[Fall 1998; Vol.25 No. 2]
Editor: For the third article in our series, Teaching Psychotherapy to Residents: Now and Then, we have decided to do an interview. In your previous articles in the Fall 1997 and Winter 1998 issues of The Maryland Psychiatrist, (TMP), you discussed the dramatic and often troubling changes taking place in residency training. The most recent issue, Spring/Summer 1998 contained articles about psychotherapy by various authors. To round out the discussion you have chosen the subject of teaching psychoanalytic psychotherapy. Where shall we begin?
Dr. Weintraub: The teaching and practice of psychoanalytic psychotherapy (PPT), is vitally important to psychiatry. This subject follows naturally from my previous articles. I would like to talk about my observations, concerns and hopes for this form of treatment.
Editor: Let’s start with your observations.
Dr. Weintraub: Although my observations are drawn from experiences at the University of Maryland and its affiliate clinical facilities, I believe that the changes I shall describe are nationwide. The amount of time residents spend learning and practicing psychoanalytic psychotherapy (PPT) has declined significantly in recent years.
Editor: How has this happened and what impact will it have on our profession?
Dr. Weintraub: There are many forces at work in the climate of residency training that have made the teaching of this mode of treatment more difficult. These include managed care, short hospital stays, the demand for quick results, psychopharmacology and the trend of turning psychotherapy over to nonmedical therapists. The loss of PPT threatens to tear the heart out of psychiatry.
Editor: Is the term psychoanalytic psychotherapy interchangeable with the term psychodynamic psychotherapy?
Dr. Weintraub: I would use the terms interchangeably.
Editor: What is psychoanalytic psychotherapy (PPT)?
Dr. Weintraub: There are probably as many definitions of psychoanalytic psychotherapy as there are therapists who practice it. I would characterize as psychoanalytic psychotherapy (PPT) any mode of treatment that encourages free verbal expression, seeks to make the patient aware of unconscious thoughts and feelings, and analyzes resistances to the expression of ideas and feelings, and interprets patients’ behavior towards their therapists.
Editor: How does it differ from formal psychoanalysis?
Dr. Weintraub: Unlike formal psychoanalysis, psychoanalytic psychotherapy has no agreed upon method. It recognizes transference, but seldom attempts to fully analyze it. It differs from many of the recent types of psychotherapy in stressing interpersonal relations and self-understanding rather than symptom removal.
Editor: Some psychiatrists describe their psychotherapeutic techniques as including a wide variety of other approaches, varying with the needs of the patient, as part of their “psychoanalytic psychotherapy”. Is this consistent with what you are saying?
Dr. Weintraub: There is no copyright on the name psychoanalytic psychotherapy or any other therapy that I know of. This can and does sometimes lead to confusion. Although purists would object, I see nothing wrong with varying the approach depending upon the needs of the patient. There is the risk, however that the psychoanalytic aspect of the therapy will unintentionally get lost in the process. I doubt that any effective clinician of any type can stick very long to a rigid program that ignores the unfolding understanding of the patient. Sometimes this will mean dropping most of the psychoanalytic side of treatment, but not always. In some cases, it is possible to combine approaches such as psychopharmacology or family therapy with PPT. In my opinion, PPT can also be viewed as a conceptual approach, in which the therapist includes psychoanalytic concepts in his/her understanding of the patient, no matter what type of therapy is being utilized. For the beginning resident who is just learning about PPT, it is best to assign a carefully selected patient who is likely to benefit from PPT without the need for other interventions.
Editor: Don’t some people believe that such interventions interfere with the transference?
Dr. Weintraub: Other interventions would alter it and could make it more difficult to deal with. Despite theoretical concerns, it is the experience of many clinicians that this does not necessarily cause serious obstacles to effective handling or even partial analysis of the transference. Just think of the transference problems that can result from denying the best treatment to the patient. As we all know, this may be harmful to the patient and can even lead to malpractice suits. As I just mentioned, however it might be too much for a beginning resident to try to balance a variety of different approaches simultaneously with the same patient. The ability to skillfully synthesize the various approaches comes with more experience.
Editor: Why do you believe it is important to teach psychoanalytic psychotherapy?
Dr. Weintraub: Because it is a vital part of psychiatry. With the role of the “new psychiatrist” being redefined by managed care to include primarily psychopharmacology and management, those of us who believe in the usefulness of psychoanalytic psychotherapy are finding it increasingly difficult to defend its inclusion in training programs as a mandatory experience. Why spend so much time and effort learning a skill of unproven therapeutic value that most residents do not expect to use after graduation? There is already a movement among training directors to make the learning of psychoanalytic psychotherapy optional. I consider this to be a tragic mistake.
Editor: What is your answer to this?
Dr. Weintraub: In my judgment, psychoanalytic concepts offer us the most help in understanding patients and their symptoms. As a theory of the mind, I believe it has no serious competition in our culture. When I say this, I am referring more to clinical theory having to do with defense mechanisms, rather than to Freud’s metapsychology. Any American who thinks he has not been profoundly influenced by psychoanalysis need only travel to a nation unfamiliar with Freudian ideas to learn how much of a psychoanalyst he is. This does not make Freudian concepts valid, but it should make us pause before depriving residents of a model of the mind that helps patients feel understood by their therapists. A great many psychiatrists and patients have found PPT to be extremely effective for some people. Scientific reductionists and other critics will point to the sparse experimental evidence to support some of my assertions. My reply is that while it is desirable to promote science, it is a mistake to abandon widely recognized forms of treatment such as PPT before finding replacements that offer the same breadth. Psychoanalysts have been criticized for claiming that psychoanalysis is a science. In its present state of development it is not a full-fledged science. Although some other forms of treatment have scientific features, I don’t believe that any are based upon mature sciences. It is common for therapists of various persuasions to claim that theirs is the only valid theory and the only effective treatment and that it should be practiced to the exclusion of others. Much of the rhetoric on this subject is based upon professional rivalry. My claims are more modest. Many forms of treatment are useful. Many of the newer ones are much more specific than PPT. Their specificity can be a great advantage when targeting well-defined symptom complexes. For example, most patients with OCD will have greater symptom relief from a combination of behavior therapy and pharmacotherapy. (Greist Spring/Summer 1998 TMP). Few patients however, have problems limited to a single diagnostic category. PPT, besides being a more general form of treatment is also a good way of gathering information about patients. If we don’t spend significant time allowing the patient to speak freely, how can we learn what’s going on? Questionnaires and checklists have their place, but they inevitably narrow the field of information we can gain. If we rely on them excessively there is a risk of under-diagnosis or misdiagnosis which lead to ineffective treatment.
Editor: As you have pointed out, there is an increasing emphasis on biological approaches to treatment in psychiatry and this is usually at the expense of psychological approaches such as PPT. In this decade of the brain, many believe that the medical model and biological approaches are more valid than psychological approaches. What would you say in response?
Dr. Weintraub: You will probably agree that dividing things up into psychological vs. the biological is a false dichotomy. Even as we speak and listen to each other, the synapses in our brains are being altered. PPT or any other psychotherapy is a more delicate biological intervention than drugs and is less likely to have toxic side effects. PPT is being dismissed too quickly on the basis of false assumptions. Psychoanalysis and PPT deserve more respect than they currently receive.
Editor: Can you describe how things are different in this regard, compared with the time when you were in training?
Dr. Weintraub: After World War II, there was a boom in psychoanalysis. Residents and young practitioners made great sacrifices to undergo psychoanalysis and to obtain psychoanalytic training. As an example, for many years psychiatrists commuted as far as from Oklahoma City and Denver to Chicago to complete psychoanalytic training. The trainees met all the costs out of pocket.
Editor: At what point in your career did you enter psychoanalysis?
Dr. Weintraub: I entered analysis while I was in medical school in Geneva, Switzerland. Later, during the end of my residency in the 1950’s I re-entered analysis in Baltimore and became a student in the psychoanalytic institute.
Editor: There is a widespread belief among younger psychiatrists that during those days psychiatric residency training emphasized psychoanalysis almost to the exclusion of everything else. Moreover, it is believed that the current swing of the pendulum toward the physical is only a healthy correction to previous bias. Do you have any comments on this view of historical changes?
Dr. Weintraub: As the saying goes, psychiatry went from being brainless to becoming mindless. I hate to shatter a comfortable myth, but at least here in Baltimore, both at Maryland and Hopkins, there was intense interest in experimental approaches including brain physiology, psychopharmacology and much more. As residents we were heavily exposed to these diverse theories, and involvement in basic research was usually considered an essential part of our training. Attempts were being made to integrate the growing knowledge in these fields with older theories and practices. For example, we rode the first wave of the revolution in psychopharmacology and attempted to understand the application of pharmacological methods at both chemical and psychological levels. Studies were also well underway at that time to penetrate the chemical basis of psychosis. At the same time we were interested in language, and symbolic processes, which has remained one of my research interests for over forty years. It is true that there were opposing camps of theory and practice, with some hard liners on both sides claiming possession of the whole truth, but few of us believed that anyone had all the answers. It was an exciting time to be in training. As residents and later as teachers, most of us attempted to continue the tradition of synthesizing approaches from many directions. It worries me that psychiatry as it is taught and practiced today often has a much narrower base than before.
Editor: As you say, psychoanalysis and its offspring PPT are no longer as popular as they were, and psychiatrists are less willing to make sacrifices to learn them. You have observed that there is pressure to obtain quick, symptomatic results. There is more management and manipulation of patients and less interest in listening to them or getting to know them or their life situations. They are seen less often and for briefer visits. These are disturbing trends, but do the advocates of psychoanalysis and PPT deserve any of the blame for their decline in acceptance?
Dr. Weintraub: I'm glad you asked. Psychoanalysis was oversold. For some people it was the Holy Grail. Some proponents tried to explain everything and to treat everything with it. Hollywood glamorized it and ridiculed it, in neither case with much understanding. Psychoanalysts have seldom been interested in the scientific methods employed by other disciplines and have often imposed dogma in place of scientific evidence. Fratricidal wars within analytic institutes and among psychoanalysts undermined their credibility. PPT, with less fanfare has suffered similar vicissitudes. It is enough to raise doubt in the minds of any objective observer. I will not attempt to explain why these things happened beyond the fact that especially where objective evidence is lacking, psychiatrists, like other people fall prey to emotion and bias in their thinking. These somber facts force us to approach PPT with greater humility than in the early days, but do not necessarily indicate that it is without value. Few human endeavors, including medical and psychological disciplines, have been free of false steps and controversy. That is the way with humans. We are emotional and often irrational creatures and that is one of the reasons why there is a place for PPT, which recognizes and deals with this side of ourselves.
Editor: You have made it clear that neither psychoanalysis nor PPT is suitable for all patients or all conditions. For whom is PPT a suitable treatment?
Dr. Weintraub: As I have defined it, PPT should usually be limited to patients with neurotic and certain personality disorders. Most psychotherapists trained in conservative Freudian institutes would agree with me. Sullivanian therapists, particularly those trained in the Washington Psychoanalytic Institute, believe that with modifications PPT can be useful treatment for certain schizophrenic and bipolar patients. This complex debate is beyond the scope of this article.
Editor: In residency training, when PPT is used, is it always with the right patients?
Dr. Weintraub: Unfortunately PPT is often attempted with patients who are unable to benefit from it. Examples would include most patients suffering from drug abuse or psychotic disorders. Such inappropriate use is worse than ineffective. It can easily lead to demoralization of both patient and doctor. This is one of the contributing factors in the loss of acceptance of PPT.
Editor: At the risk of sounding facetious, does that mean that we should discourage residents from listening to such patients?
Dr. Weintraub: Of course I don’t believe that, but it brings up an important point. A fundamental aspect of clinical medicine and of science is the importance of observation. Listening is an essential aspect of observation. A lot can be learned from it. The need for observation is not confined to PPT.
Editor: We learned in the Winter issue of TMP that fewer and fewer residents engage in personal psychotherapy during or after training. (Ref : Daniel Weintraub MD, TMP, Feb, 1998) What does this mean in regard to their learning PPT?
Dr. Weintraub: The decline in residents entering therapy themselves seems to at least partially reflect a loss of belief in the value of this form of treatment. This lack of personal experience may reduce the resident’s ability to understand PPT as well as to increase the resistance to learning it. This snowballs, as residents are increasingly exposed to supervisors who themselves do not consider PPT to be of value. It is quicker and easier to medicate patients than to spend time with them. Patients themselves are often glad to be spared the effort required for self-scrutiny. Modern psychiatric drugs are often of immense value, but they are frequently mis-prescribed, especially when employed to dispose of the patient quickly.
Editor: What can be done to reverse this trend?
Dr. Weintraub: Obviously there is no simple solution. Eventually the tide will turn. This will happen when people recognize that oversimplified formulas designed to fit patients into tidy little categories for diagnosis and treatment have their limitations. Already there is a huge public outcry against HMOs. At present there are some simple steps that can be taken. For example, I believe that training in PPT should be a required part of training for every resident. To overcome the financial and other obstacles imposed by managed care, I suggest the establishment of a resident’s clinic, in which all payments would be out of pocket and fees would be set by agreement between patient and therapist. Residents would be allowed to keep all the fees they collect. Patients admitted to the clinic would be carefully screened beforehand and would be limited to those for whom PPT seems to be the appropriate treatment. The resident would be expected to treat at least two patients - one man and one woman - for a minimum of one year with a frequency of sessions of at lest twice a week, under the supervision of qualified instructors. It should not be difficult to enlist experienced supervisors who would provide such assistance on a pro-bono basis.
Editor: Except for the limitation to two such patients during a residency and allowing the resident to keep the fee, that plan sounds familiar. Isn’t that something like it used to be?
Dr. Weintraub: Yes it is, I am suggesting something that was observed to be a valuable part of training over a long period of time. I hope that listening to patients and relating to them will never go out of style. Much of what the resident learns in this process will help in conducting many other types of treatment or in developing research ideas. Let’s not forget that testable hypotheses can be generated through therapy and tested later under more controlled conditions. New therapies may also arise from the experiences gained in listening to individual patients. For example, family therapy, cognitive therapy and interpersonal therapy were generated by clinicians (including psychoanalysts), initially listening to patients in an unstructured way.
Editor: Thank you Dr. Weintraub for your stimulating comments.
Gerald D. Klee MD, Editor, The Maryland Psychiatrist
Walter Weintraub MD is Clinical Professor of Psychiatry , University Of Maryland School of Medicine, Baltimore, Md. He served as Director of Residency Training at the University of Maryland Psychiatric Institute for many years.