HOW ENDANGERED IS DYNAMIC PSYCHIATRY?

MELLMAN

How Endangered is Dynamic Psychiatry in

Residency Training?
Lisa A. Mellman
Abstract: The future of psychodynamic psychotherapy in residency training is in
jeopardy. New priorities and forces currently aligned in academic psychiatry
challenge the importance of psychodynamic psychotherapy and, by extension,
its core concepts of the unconscious, defense and resistance, transference and
countertransference, and the past repeating itself in the present. The exit of psychoanalysts from academic centers in the last quarter of the past century was
propelled by forces including biological psychiatry, managed care, and competition from other mental health disciplines. ACGME psychotherapy competencies introduced in 2001 renewed the focus on psychotherapy training in
residency and set a residency training standard for psychotherapy competency.
A recent shift in academia prioritizing evidencebased medicine and a shortage
of psychiatrist researchers may threaten those gains.

The future of psychodynamic psychotherapy in psychiatry residency

training is in jeopardy. Although this alarm has been sounded before,
new priorities, forces, and objectives currently aligned in academic psychiatry challenge the importance of psychodynamic psychotherapy education and, by extension, its core concepts, including the unconscious,
defense and resistance, transference and countertransference, and the
past repeating itself in the present.
A number of authors have described forces that have an impact on the
field of psychodynamic psychiatry in the United States, moving it into
its current place today (Auchincloss, Gabbard, Kernberg, Lieberman,
Mellman, Tasman). Once dominant in academic psychiatry, psychoanalysis failed to fully realize its postwar promises of the 1950s and
1960s. Benefits to patients, though substantial, turned out to be more
modest than predicted. Its cousin, psychodynamic psychotherapy, has
survived in a few academic centers. Even in those instances, the heyday
of psychoanalysis has been replaced by the era of biological psychiatry
and novel medications. Although drug development has been a tremendous boon to the armamentarium of psychiatrists, and provided treatment solutions for many patients, the biological era has also turned out

Lisa A. Mellman, M.D., College of Physicians and Surgeons, Columbia University.

Journal of The American Academy of Psychoanalysis and Dynamic Psychiatry, 34(1) 127-133, 2006
2006 The American Academy of Psychoanalysis and Dynamic Psychiatry

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MELLMAN

to have limits. By the 1990s, many psychopharmacologists acknowledged that cure is sometimes evanescent and drugs may not produce
complete recovery. Where have these shifts left psychodynamic psychotherapy? The exodus of psychoanalysts from academia eroded the
teaching of psychotherapy. In many departments, new leadership felt it
was expendable. Psychodynamic teachers felt unwanted. The growth of
pharmaceuticals has left talk therapy out of the loop.
Other factors have further eroded the place of psychodynamic therapy in residency education in the past two decades. Managed care has
controlled the role of the psychiatrist, often explicitly or implicitly preventing psychiatrists through low reimbursement from delivering therapy (Domino, Salkever, Zarin, & Pincus, 1998) Everexpanding numbers of therapists from other mental health disciplines and alternative
treatments compete with psychiatrists for the same pool of prospective
therapy patients. Meanwhile, exciting developments in neuroscience research and the completed mapping of the human genome focused attention and research funding on the brain and genetics (Tecott & Nestler,
2004). For a long time, psychodynamic psychiatry responded by burying its head in the sand. Despite annual meeting themes in psychiatric
organizations invoking the mind, relatively speaking, the mind has
lain fallow.
Residency training is regulated by the Accreditation Council of Graduate Medical Education (ACGME) and its specialty Residency Review
Committees (RRC). Although residency training regulations until 2001
required residents to have didactic and clinical experiences in
psychodynamic and other psychotherapies, programs had enormous
latitude in interpreting these requirements. They were not defined by
content, duration, or skill set. As analysts were pushed out from and fled
academia, fewer faculty had the psychodynamic psychotherapy background necessary to teach it, and less room existed for it in curriculae.
Residents began to associate psychodynamic therapy only with the outpatient setting and a minority of patients. As a field, psychodynamic
psychotherapy clinicians and educators became increasingly concerned
about these changes in psychotherapy education. Over the past 15 years,
some moderately successful efforts have been implemented and have
even been sustained. For example, the American Psychiatric Associations Commission on Psychotherapy by Psychiatrists, established in
1996, responded with a variety of initiatives, including papers demonstrating that psychotherapy was cost-effective (Lazar & Gabbard, 1997),
and a series of teaching conferences for residency training directors on
aspects of psychotherapy training addressing pedagogy, supervision,
and formulation. The American Psychoanalytic Association developed
an outreach fellowship program to expose trainees interested in

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129

psychodynamics to psychoanalytic thinking and mentoring

(www.apsa.org/fellows). The commitment of resources for this popular
fellowship program is substantial. Local psychoanalytic institutes have
developed parallel local fellowship programs to encourage interest in
psychodynamics. In response to a decline in interest in psychoanalytic
training among psychiatrists, some psychoanalytic institutes have
developed postgraduate 2-year psychotherapy training programs to
address the changing environment.
The erosion of psychotherapy education, especially evident in oral
board examinations by the American Board of Psychiatry and Neurology, led the regulatory agency accrediting psychiatric residencies to issue a new mandate. The ACGME and its RRCs were already planning to
mandate in 2001 that all residencies in all specialties train residents to a
level of competency in six core areas: medical knowledge, patient care,
interpersonal and communication skills, professionalism, practice-based learning, and systems-based practice. In response to concerns
about psychotherapy education, the Psychiatry RRC alone issued an additional mandate: to train to competency in five psychotherapies, including cognitive-behavioral therapy, psychodynamic psychotherapy,
supportive therapy, brief therapy, and combined psychotherapy and
psychopharmacology. The American Association of Directors of Psychiatric Residency Training (AADPRT) and other organizations had encouraged the RRC to require psychotherapy training. Psychotherapy
educators celebrated that psychotherapy education was now
resuscitated.
Fast forward four years later to 2005. Psychotherapy educators have
raised many questions and learned a great deal. Competency has turned
out to be difficult to define. For example, should resident competency in
psychodynamic therapy include the ability to interpret defenses, or simply the ability to recognize that patients have unconscious defenses?
Should residents be expected to address negative transference or merely
recognize it? Because most residents have difficulty addressing negative
transference, for example, and many programs lack the faculty for individual supervision with someone well trained in psychodynamics, can
we consider residents competent when they have only a basic understanding of these concepts? In fact, many residents have never treated a
given patient in therapy for longer than a few months, and most never
treat patients more frequently than once a week. In select programs,
most residents do develop substantial understanding and skill in
psychodynamic therapy. Using driving as an analogy, basic skills and
minimal practice are enough to obtain a drivers license. Society expects
a minimum standard of competency, and expects skills to grow with

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practice. Some drivers drive infrequently but maintain their license. Is

psychotherapy competency similar (Yager & Bienenfield, 2003)?
More difficult than defining competency is measuring it. Do supervisors across programs or even within the same program focus on the
same competencies, or is there great variability between supervisors?
On what basis does a supervisor rate a resident as competent on each
competency? Does interrater reliability exist among supervisors so that
evaluations are standardized? The literature tells us no (Goin & Kline,
1974). Furthermore, is a supervisor able to evaluate a resident without
being biased by the developing relationship? Are supervisors honest
when they write their evaluations? All of these issues came to the fore as
the field of training directors grappled with the mandate. Until the competency movement forced the field to carefully consider methods of assessment, many programs rated most of their residents excellent most
the time on evaluation forms.
Developing standardized tests for psychotherapy competency is
timeconsuming and expensive. The Columbia Psychodynamic Therapy Test, developed by Drs. Linda Mullen, Ronald Rieder, and Robert
Glick from the Columbia University Department of Psychiatry, is to date
the only standardized competency measure in psychiatry (Mullen et al.,
2004). This multiple choice paper-and-pencil test, now available online
(http://psychotherapy.cursum.net), assesses psychodynamic understanding and technique for residents. Administered to more than 1,000
residents, it has demonstrated that experts perform better than residents, and that performance correlates with time spent conducting
psychodynamic psychotherapy and in supervision. In addition to utilizing written supervisor evaluations, a few programs require residents to
videotape psychotherapy sessions for use in supervision. The rare program asks outside raters on the faculty to rate videotaped psychotherapy sessions for competency, and to discuss the ratings with the resident
as an educational exercise (Mellman, 2005). Some training directors report that they are putting a great deal of time and energy into psychotherapy evaluation, and a few question its cost-effectiveness in time,
priorities, and learning (personal communication).
Four years after the ACGME mandate for demonstration of competency,
new developments affect training. RRC site visitors have not focused on
psychotherapy competency, leaving program directors wondering
whether their efforts matter. In 2001 the former director of the National Institute of Mental Health, Steven Hyman, commissioned the Institute of
Medicine (IOM) to address the decline of psychiatrist clinician scientists in
the United States. Although there are many reasons for the decline in researchers that belong outside of residency training, the IOM committee
chose to focus their final report, Research Training in Psychiatry Residency:

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Strategies for Reform (200?; http://www.nap.edu/catalog/10823.html), and

recommendations on residency. Recommendations are organized into five
categories: longitudinal factors, continuum of education, regulatory factors, personal factors, and implementation by stakeholders. To address implementing the recommendations, Thomas Insel, Director of the NIMH, established a National Psychiatry Training Council (NPTC) comprising
researchers, educators, leaders in psychiatry, and residency training directors to address the problems that were identified in the IOM report. NPTC
task forces are studying the issues, namely, pipeline, research literacy,
model programs, regulatory revisions, retention, finance, outcomes, and
dissemination. The goal of the NPTC is to reform psychiatric residency
training to allow flexibility to facilitate research and subspecialty training
during residency, and to require competency in research literacy and the
principles of evidencebased medicine (Fenton, James, Insel, 2004; Yager,
Greden, Abrams, & Riba, 2004). Residency training directors point out that
the current RRC requirements already allow up to 16 months, or one third
of adult residency training, to be devoted to research without changing any
RRC regulations.
Consequently, the landscape has shifted in a few short years from a
psychotherapy and competency focus to research literacy and research
training, facilitating the development of more general psychiatry and
subspecialty researchers. Some in the research community believe that
only evidence-based treatments should be taught, leaving
psychodynamic psychotherapy in the dust because its established evidence base is weak when using the gold standard of randomized controlled trials. A dichotomy has developed in which some researchers believe that psychotherapy training, especially psychodynamic
psychotherapy training, which requires more time to learn because of its
complexity, takes precious time from research training, creating an eitheror educational environment. At the same time, researchers and
training directors alike believe that residents need more training in neuroscience and research literacy. Many researchers and some training directors feel that teaching psychotherapy to competency and teaching neuroscience well is an impossible task, and consequently they recommend
only exposure to psychotherapy in residency, without an expectation of
competency. This issue was debated by Drs. Joel Yager, Allan Tasman,
Lisa Mellman, and Eugene Rubin at the 2004 APA annual meeting (Yager,
Mellman, Rubin, & Tasman, 2005).
The RRC is currently in the process of revising the Program Requirements for Residency Training in Psychiatry, a task that recurs every 5
years. The new ones will be issued in 2006. AADPRT conducted a detailed survey of residency training directors in 2004 that demonstrated
substantial support for the continued requirement of psychotherapy

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training at the level of competency. Most training directors recommended, however, a reduction in the number of required
psychotherapies, and particularly endorsed cognitive-behavioral,
psychodynamic, and supportive therapies. Brief therapy and combined
therapy are subsumed under those three. Although training directors
still struggle with implementing the 2001 mandate in their programs,
given limited resources in time, trained faculty, suitable patients, and financial coverage, and though some believe the mandate excessive,
many believe that their psychotherapy teaching has improved because
of the mandate. Some training directors believe that strong programs
with substantial resources indeed train residents to a standard of competency that psychotherapy experts would endorse. Nevertheless, for
the field, the definition of competency for training directors has
quietly shifted to a level more realistic for psychiatry residents.
To provide some perspective, it is especially worthwhile at this time to
compare psychotherapy expectations with those in other important areas such as psychopharmacology. Although residents are expected to be
skilled in providing psychopharmacologic treatment, competency in it
has not been systematically defined or evaluated thus far. The standards
used in psychotherapy assessment must also be considered in other
areas of psychiatry training.
Standards set the floor in defining expectations. Without clear standards for psychotherapy education requirements, many programs will
take the path of least resistance. Residents should learn psychodynamic
psychotherapy from trained faculty in individual supervision and treat
suitable patients for adequate lengths of stay. Without standards, residents will likely be exposed to some degree of psychodynamic didactic
teaching and a watereddown, eclectic experience in treating patients
and receiving supervision that will be called psychodynamic psychotherapy. Programs already exist in which few psychiatrists have the
skills to teach psychotherapy. If psychotherapy competency is not expected of residents, residents receive a clear message that it is expendable, not in their job description, and they will have no psychiatristtherapist role models to emulate. Psychodynamic concepts will further
disappear from clinical discussion, ironically, just at the time the field of
cognitive neuroscience is beginning to study them. Except in a few programs, psychotherapy will die out in residency training. Medical students choose psychiatry because they want to talk to patients. A residency training world teaching diagnosis and medication as the only
important venues will discourage students from choosing psychiatry,
produce unfulfilled psychiatrists, and ultimately limit the discoveries
researchers can make.

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