Should residency programs prepare trainees to function in the prevailing practice environment as third-party payers mold it or to be competent in all dimensions of psychiatry and what it can offer patients?

It's a question that is crucial in determining whether training in psychodynamic psychotherapy has a future in psychiatric residency programs.

A small, qualitative survey of residency training programs in two geographic areas suggests that training directors recognize that psychodynamic psychotherapy is a vital part of the psychiatric identity and want to graduate psychiatrists who are competent to do it. But they may also face manpower, financial, and—sometimes—institutional and attitudinal obstacles.

The survey was presented by Norman Clemens, M.D., and Malkah Notman, M.D., during a symposium at APA's annual meeting in May that focused on teaching psychodynamic psychotherapy.

Clemens and Notman queried directors of 11 training programs—seven in Boston and four in northeast Ohio.

All of the programs were affiliated with medical schools.

In answer to the question, "Does your residency teach psychotherapy of any type with the aim of achieving a phase-appropriate level of competence in providing it?," all 11 programs said "yes." And in answer to the question, "Does your residency teach psychodynamic psychotherapy with the aim of achieving a phase-appropriate level of competence in providing it?," 10 said "yes" and one said "no."

There was wide variation in number of hours of teaching devoted to varying types of psychotherapy—psychodynamic, supportive, and cognitive-behavioral therapies, for example—but estimates were bound to be crude, with considerable "fuzziness" about differentiation of therapies, especially supportive, Clemens noted. Moreover, it was difficult or impossible to quantify time spent in "informal" teaching of residents, he added.

More salient perhaps were some subjective responses of residency directors. In response to the question, "What does your program see as the role of psychodynamic understanding of individuals in deciding which treatment would be appropriate for a given patient?," responses varied, with most training directors expressing that it was important, but some saying attitudinal and manpower factors limited the extent of psychodynamic psychotherapy teaching they were able to provide.

One training director responded, "We have to convey the perspective and skills of psychotherapy. Otherwise [psychiatrists graduating from programs] will be dangerous. I don't want to send people out there who don't know any better and think that is psychiatry."

Training directors responding to the survey also expressed their need for access to more patients suitable for psychodynamic psychotherapy conducted by residents—and more money to pay teachers and supervisors.

The presence of a local psychoanalytic community appeared to play a part in the intensity of psychodynamic education of residents. In Boston, where there are more than 300 trained psychoanalysts, analysts teach in all seven of the surveyed programs; in Northeast Ohio where analysts are limited in number, they work in just two of the four surveyed programs.

And one director stated that the attitude of the psychiatry department would not be receptive to the participation of psychoanalysts in training.

Among the recommendations Clemens and Notman offered were the following:

Echoing a theme expressed throughout the symposium, Clemens said that training directors' survey responses underscored the need for programs to demonstrate the clinical value of psychodynamic principles in all psychiatric practice as well as in formal psychotherapy.

"One of the major points that emerged from the survey is that education of residents about psychotherapy is not just about teaching them how to do it formally, but also teaching how to think psychodynamically about all patients in all settings," Clemens told Psychiatric News in a later interview. "It contributes to the care of patients who are mainly being treated with psychopharmacology and who are hospitalized. To understand the whole person with the illness is really what psychiatry is about, and contributes to the doctor-patient relationship even when you are not doing formal psychotherapy."