MEDICAL STUDENT EDUCATION AND PSYCHOANALYSIS
MEDICAL STUDENT PERSPECTIVE: PsychSIGN The Psychiatry Student Interest Group Network
Pallavi Joshi and Robert Rymowicz
Pallavi Joshi, M.D., is PsychSIGN national chair.
Robert Rymowicz, M.D., is PsychSIGN facilitator.
Students interested in psychiatry show a strong curiosity about psychotherapy. Talks by psychodynamic speakers are perennially well attended at PsychSIGN, the American Psychiatric Association’s student interest group annual meeting, where medical students from around the country gather to learn from leaders in psychiatry. The annual roundtable dinner at the PsychSIGN conference encourages students to ask invited guests about their motivation for choosing their specialty within psychiatry. The attendance at the psychotherapy table is among the highest, and the discussion one of the liveliest. The fact that students so often ask how to best approach and engage patients psychotherapeutically shows both an interest in the approach and a desire for guidance and direction that is all too commonly absent in training. An introduction to the psychodynamic approach helps medical students foster a deeper interest in the mind, opens new avenues of thinking and explores the heart of psychiatry.
This speaks to the need for opportunities for medical students interested in psychiatry to obtain a better understanding of psychotherapy. As medical students eager to learn more about psychodynamic psychiatry, we struggled to find elective rotations open to medical students. Private practices rarely welcomed medical students, and academic centers did not have rotations focused on therapy. One of us (Robert) was fortunate to spend the final month of third year at the Austen Riggs Center—an opportunity we hope more medical students will learn about and consider. PsychSIGN has sought to provide a venue for nationally recognized experts in psychodynamic psychiatry to speak to medical students at meetings at both the regional and national level, and will continue to do so. PsychSIGN encourages psychodynamically focused psychiatrists to volunteer to speak at a regional meeting in their area through contacting a representative in their area listed at http://www.psychsign.org/. This will allow them not only to reach many future psychiatrists before their careers have even started but also to offer their mentorship as students progress towards residency.
MEDICAL EDUCATOR PERSPECTIVE
David Mintz
David Mintz, M.D., is staff psychiatrist at the Austen Riggs Center, on APsaA’s Committee on Medical Student Education and trustee of the American Academy of Psychoanalysis and Dynamic Psychiatry.
Thirty years ago, psychoanalysis began its exodus (or exile) from academic psychiatry. Since then, there have been major shifts in the science and economics of mental health that have promoted biomedically reductionistic models of care. One consequence is that medical students are often exposed to points of view that denigrate a psychoanalytic perspective. My sense, as someone involved in the education of medical students for the last 15 years, is that while some students become turned off to psychoanalysis, a great many more are turned off by psychiatry. Those students who are initially attracted by psychiatry tend to be idealistic, patient-centered, and interested in a deeper understanding of people and human suffering, and they are often discouraged by what they experience in their clinical clerkships. In this sense, academic psychiatry needs psychoanalysis to attract the most committed and idealistic students. Exposure to psychotherapy and psychoanalysis is also necessary to give students a fuller and more accurate picture of the professional possibilities in psychiatry.
While there are many opportunities for psychoanalysts to participate in the education of medical students, extensive education about this important aspect of psychiatry is often eclipsed by pressing exigencies of teaching basic psychopharmacology and psychodiagnostics. Learning about psychoanalysis occurs outside of the formal educational structure.
Though not affiliated with any medical school, I have been involved at the national, regional and local level with PsychSIGN, a national organization of affiliated psychiatry interest groups. This is, I believe, a very effective way for psychoanalysts outside of academia to bring a psychoanalytic presence to the education of medical students. I have found it also to be highly rewarding. The students in PsychSIGN are those who already have an interest in psychiatry. Their hunger for perspectives that embrace the subjectivity of the patient is palpable. Commonly, they are confused about psychiatry, as their interest in the inner lives of people drew them to the field, only to find many potential role models reducing patients monodimensionally to diagnoses or neurotransmitter receptors. Their relief and gratitude is obvious at being exposed to psychiatrists who have been able to make a career out of the exploration of the inner lives of patients.
When I started working with PsychSIGN at the National Meeting, where the American Psychiatric Association supports one to two students from each local chapter, psychodynamic psychiatry was often an afterthought. Since then, it has increasingly become a focus of interest among the membership. At the National Meeting, PsychSIGN leadership has invited me to present on topics including the evidence base for psychodynamic psychotherapy and psychoanalysis, the psychodynamics of psychopharmacology, patient-centeredness and developmental issues involved in becoming a psychiatrist.
More conveniently, there are many opportunities to become involved at the regional and local level. There are regional meetings which draw a significant proportion of medical students from a number of local medical schools, and which provide opportunities to meet with larger groups of interested medical students. Volunteering with local chapters allows for more casual and intimate engagements with interested medical students, such as educational events hosted in the home of a faculty volunteer. Movie nights with a psychoanalytic focus are another enjoyable way to introduce a psychoanalytic perspective into medical education.
MEDICAL EDUCATOR PERSPECTIVE
Debra Katz
Debra Katz, M.D., is clinical professor of psychiatry and neurology at the University of Kentucky College of Medicine, member of APsaA’s Committee on Medical Student Education and Trustee of the American Academy of Psychoanalysis and Dynamic Psychiatry.
What makes a difference in enhancing medical student interest in psychotherapy and psychoanalysis? As a longtime residency program director and medical educator, I have combined personal reflections with findings from the literature looking at some of these questions.
Curiosity and Knowledge
There is often the perception that students and residents are not interested in psychotherapy or psychoanalysis. I have found that students and residents express strong interest and curiosity but often lack knowledge about psychotherapy. Their desire to know their patients in deeper ways typically motivates their choice of psychiatry as a specialty, and they are eager to hear about cases where psychotherapy has been an integral part of treatment.
It is a gratifying experience as a teacher to see medical students begin to grasp psychoanalytic concepts like transference, resistance and unconscious conflict and to sometimes link these to aspects of their own life experience. I have spoken at local and national PsychSIGN conferences on topics such as the developmental trajectory of becoming a psychiatrist, the connection between childhood experiences and adult psychopathology and the ways a dynamic understanding of patients can enhance treatment of patients in acute medical settings. Written psychotherapy case vignettes or video clips (e.g., In Treatment) have engaged groups in lively discussion and a greater understanding of psychotherapy.
Being open about my personal journey to psychiatry and psychoanalysis has been especially compelling to students. I have encouraged frank discussion of issues such as stigma, status and family reactions to psychiatry as a career choice, lifestyle and income expectations as well as deeper issues such as purpose, gratification and sense of meaning in one’s work. I have been open about the ways personal treatment has affected my understanding of myself, my family relationships and my work with patients. Students have appreciated these frank discussions and commonly affirm their wish to do therapy but admit to anxieties about whether such work is possible in today’s economic climate and whether psychotherapy can still be a significant part of a psychiatric practice. Being a physician who identifies as both an analyst and a psychiatrist has been especially important in these discussions.
The literature also confirms these personal experiences with students—namely, that interest in psychotherapy is alive and well. Given the economic, political and administrative factors that threaten psychoanalytic work, it is easy to assume that students have negative perceptions of psychoanalysis. Clinicians and teachers may need to reorient themselves regarding these perceived biases and be eager to share their enthusiasm about their work. Because of insecurity about knowledge and skills, educators should begin with basic concepts, avoid jargon and illustrate concepts with clinical examples.
Teachers, Mentors, Supervisors
Students need exposure to mentors, supervisors and teachers who practice from a psychoanalytic perspective to serve as professional role models. This is especially important where there are no or few analysts in a medical school or community. Group supervision or a psychodynamic case conference has allowed more students access to analytically oriented supervisors. Students are particularly interested in hearing about psychoanalytic clinical work, watching analysts interview patients and utilizing psychoanalytic concepts to understand patients they encounter in medical settings.
Personal Treatment
Personal treatment is a crucial experience in developing conviction about the usefulness of psychotherapy. Speaking openly about the benefits of one’s own treatment, encouraging students to pursue treatment, providing low-cost treatment and working to reduce logistic barriers (e.g., advocating for protected time, reduced fees, phone or Skype sessions) promote access to these important experiences. Efforts to encourage students to have a personal treatment experience are vital to developing and sustaining interest in psychoanalysis and facilitating entry into analytic training.
Awards, Visiting Scholars and Distance Learning
The exodus of analysts from many medical schools and residency programs has created a need for innovative ways to connect analysts with students. Awards such as the APsaA Fellowship or the Teacher’s Academy provide important experiences with mentors and bring national recognition to individuals and programs. Video conferencing may allow distant teachers to teach courses, lead a case conference and build relationships with students. Psychoanalytic institutes may consider co-sponsoring local awards, inviting students to events, and offering speakers to local psychiatry interest groups
Research and Evidence-Based Treatments
Medical school and residency training have increasingly moved toward evidence-based practice. There is often bias against psychodynamic psychotherapy as not having an evidence base or as being a treatment only for high functioning patients. Teachers and supervisors should develop familiarity with evidence-based practice and the literature on psychodynamic psychotherapy and psychoanalysis to be able to respond to challenges regarding the efficacy of these treatments.