by Walter Weintraub, M.D.
[Winter 1997; Vol. 24 No. 4]
In the fall 1997 issue of The Maryland Psychiatrist, I wrote about a number of changes in residency training that have occurred during the past two decades. These changes have mostly resulted from shorter inpatient stays, and in my opinion, have brought about an erosion in the quality of inpatient residency training. In discussing changes in residency training, I omitted a consideration of formal psychotherapy, the area in which the most dramatic changes have occurred. This article will deal with problems in teaching psychotherapy to beginning residents, problems caused in large part by shorter patient stays.
What is the status of inpatient psychotherapy training today? Impressions gathered from residents-in-training and from psychiatrists who trained many years ago suggest that fewer inpatients are engaged in formal psychotherapy today than were involved twenty years ago. Two decades ago, residents-in-training considered formal psychotherapy the most important educational experience of their inpatient years. Only a minority of today's beginning residents have supervised psychotherapy experience with hospitalized patients. What is responsible for this dramatic change?
Various factors contribute to the decrease in the importance of psychotherapy in the training of beginning psychiatric residents.
Many would argue that inpatient psychotherapy has not proven a useful treatment for severely ill patients. Why mourn its demise? I believe that inpatient psychotherapy has been extremely important in the education of beginning residents, and no substitute has been found for it. In talking to practicing psychiatrists, I am impressed by how many consider their inpatient year the most important in their acquisition of psychotherapy skills.
Even for residents not planning to include the practice of dynamic psychotherapy in their future careers, the loss of an inpatient psychotherapy opportunity is regrettable. Experiencing a psychotic patient's illness, developing an empathic relationship with him or her, and learning how to decode an idiosyncratic language are all enhanced by an inpatient psychotherapy experience.
How is the development of a beginning resident affected by the loss of inpatient psychotherapy opportunities? In my experience, today's residents try to deal with seriously ill patients by suppressing their symptoms with drugs and ECT. When unaccompanied by psychotherapy, such an approach may result in a failure to develop empathic relationships with inpatients, in a lack of continuity of care when these patients are discharged, and with poor patient compliance with treatment recommendations.
Under managed care, the decay of inpatient psychotherapy will not likely be reversed in the foreseeable future. What can we substitute for formal psychotherapy that will enable beginning residents to acquire the psychological sophistication and interpersonal sensitivity so important to the development of psychotherapy skills in the outpatient years?
During clinical supervision, great emphasis should be placed upon the resident experiencing the patientµs symptoms. We must remember that the average residents begin psychiatric training in their late twenties. They are assigned patients who are often much older than they and who are facing problems with which the residents are unfamiliar, such as drug addiction, the sequelae of military combat, issues associated with aging, and so on. Complicating an already difficult situation, beginning residents discover that many of their patients cannot communicate in the usual way. They must learn a new language in order for their patients to feel understood.
Attendings and supervisors should focus the residentsµ attention on aspects of patientsµ illnesses with which they cannot be expected to be familiar. To understand how a combat veteran experiences post traumatic stress disorder, it may be necessary to encourage residents to think of past fearful episodes in their own lives. To understand the language of schizophrenic patients, residents should be challenged to examine their own dreams and to compare psychotic language with poetic devices. Converting a metaphor into a simile can be extremely useful in decoding otherwise incomprehensible speech. Most important, residents should be encouraged to examine their reactions to patients' behavior when these reactions interfere with the doctor-patient relationship.
Formerly supervisors encouraged their residents to seek personal therapy to increase their sensitivity. I believe that this recommendation is made less frequently today. The study carried out by Dan Weintraub and Betsy Kohlhepp (see "Psychiatry Residents in Personal Therapy and Analysis") shows that fewer of today's residents are engaged in personal therapy. How they deal with problems brought on by the vicissitudes of life is not clear. Are todayµs residents taking prescription drugs? A more hopeful interpretation would be that fewer of today's residents require therapy but I know of no evidence to support this conjecture.
Those who would remove psychotherapy from inpatient psychiatry should ask themselves how patients can feel understood if nobody makes an effort to understand them. Not feeling understood by one's doctor is a complaint that goes beyond inpatient psychiatry, indeed, beyond psychiatry itself. Can anyone doubt that the popularity of non-mainstream medicine results in part from patients not feeling understood by their physicians? Until now, psychiatry has been the branch of medicine that has dedicated itself to the understanding of implicit patient communication. If we, in our reaction to the pressures of managed care, abandon our efforts to experience patients' illnesses, if we consider management and medication to be our sole patient responsibilities, who in medicine will preserve the tradition of interpreting the meaning of symptoms?
Dr. Walter Weintraub, a clinical professor of psychiatry at the University of Maryland Psychiatric Institute, directed the psychiatric residency program from 1970 to 1990. He was the major architect of The Maryland Plan.