It was not your standard case conference with faculty and residents.
Caroline Lewis, M.D., a fourth-year psychiatry trainee at the University of
New Mexico, sat at a table with her fellow residents discussing a patient in
psychotherapy. What—she needed to know—was she to make of the
wealth of material the patient presented?
Her training director and some senior faculty were present, and her fellow
trainees spoke up at times, contributing when they could. This much was
Not so typical was the image on the wall facing the residents of consulting
psychoanalyst David Stevens, Ph.D., televised via video camcorder from his
laptop in his office in Denver. He listened in on the case description as if
he were there at the table. Then he offered a veteran's advice on Lewis's
perplexing case, seeming after only a brief introduction to cut to the
Stevens is a seasoned educator and clinician in private psychoanalytic
practice, with experience working with psychiatry residents at the University
of Colorado Health Sciences Center and with psychoanalytic candidates at the
Denver Psychoanalytic Institute.
"It was awkward at first," said Lewis of the video conference
encounter, "but once I got used to it, it felt really natural. And I
feel very fortunate. [Dr. Stevens] could take what felt like a huge amount of
complex information and get right to the heart of the matter. And he always
made me feel validated in my own opinions. He seemed very comfortable in
meeting residents where they were."
The psychotherapy training teleconference is an innovative exercise at the
University of New Mexico (UNM) Department of Psychiatry to harness the
technology of telemedicine for the purpose of making psychodynamic theory and
practice more accessible to trainees by bringing psychoanalytic leaders from
around the country to the residency case conference table.
The effort is an offshoot of Project Echo, an initiative of the University
of New Mexico to use telemedicine to transmit expert advice about common,
chronic, and complex diseases to primary care physicians in remote regions of
the desert Southwest. Psychiatrists at UNM have participated by providing
consultation on psychiatric aspects of such medical problems as hepatitis C,
pain, addiction, and diabetes; the project was extended also to bring
psychotherapeutic expertise at UNM to nether regions of New Mexico.
But the really transformative innovation occurred when Jeffrey Katzman,
M.D., a professor and vice chair for education and academic affairs in UNM's
Department of Psychiatry, seized on the fact that the technology had now made
it possible to expand the search for psychodynamic expertise beyond the
"The University of New Mexico has long had an interest in
psychodynamic psychotherapy, but has been looking to expand its resources even
further," Katzman said at a workshop presentation on the project at the
annual meeting of the American Association of Directors of Psychiatric
Residency Training in Tucson, Ariz., in March. "So we wondered, 'Was
there a way to consider faculty outside of this department as potential
psychodynamic supervisors and teachers?'"
Katzman began to talk the idea up. "I collected some names from
people I knew in the psychoanalytic community around the country," he
told Psychiatric News. "I knew the analysts would need to be
not only expert in psychodynamic theory, but good at talking to residents and
flexible enough to think about a case while simultaneously attending to the
Stevens, in Denver, and three other analysts were contacted from institutes
in Los Angeles and New York City. The supervising analysts were offered an
honorarium for eight hours of consultation time and were able to connect to
Project Echo's already existing software program from their private offices
using camcorder equipment that is standard today on most laptop computers.
Fourteen third- and fourth-year psychiatry residents participate in the
program; each week a different resident presents a case, and the case is
discussed with the supervisor.
"What interested me when I was approached was the technology,"
Stevens told Psychiatric News. "I knew New Mexico was on the
cutting edge of telemedicine, and I wanted to see how far the technology had
"I had once led a video conference with a group of analytic
candidates about eight years ago," he added. "At the time the
technology was terribly primitive. I couldn't make out faces so I couldn't
tell who was talking. It was extremely fatiguing to teach in that format, and
I ultimately stopped.
"But what struck me about this experience was how much better the
technology is today. On my end, all it really required was that I have
broadband capacity to upload and download at sufficient speed to make the
images fluid. I was impressed with how radically improved the images and
sounds felt, and I didn't have the feeling that I was just connecting to a
voice, but could see who was speaking. And I think it did overcome the feeling
of being disconnected."
Katzman and Lewis agree that psychotherapy videoconferencing has helped to
bond residents while also connecting them to the larger world of psychodynamic
theory and practice.
"Residents are at very different levels, and the supervising analysts
have been able to adapt to where they are at any given moment," Katzman
said. "The trainees feel more connected with each other because it's
been a process of sharing their work with each other, and they feel connected
to a national network by being exposed to practitioners in multiple
The program offers some advantages over the traditional faculty case
conference. Because the supervising analysts are from outside the training
institution, they don't bring to the encounter any threat of judgment or
influence over the trainees' future.
"I think it might be quite liberating to have instructors who aren't
on the faculty of the institution," Stevens said. "I'm not grading
anyone, and I can't help wondering if in fact that might help people to let
their hair down and really talk about what is going on with a case."
Katzman said there are plans to grow the program by linking to other
interested training programs. And the project does seem to offer a new
opportunity to exponentially diffuse a specialized body of theory that has
traditionally been somewhat exclusive.
"This so clearly offers a way to connect with people at a relatively
low cost and to create meetings and collaborations and study groups of all
kinds," Stevens said. "Within the psychoanalytic community, people
are connecting through these technologies across great spaces. I'm quite
excited about what this technology can make possible."
And not just to residents who are determined to pursue a career in
"There is the practice of psychoanalysis, and then there is the
theory, which is a general theory of personality and development," said
Stevens. "To me there is no conflict around teaching the theory of
psychoanalytic development to people who intend to prescribe medication or do
cognitive-behavioral or some other kind of psychotherapy. Psychoanalytic
theories, I believe, can inform practitioners of any kind who want to make
sense of human behavior."
Lewis intends to pursue a career in psychodynamic psychiatry. She said that
teleconferencing with experts in the field has helped her navigate the strange
and mysterious waters of psychotherapy.
"Part of the challenge in doing psychotherapy is to take stock of
what is going on with you and how you are reacting to the patient during the
therapy," she said. "It's a very strange and intimate relationship
you have with a perfect stranger. But it works, and the supervision has made
me much more comfortable doing it. And it's made me aware of how important it
is to have really good supervision."
Information about Project Echo is posted at<http://echo.unm.edu/>.
Individuals interested in learning more about the project at UNM may contact
Jeffrey Katzman, M.D., at