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? FIG1

Her training director and some senior faculty were present, and her fellow trainees spoke up at times, contributing when they could. This much was typical enough.

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 chase.

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 in-state community.

"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 group process."

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 come.

"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 sites."

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 psychodynamic psychotherapy.

"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 JeKatzman@salud.unm.edu▪