.  I would go a step beyond that and say that there should be a culture within organized psychiatry so that every psychiatrist should have access to the same material.  Establishing a culture where everyone (trainees and practicing psychiatrists alike) is up to speed and competent across the broad array of topics that psychiatrists need to be familiar with is a proven approach that is rarely used in medical education.

Psychiatry also needs to be focused on old school quality.  Not the kind of quality that depends on a customer satisfaction survey.  The issues of diagnostic assessment and appropriate prescribing at at the top of the list.  How do we make sure that every person consulting with a psychiatrist gets a high quality evaluation and treatment plan and not a plan dictated by a managed care company?  The University of Wisconsin has a paradigm for networking with all physicians in their collaborative Memory Clinics program.  I see no reason why that could not be extended to different diagnostic groups across the state.  The focus would be on quality assessment and to prevent outliers in terms of treatment.  It could be open to any psychiatrist who wanted to join and it could have additional benefits of providing university resources like online access to the medical library to clinicians in the field.

An interested, excited, and technically competent psychiatrist is the ultimate goal of residency and it should continue throughout the career of a psychiatrist.  That can only happen with a focus on professionalism at all levels.  My definition of professionalism does not include managing costs so that  a managed care organization can make more money.  Psychiatrists need to forget about being cost effective and get back to defining and providing the best possible care.   

George Dawson, MD. DFAPA