by Daniel Weintraub, M.D.
[Winter 1997; Vol. 24 No. 4]
Psychiatry has undergone many changes in recent decades, from the ascendance of biological psychiatry and psychopharmacology to the introduction and rapid domination by managed care. These changes in the conceptualizing of psychiatric disorders, their treatment, and the delivery of services have impacted on residency training in many ways: psychodynamic formulations have been de-emphasized, and rapid symptom-based diagnoses according to DSM-IV criteria are stressed. Also, learning how to deliver long-term insight-oriented psychotherapy is no longer a priority and is being replaced by training in various types of brief psychotherapy. Psychopharmacology has become the predominant treatment for patients. The pace of the training experience is much faster than previously and the experience is more fragmented.
Debate is ongoing about what constitutes appropriate psychiatric training. Is the mission of residency programs simply to “train” psychiatrists to deliver the types of care that will be expected of them (i.e., doing rapid assessments and dispensing medication), or is their mission to educate residents in the intricacies of human behavior?
In 1995, my two co-chief residents (Betsy Kohlhepp, M.D., and Janet Woolery, M.D.) and I at the University of Maryland, with the assistance of Lisa Dixon, M.D., examined one traditional aspect of residency training that we thought had changed recently. After talking to our fellow residents and to the current faculty members who had trained at Maryland, we became convinced that current residents were much less likely than former residents to engage in insight-oriented personal therapy or psychoanalysis during training. Why was this so? If our hypothesis was correct, had psychiatry or psychiatric residents changed so much that personal therapy was no longer of value? Each of us was engaged in long-term psychotherapy at the time and attributed personal and professional benefits to it.
We surveyed current psychiatry residents at the University of Maryland, Sheppard Pratt Hospital, and Johns Hopkins University, and residents from the past twenty-five years at the University of Maryland. We collected information about demographics, participation in personal therapy, and general attitudes towards psychotherapy. We received responses from 96 out of 119 current residents (81 percent response rate) at the three Baltimore programs, including 54 out of 59 (92 percent) at the University of Maryland, 25 out of 28 (89 percent) at Sheppard Pratt, and 17 out of 32 (53 percent) at Johns Hopkins University. We received responses from 113 out of 209 (54 percent) former residents at the University of Maryland. When analyzing the data we first compared current with former residents at the University of Maryland and then compared only current residents at the three Baltimore programs with each other.
A paper based on our findings, the highlights of which we present here, has recently been accepted for publication in Academic Psychiatry.*
Examining the data for current and past residents at the University of Maryland, we found that current residents (20 percent or 11 out of 54) were significantly less likely than former residents (70 percent or 79 out of 113) to engage in personal therapy while in training. Even when allowing for the possibility that current residents might still enter therapy prior to completing training, the difference remained significant. Logistic regression controlling for period of training (i.e., former versus current residents), race, gender, educational debt, and country of medical school training showed that only the period of training was significantly associated with whether or not a resident entered therapy.
Of the trainees in therapy, almost all current residents were in once a week therapy (91 percent or 10 out of 11), whereas most former residents had been in psychoanalysis (41 percent or 32 out of 79) or twice per week therapy (30 percent or 24 out of 79). There was no difference between the groups in the type of therapist seen (most saw psychoanalysts), in the reasons for seeking therapy (personal followed by professional reasons), or in the percentage of gross income spent on therapy.
The reasons given for not seeking personal therapy did differ between current and former residents. Current residents were more likely to list cost as the primary factor, but former residents listed time restrictions. Interestingly, only a small number of former residents (9 percent or 3 out of 34) started personal therapy after completing training.
Examining the data for the current residents at all three Baltimore programs, we found overall that 28 percent (27 out of 96) were in insight-oriented therapy and 8 percent (7 out of 96) were in non-insight-oriented therapy.
Residents at Sheppard Pratt (60 percent or 15 out of 25) were significantly more likely than those at Maryland (20 percent or 11 out of 54) or Johns Hopkins (6 percent or 1 out of 17) to engage in therapy; there were no statistically significant differences between Hopkins and Maryland. Logistic regression controlling for year of training, ethnicity, age, gender, marital status, educational debt, training program, and country of medical school training showed that only the training program was significantly associated with involvement in personal therapy. Of those residents in therapy, most had started prior to training (70 percent or 19 out of 27). The overwhelmingly majority of those in therapy were in once a week therapy (81 percent or 22 out of 27), and only one was in psychoanalysis.
First, we must point out that we gathered our data from one area (Baltimore) and that the current group of residents may have represented an aberration. However, the findings appear to show that personal therapy for psychiatry residents, traditionally a component of the training experience for most trainees, is rapidly disappearing. The change over time at the University of Maryland may reflect changes in that training program or department, but the low rate for current residents at the three Baltimore programs suggests that this may be a regional or national trend.
Several possible explanations may account for the decline in the percentage of residents entering therapy. Cost was cited by current residents as the main reason for not entering therapy, yet educational debt was not associated with participation in therapy. Though insurance coverage for personal therapy may have changed over the years, residents at the University of Maryland at the time of the study were still entitled to receive partial reimbursement (50 percent of reasonable cost for 50 sessions per year) for psychotherapy through their health insurance. Possibly, current residents feel less comfortable using insurance coverage for what may be seen as partly educational purposes, or perhaps they have concerns about confidentiality. However, reduced-fee therapy and reduced-fee psychoanalysis are available for those residents paying out-of-pocket.
Just as the emphasis in psychiatry has shifted from psychotherapy to psychopharmacology, possibly current residents are more likely to take medication to alleviate psychological distress. The trends towards managed care and a biological focus, with a subsequent de-emphasis of psychotherapy skills for psychiatrists, may also be leading to the recruitment of residents with a decreased interest in psychodynamic therapy for themselves. Residents may be engaging in non-insight-oriented therapy to a greater degree than previously, though 8 percent of current residents reported receiving this type of therapy. Finally, as only a small percentage of total residents started personal therapy after entering training, it is possible that programs do not communicate to residents that personal therapy may be of value.
No one can substantiate the claim that personal therapy makes one a better psychiatrist or therapist. It does allow the trainee to explore his or her characterological style, unconscious conflicts, transference and countertransference issues, and to understand and empathize with the patient role. In addition, it provides a resident with a model of psychotherapeutic technique at a time when training experiences in long-term psychodynamic therapy are diminishing.
Psychiatry continues to undergo tremendous changes, and the training experiences of current residents reflect many of them. While residents are benefitting from biological advances in the field, is their training at the same time suffering from the de-emphasis of a psychological perspective on human behavior? Personal therapy for residents, never a formal part of training but long a mainstay, may soon quietly fade from existence and become another relic of psychiatry’s past.
Dr. Daniel Weintraub is a fourth year fellow in psychiatry at the University of Maryland Psychiatric Institute.
* Weintraub D, Dixon L, Kohlhepp E, Woolery J. Residents in personal psychotherapy: a longitudinal and cross-sectional perspective. (italics)Academic Psychiatry(end italics) (in press).