ranking Midwest programs

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

nereids

Full Member
7+ Year Member
Joined
Jun 22, 2015
Messages
22
Reaction score
4
I am finished with interviews now that I have decided to withdraw from programs outside the Midwest. After the interview process, I feel more confused about where I am headed in my career. Maybe it is because I am more aware of the endless possibilities. I could use some help deciding between my favorite programs on the trail. Main qualities I am looking for in a program: (1) excellent mentorship and teaching from faculty along with superb didactics (2) broad range of clinical exposures/no defects in clinical training with strong CL experiences (3) intellectual, inspiring residents as peers (4) integrative approach with strong psychotherapy training.

Northwestern
pros--loved the program director, dedication to teaching residents AND faculty, entire day for didactics, residents were very accomplished, many fellowship options and exposure to forensics, advocacy and engagement in leadership, strong psychotherapy supervision and collaboration with psychology, best gut feeling after leaving interview

cons--still developing a strong research presence (although I think I would find great mentorship), expensive lifestyle

University of Iowa
pros--many inpatient units, specific inpatient beds for eating disorders and intellectual disabilities, great partial hospitalization programming, mindfulness class in first year, near family support and Iowa City is a great place to live

cons--some faculty not very devoted to teaching, not sure about dedication to developing faculty as teachers, no forensics, not confident in psychotherapy teaching

University of Wisconsin
pros--tons of research in my area of interest and others including mindfulness and emotions, interviewed for research track with protected time and lots of financial support for conferences, amazing psychotherapy training along side psychologists, Madison is one of my favorite cities and very livable, great for some of my outdoor hobbies, residents were awesome, faculty seemed very approachable, interviewed over 2 days and got a great feel for the program, lots more because I learned a lot about the program over 2 days

cons--didn't seem as strong in CL as programs in Chicago I interviewed at

University of Michigan
pros--great forensics, friendly atmosphere, well-regarded program, very nice units and outpatient building, resident union and great salary/benefits

cons--seems too far from home for me

WashU
pros--well-respected program and research powerhouse, amazing academic opportunities, unparalleled research funding support for residents and junior faculty, lots of autonomy, liked the residents and faculty I met

cons--not crazy about St. Louis, looking for more integration with psychology
 
Yeah, the only real knock on Northwestern is their reputation for a patient population of "worried well of Lincoln Park" and "malingering homeless guys who want a place to sleep after a week of begging on the Mag Mile" with not a lot to fill the gap between those two groups. How true that rep is will depend on which resident you talk to. Otherwise it's solid all around.
 
In terms of academic reputation, Michigan and Wash U are the best on that list- then comes everything else. Northwestern has a brand name with a big name chair (who used to be at Wash U) and really strong residents but is still not as established as the others. Iowa is a huge name in psychiatry and was cast in the mould of Wash U because Winokur became chair in the ?60s, but the current chair is from Hopkins and from what I hear wants to bring in the Perspectives (if he hasn't done so already- I have no idea as I don't keep tabs on Iowa psychiatry). Nancy Andreasen is on faculty and one of the biggest names in all of psychiatry.

Also, Michigan has the best coach in college football, and once Harbaugh brings in legitimate talent, we (I'm a Wolverine) will perennially be B1G title contenders as well as playoff contenders, and more importantly, beating that "school" down south! GO BLUE!
 
In terms of academic reputation, Michigan and Wash U are the best on that list- then comes everything else. Northwestern has a brand name with a big name chair (who used to be at Wash U) and really strong residents but is still not as established as the others. Iowa is a huge name in psychiatry and was cast in the mould of Wash U because Winokur became chair in the ?60s, but the current chair is from Hopkins and from what I hear wants to bring in the Perspectives (if he hasn't done so already- I have no idea as I don't keep tabs on Iowa psychiatry). Nancy Andreasen is on faculty and one of the biggest names in all of psychiatry.

Also, Michigan has the best coach in college football, and once Harbaugh brings in legitimate talent, we (I'm a Wolverine) will perennially be B1G title contenders as well as playoff contenders, and more importantly, beating that "school" down south! GO BLUE!

As someone who went D3.. I'd say that Harbaugh needs to worry about the other school in the state that actually is in this year's playoff first.
 
...
Also, Michigan has the best coach in college football, and once Harbaugh brings in legitimate talent, we (I'm a Wolverine) will perennially be B1G title contenders as well as playoff contenders, and more importantly, beating that "school" down south! GO BLUE!
I stand by my prediction that there will be more psychotic breaks on the Michigan sideline than B1G Football titles in the next 5 years.
 
if you are looking for good psychotherapy training then WashU and Iowa are definitely NOT the places to go. The training at these programs is very dogmatic and while they excel in their particular brand of biomedical psychiatry it is somewhat deficient. even if you lean more biological you still want to be able to see through different lenses for trickier patients who might not conform to the way you see the world.

Northwestern probably is most where you'd be interested in. Michigan and Wisconsin are also very good. the benefits are excellent at michigan and they've just poached Deb Pinals, a very highly regarded forensic psychiatrist to lead their forensics program. if you are into the research track then you're probably a shoe-in as I don't think they've ever had any one match into their research track

Splik, would you be able to elaborate what you mean about WashU/Iowa being dogmatic in therapy training? I loved the Iowa program otherwise, but the question about quality of psychotherapy in a traditionally biological program has loomed in my mind.
 
the training (not psychotherapy) is dogmatic in that they subscribe to a specific framework for understanding mental disorders but there are so many different kinds of problems we treat in psychiatry that you need to be open minded and accept that no model can meaningfully and parsimoniously explain all of mental life. grief, marital discord and fearfulness following rape cannot be explained in the same way as delirium and dementia, nor can we explain why a patient stays with her abusive boyfriend using the same framework we understand hallucinations or the patient we have homicidal feelings toward cannot be understood in the same way we understand autism. that is the major flaw with these programs that do provide excellent training within their particular world view, they don't allow for the pluralism that clinical psychiatry demands. despite the calls for psychiatry to become a clinical neuroscience discipline this has not happened nor will it. we are more than our brains.
 
As someone who went D3.. I'd say that Harbaugh needs to worry about the other school in the state that actually is in this year's playoff first.

True, but Michigan played right with a much more talented spartan team this year, and any single play in that game (not just the mishandled punt) could have changed the outcome. MSU has benefited from the counterculture failure of the RichRod era and Brady Hoke's complete incompetence. A Harbaugh coached team with the best recruits in the midwest will shift the series back to its proper place. OSU, on the other hand, is a much more difficult hurdle to surmount. They were probably the most talented team in the country this year (besides maybe Bama) but at times embarassingly under performed until they came to Ann Arbor. Nevertheless, in 2-3 years, Harbaugh will have Michigan consistently and legitimately competing for B1G championships.
 
I went to medical school at Wisconsin, so while it's been 5 years, I will say their CL service was great. In fact, its the only reason I am a psychiatrist at the moment, probably the best last-minute choice I have made in my life. The service covers the whole UW hospital (which is large, has tons of subspecialty cases, lots of neuro ICU etc) and the VA which is actually quite a good VA but still has the VA standards (massive substance abuse, etc.). The faculty are awesome and the residents tend towards a very approachable/well adjusted crowd. The psychotherapy training is also very good at UW.

Judging from your overall list, and you really cannot go wrong with that list, I would definitely err towards the residents you felt you got along the best with. The residents at those programs likely vary quite a bit (at least they did when I interviewed at them) and I think that while each individual year varies, programs and residents of a similar type tend to gravity towards each other. Feel free to PM if you have further questions.
 
the training (not psychotherapy) is dogmatic in that they subscribe to a specific framework for understanding mental disorders but there are so many different kinds of problems we treat in psychiatry that you need to be open minded and accept that no model can meaningfully and parsimoniously explain all of mental life. grief, marital discord and fearfulness following rape cannot be explained in the same way as delirium and dementia, nor can we explain why a patient stays with her abusive boyfriend using the same framework we understand hallucinations or the patient we have homicidal feelings toward cannot be understood in the same way we understand autism. that is the major flaw with these programs that do provide excellent training within their particular world view, they don't allow for the pluralism that clinical psychiatry demands. despite the calls for psychiatry to become a clinical neuroscience discipline this has not happened nor will it. we are more than our brains.

I completely agree with you on this front. How much of an uphill climb do you think it would be to get this kind of perspective in a more biological program? I'm divided- I love the idea of different therapies but I'm attracted to the program (and its location) of a more biologically-oriented place.
 
I completely agree with you on this front. How much of an uphill climb do you think it would be to get this kind of perspective in a more biological program? I'm divided- I love the idea of different therapies but I'm attracted to the program (and its location) of a more biologically-oriented place.

Keep in mind that to some extent what Splik is saying is true, but I think it's unfair to say that you will get inadequate psychotherapy training at either program. Will you learn how to do proper analysis on Borderlines from Otto Kernberg himself? Of course not, but I think you will get well grounded in most of the evidence based therapies. And both programs have enough infrastructure that if you want to do extra therapy training, it's probably open to you.
Also, Wash U's most famous faculty member, C. Robert Cloninger is an authority on personality disorders and created the Temperament and Character Inventory. While his model of personality disorders is grounded in rigorous research (large genetic studies, etc) and phenomenology, it definitely takes a different perspective in one of psychiatry's most important areas that does not completely fall within the dogmatisms of the medical model.
 
i always have to laugh when you washu folks are all "but we have robert cloninger!" - he is a biological psychiatrist through and through and his personality research is very much grounded in the biomedical tradition (not that there is anything wrong with that, it was much needed) but it illustrates the point!

Does the term "biological psychiatrist" have any relevant meaning anymore? Cloninger's model of temperament describes individuals as falling on a continuum of four temperamental traits that may or may not be maladaptive as well as modifiable dimensions of character. More simply, there isn't a clear line between "sick" and "not sick", and he argues this point very thoroughly in his book, appropriately titled "Feeling Good: The Science of Well Being." He even references Freud more than Kraepelin! A strictly medical model view of personality would describe the personality disorders as distinct clinical pathologies completely separate from normal as conditions to be further researched, which is how the Feighner Criteria described Antisocial Personality Disorder.
 
Does the term "biological psychiatrist" have any relevant meaning anymore?

That's the thing. Biological psychiatry certainly does not mean that psychotherapy, empathy or social support are useless or even less important than genes and molecules. It just means that ultimately all of these things, including genes, neurons and molecules are rooted in the brain and the biology. It's a philosophical issue really, and it's hard to argue against that unless one is a dualist, and that is not a tenable position imo. And I don't believe that the "medical model" of psychiatry implies that psychiatric illness has some sort of objective standard. The distinction between disease and illness generalizes to every medical specialty. Ultimately we don't attempt to treat MIs or Rheumatoid Arthriits because they are abnormal processes, but because they are socially and functionally debilitating.
 
Last edited:
"We are biological" = "We don't care about teaching therapy" is probably unfair, but quite often it is true.

That's what I feared. I agree with finding an objective standard for psychiatric diagnoses, but I don't like the rejection of psychodynamic, etc viewpoints in return. They're just additional conceptualizations, as much as a biological/medical one is. It seems, at least at the programs I'm looking at (all Midwest), I either get therapy (Wisc-Madison and MCW for my list) or "biological" (Iowa, etc.). I was hoping the presence of STEPPS was a good indicator, but seemingly I didn't learn enough about its origins.
 
Northwestern probably is most where you'd be interested in. Michigan and Wisconsin are also very good.

You indicated Northwestern might be a better choice over Michigan and Wisconsin. Are there specific strengths to the program over the other two?
 
You indicated Northwestern might be a better choice over Michigan and Wisconsin. Are there specific strengths to the program over the other two?
you cant go wrong with any of them though you mentioned wanting a nice environment and strong psychotherapy training and Northwestern gives you that (particularly on psychodynamic psychotherapy though).
That said, Michigan would give you a broader, more diverse experience and they have pretty much everything. the one area they are lacking in is neuropsychiatry which is a bit niche anyway. Conversely Northwestern has Marcel Mesulam one of the worlds leading behavioral neurologists (he first described primary progressive aphasia) and there is a fellowship in this.

but these are all great programs, not heard anything bad about any of them
 
you cant go wrong with any of them though you mentioned wanting a nice environment and strong psychotherapy training and Northwestern gives you that (particularly on psychodynamic psychotherapy though).
That said, Michigan would give you a broader, more diverse experience and they have pretty much everything. the one area they are lacking in is neuropsychiatry which is a bit niche anyway. Conversely Northwestern has Marcel Mesulam one of the worlds leading behavioral neurologists (he first described primary progressive aphasia) and there is a fellowship in this.

but these are all great programs, not heard anything bad about any of them

Also consider the cost of living. Northwestern's hospital is just off of the Magnificent Mile, and housing within walking distance is going be pretty expensive. There is affordable living in Chicago, but it's going to be a commute, but the L is pretty reliable and easy to navigate. Ann Arbor, even for a college town, is expensive, but the housestaff is unionized, and salary is about $10,000 higher than most other places. And you can find reasonably priced housing around the medical center.
 
Also consider the cost of living. Northwestern's hospital is just off of the Magnificent Mile, and housing within walking distance is going be pretty expensive. There is affordable living in Chicago, but it's going to be a commute, but the L is pretty reliable and easy to navigate. Ann Arbor, even for a college town, is expensive, but the housestaff is unionized, and salary is about $10,000 higher than most other places. And you can find reasonably priced housing around the medical center.
...or in Ypsilanti. (Greek word meaning "I can't afford Ann Arbor")
 
Also consider the cost of living. Northwestern's hospital is just off of the Magnificent Mile, and housing within walking distance is going be pretty expensive. There is affordable living in Chicago, but it's going to be a commute, but the L is pretty reliable and easy to navigate. Ann Arbor, even for a college town, is expensive, but the housestaff is unionized, and salary is about $10,000 higher than most other places. And you can find reasonably priced housing around the medical center.

I agree with almost everything Harry says, but I really wouldn't consider cost of living in a residency choice. Unless you are supporting a family, the difference in 4 years between Chicago and Ann Arbor even with a maximum 10k difference in salary (NW has good pay for a non-union place) might make out 80k or generously 100k. That's really pennies in the long run compared to being happy with the program and getting the type of education you want. Also, the reason places have higher costs of living is usually they are more desirable places to live for the average person, so unless you dislike big cities and have no desire to live in one, you are at least getting something for that extra price.
 
Even the psychosocial intervention they developed for BPD at Iowa (STEPPS) is more a biomedical treatment than it is a psychological one (though draws heavily from CBT).

Have any of these "biologically" oriented places come up with a proposed treatment for antisocial PD? When they cure that, I'll start to believe that they know what they're doing.
 
Have any of these "biologically" oriented places come up with a proposed treatment for antisocial PD? When they cure that, I'll start to believe that they know what they're doing.
A regimen of Adderall, Klonopin, and Vicodin has been shown to significantly reduce their complaints...
 
Have any of these "biologically" oriented places come up with a proposed treatment for antisocial PD? When they cure that, I'll start to believe that they know what they're doing.
I actually hated every program I looked at for residency. None one single one had a cure for antisocial. It was pretty obvious none of them knew what they were doing.
 
Have any of these "biologically" oriented places come up with a proposed treatment for antisocial PD? When they cure that, I'll start to believe that they know what they're doing.
funny you should say that because the PD at Iowa, a biological psychiatrist through and through, is a personality disorders researcher and believes that antisocial PD is treatable. He talks about the "untreatability myth". Im pretty sure it isn't a myth. there is some emerging evidence for mentalization-based treatment but i dont think that is what he was talking about.
 
Have any of these "biologically" oriented places come up with a proposed treatment for antisocial PD? When they cure that, I'll start to believe that they know what they're doing.

Capital punishment would be a fairly biological approach. I haven't combed through the data but, selection bias aside, I've never evaluated a patient for continued antisocial behaviors post treatment.
 
funny you should say that because the PD at Iowa, a biological psychiatrist through and through, is a personality disorders researcher and believes that antisocial PD is treatable. He talks about the "untreatability myth". Im pretty sure it isn't a myth. there is some emerging evidence for mentalization-based treatment but i dont think that is what he was talking about.

The whole point of ASPD is that people with it can't empathize, so how are they supposed to "mentalize?"

Of all the personality disorders, antisocial has the most genetic component. My point above is that if these so called biological programs really think they can tackle personality disorders, they should prove it by treating the one that's the most notoriously untreatable, but also has the most potential to be treated using a biological approach, such as gene therapy.

I don't know much about STEPPS but it just seems to me that we need more psychosocial interventions about as much as we need more benzos and stimulants right now. My problem with the idea of "biological psychiatry" is that it seems to be more talk than action.
 
I think the “untreatability” thing comes from both the truth, and our legitimate fear that we will be tasked with doing something about reducing the risk to society or justifying the release of sociopaths. Could you imagine how much you would hate life if you developed the first and only successful treatment? It had better be easy to teach and disseminate or you would be doomed to a very creepy practice. You would become plea-bargaining lawyer’s best friend overnight. :naughty:
 
I think the “untreatability” thing comes from both the truth, and our legitimate fear that we will be tasked with doing something about reducing the risk to society or justifying the release of sociopaths. Could you imagine how much you would hate life if you developed the first and only successful treatment? It had better be easy to teach and disseminate or you would be doomed to a very creepy practice. You would become plea-bargaining lawyer’s best friend overnight. :naughty:

If I invented the first and only treatment for ASPD I would no longer be practicing psychiatry. I would be living on a yacht in the Mediterranean, eating caviar every single day.

Anyway most people with ASPD are not in prison. They are in health care administration.
 
Two points:
1) Everyone agrees that copd is a "biological" illness, yet no one makes similar comments about pulmonologists dispite a lack of pathology reversing (vs symptomatic) treatments. Why don't you just cure something is kind of a bad argument in medicine. We don't cure many things, especially not without side effects/long term consequences.
2) A trial of q6h mdma could be interesting...
 
Two points:
1) Everyone agrees that copd is a "biological" illness, yet no one makes similar comments about pulmonologists dispite a lack of pathology reversing (vs symptomatic) treatments. Why don't you just cure something is kind of a bad argument in medicine. We don't cure many things, especially not without side effects/long term consequences.
2) A trial of q6h mdma could be interesting...

But there is a cohort of psychiatrists who call themselves "biological," which was the topic of this thread earlier. I'm not sure what distinguishes them from other psychiatrists, other than the fact that they claim to be more biological, and are dismissive of psychotherapy, especially psychodynamic psychiatry. If they really are more biological, why don't they have more biological interventions? Even psychoanalysts in this day and age, if they are MDs, use medications. Everyone does. So what do the "biological" people offer that makes them better or different?

COPD is not a good comparison if you ask me, because even if it not curable, there are some treatments for it, such as inhalers and steroids and even lung transplants. But there is nothing at all for ASPD. Plus, you can find plenty of examples in internal medicine for diseases that actually can be cured. I'm not saying the "biological" psychiatrists should be expected to cure everything in the DSM, but they should present a few effective treatments that aren't being used by the "non-biological" psychiatrists if that label actually means anything.

I realize, labels like that mean a lot in the hallowed halls of academic psychiatry where people like to talk about things - but in actual practice, no one in psychiatry is putting out much by way of new treatments, if you ask me. If you can't advance the science, I don't care what your theoretical orientation is.
 
But there is a cohort of psychiatrists who call themselves "biological," which was the topic of this thread earlier. I'm not sure what distinguishes them from other psychiatrists, other than the fact that they claim to be more biological, and are dismissive of psychotherapy, especially psychodynamic psychiatry. If they really are more biological, why don't they have more biological interventions? Even psychoanalysts in this day and age, if they are MDs, use medications. Everyone does. So what do the "biological" people offer that makes them better or different?

COPD is not a good comparison if you ask me, because even if it not curable, there are some treatments for it, such as inhalers and steroids and even lung transplants. But there is nothing at all for ASPD. Plus, you can find plenty of examples in internal medicine for diseases that actually can be cured. I'm not saying the "biological" psychiatrists should be expected to cure everything in the DSM, but they should present a few effective treatments that aren't being used by the "non-biological" psychiatrists if that label actually means anything.

I realize, labels like that mean a lot in the hallowed halls of academic psychiatry where people like to talk about things - but in actual practice, no one in psychiatry is putting out much by way of new treatments, if you ask me. If you can't advance the science, I don't care what your theoretical orientation is.

I believe the biological psychiatry term is mostly used by those who are trying to insult the "movement". I think it's a useless term because everything related to humans is biological. The fact that we still use it tells a lot about the current status of the field.
 


“I am a biological psychiatrist and if you wish to claim the same you must poo poo all theories of therapy as unscientific non-sense and freely pass gas in the general direction of your local psychoanalytic institute!” Of course this is best done with a ridiculously thick French accent.
 
Truthfully, the "biological" psychiatrists are much better at insults/trolling:

""Here we meet everywhere the characteristic fundamental features of the Freudian trend of investigation, the representation of arbitrary assumptions and conjectures as assured facts, which are used without hesitation for the building up of always new castles in the air ever towering higher, and the tendency to generalization beyond measure from single observations. I must franky confess that with the best will I am not able to follow the trains of thought of this 'metapsychiatry,' which like a complex sucks up the sober method of clinical investigation." (E. Kraepelin "Frequency and Causes: Freudian Complexes, Dementia Praecox and Paraphrenia pp 250)

And from the Neo Kraepelinians:
"[Causes and mechanisms] will be discovered by scientific investigation, rather than by the use of nonscientific methods, such as pure discussion, speculation, further reasoning from the dictums of 'authorities' or 'schools of psychology' or the use of such pretentious undefined words as 'unconscious,' 'depth psychology,' 'psychodynamics,' 'psychosomatic,' and 'Oedipus complex,' and that fundamental investigation must rest on a firm clinical basis." - JJ Purtell, Eli Robins, Mandel Cohen. Observations on Clinical Aspects of Hysteria. JAMA 1951. (Mandel Cohen was the lone NON analyst at MGH/McClean in the middle part of the 20th century and constantly insulted his analyst colleagues- he was blacklisted from the Department and I think had an appointment in Neurology. Nevertheless, he was the Chief of the Consult Service at MGH, which today is one of the most respected in the world. Eli Robins was Cohen's protege who he encouraged to take a faculty position at Wash U, where he, Sam Guze, and George Winokur laid the foundation for diagnostic/biological psychiatry to become the norm in academia in America.)
 
Last edited by a moderator:
Yes, I can see how their ability to word smith is much more impressive than my suggestion to pass gas. I just couldn't resist the Spamalot reference.
 
Also consider the cost of living. Northwestern's hospital is just off of the Magnificent Mile, and housing within walking distance is going be pretty expensive. There is affordable living in Chicago, but it's going to be a commute, but the L is pretty reliable and easy to navigate. Ann Arbor, even for a college town, is expensive, but the housestaff is unionized, and salary is about $10,000 higher than most other places. And you can find reasonably priced housing around the medical center.

To be fair, the area around NW's medical campus is actually kind of... boring. If you're going to live in Chicago, it's best to live somewhere that isn't a giant tourist trap. (and lately a protest zone)

As for Ann Arbor and the medical center, just remember that if you get too close to Kerrytown, the street around Zingermans get clogged with a walking-dead sized hoard of pretentious foodie zombies in all directions.
 
he was never chief of the psychiatry consult service at MGH which was always very heavily psychodynamically oriented. psychosomatic medicine was founded by psychoanalysts.
Maybe it was neurology, then. Either way, you do NOT want an analyst consultant managing severe delirium, acute withdrawal, Bup/MTD induction in a pregnant patient (or any psychiatric issue in a pregnant patient for that matter), etc... basically any actual doctor things that require medical knowledge.
 
To be fair, the area around NW's medical campus is actually kind of... boring. If you're going to live in Chicago, it's best to live somewhere that isn't a giant tourist trap. (and lately a protest zone)

As for Ann Arbor and the medical center, just remember that if you get too close to Kerrytown, the street around Zingermans get clogged with a walking-dead sized hoard of pretentious foodie zombies in all directions.

True...but if they live too far south the streets are jammed fri night, sat morning, and until a couple hours after every home game. Merry town at least has a farmers' market.
 
I've been trying to abstain from this "biological" debate (especially as it pertains to WashU) mostly because I know I'll end up sinking a huge amount of time into it, but I just can't resist now.

First off, I think there's a fundamental flaw with the conceptualization here. Resorting to the "biological" model or the "psychoanalytic" model alone will both lead to an incomplete understanding of psychiatry. Most psychiatrists would agree that you obviously need to learn everything and integrate it appropriately. At WashU, the push is to understand the science, understand the evidence, understand the psychology, understand the socioeconomic factors (BTW, we have the best social work/public health school in the country, so our social workers do a great job of helping to make sure that we have an intricate understanding of the patient's social factors), and make a decision that you can justify based on evidence (or lack thereof) about whatever you are or aren't doing. That's why we prefer to call it the "medical" model rather than the "biological" model - treat it like a science, which will include the hard sciences (neurobiology, etc.), the social sciences (psychology, sociology), and the clinical sciences (clinical research in general) as they impact the patient.

The question arises when you ask how a training program should ideally balance these things and how it will structure your teaching. WashU's model is NOT "everything can be explained by biology." Rather, it's more like "you should have an intricate understanding of the biology, which will help you better understand how/when to use your biological treatments and how/when to use other things." Granted, the program won't teach you how to be a psychoanalyst, but that's probably not what you want anyway. But it's NOT an uphill climb to learn psychotherapy - I get weekly supervision from a great therapist who is not a CBT fan, I have several pure therapy patients, and I get interactive psychotherapy didactics for a couple of hours a week throughout third year (and some in other years). I know a couple of residents who chose to do supervision at the psychoanalytic institute, and the program was quite supportive of it. I also know a few graduates who have busy therapy-oriented practices, and they come back to teach some of our didactics too.

One major thing that gives WashU its reputation is the self-fulfilling prophecy. Even if you give a lot of psychotherapy training, the program is initially attracting people who are more interested in neuroscience. So even if they have good therapy training, you're more likely to see them end up in jobs with a biological bend to them.

One of my favorite psychiatrist/neuroscientists is a professor here with an expert in neuroimaging and movement disorders. In his office, next to his movement disorders textbook is a copy of Gabbard's psychodynamic book.

if you are looking for good psychotherapy training then WashU and Iowa are definitely NOT the places to go. The training at these programs is very dogmatic and while they excel in their particular brand of biomedical psychiatry it is somewhat deficient. even if you lean more biological you still want to be able to see through different lenses for trickier patients who might not conform to the way you see the world.

I can't speak for Iowa, but I think that this view of WashU is outdated. There has been a strong push to give active psychotherapy training that is fairly involved. We have a LOT more formal psychotherapy training now than the program had 5-10 years ago. I'm comparing it to the core curriculum at Columbia (I chose them just because they describe their core curriculum in detail on their website) - the total quantity of psychotherapy training is about the same, but we have more psychotherapy case conference-type stuff and they have more formal psychoanalytic-type stuff. Also, they have more therapy training in PGY2 and PGY4 than we do, but we have more in PGY3, and PGY1 is about the same. One could obviously argue that it's better to spread it out over the course of the program, but my point is that it's not a major difference.


the training (not psychotherapy) is dogmatic in that they subscribe to a specific framework for understanding mental disorders but there are so many different kinds of problems we treat in psychiatry that you need to be open minded and accept that no model can meaningfully and parsimoniously explain all of mental life. grief, marital discord and fearfulness following rape cannot be explained in the same way as delirium and dementia, nor can we explain why a patient stays with her abusive boyfriend using the same framework we understand hallucinations or the patient we have homicidal feelings toward cannot be understood in the same way we understand autism. that is the major flaw with these programs that do provide excellent training within their particular world view, they don't allow for the pluralism that clinical psychiatry demands. despite the calls for psychiatry to become a clinical neuroscience discipline this has not happened nor will it. we are more than our brains.

Again, I think that this is an oversimplification. More broadly, the program may subscribe to a specific framework for understanding mental "disorders," but that doesn't mean that it tries to apply the same framework to "meaningfully and parsimoniously explain all of mental life" as you describe it. Part of the framework for understanding mental "disorders" is to recognize what doesn't fit within that framework (i.e. why the patient stays with her abusive boyfriend) and to use other models to describe mental "life."


well (almost) every major psychiatry department in the country is biologically oriented, the point is the so-called "mid-Atlantic school" (including Iowa which is not really mid-atlantic but i guess psychiatrists aren't good at geography) are so betrothed to the biomedical model they pay little attention to more psychological formulations. What that means is you will theoretically get more familiarity with descriptive psychopathology and cognitive neuroscience than you would at most places. But there are no analysts, there is no analytic institute, and there is no emphasis on psychotherapy (it's the bare mininum) or psychological formulation. The PD is also one of the most biological psychiatrists you could ever meet who would argue drugs are the treatment of choice for PTSD over psychotherapy and possibly even personality disorder (seems keen on seroquel anyway!). Even the psychosocial intervention they developed for BPD at Iowa (STEPPS) is more a biomedical treatment than it is a psychological one (though draws heavily from CBT).
I can't comment on Iowa, but I don't think I hvae any PTSD patients who aren't getting some sort of therapy (either from me or from elsewhere), unless they specifically refused it despite my strong urging. And definitely for personality disorders... WashU is definitely dogmatic on personality disorders, but not necessarily in the way that you're portraying - the dogma is more along the lines of "don't try to put a band-aid on BPD by just tacking on Seroquel (diabetes!) because of the modest evidence on the topic... instead, undertand the evidence and the psychology and figure out whether the patient would benefit more from a Linehan-type treatment plan or a Cloninger-type treatment plan.


i always have to laugh when you washu folks are all "but we have robert cloninger!" - he is a biological psychiatrist through and through and his personality research is very much grounded in the biomedical tradition (not that there is anything wrong with that, it was much needed) but it illustrates the point!
His research may be grounded in the biomedical tradition, but this post suggests to me that you haven't actually had a conversation with him. He loves talking about neurobiology and genetics in a research context, but when you talk to him about a clinical case, he's all about breaking down the patient's personality and figuring out the ideal way to target it. He is actively involved in our teaching, and when we present a case to him, there will rarely be any discussion of drugs, receptors, biology, etc. And that's not just Cloninger - many people in the department are heavily influenced by his model. And there are also many people who are NOT very heavily influenced by his model, and they'll teach a different approach to therapy.

So I'd protest the notion that "he is a biological psychiatrist through and through" - he may be a biologically-oriented researcher, but as a clinical psychiatrist, that's not an accurate characterization of his practice model or his teaching style.


That's what I feared. I agree with finding an objective standard for psychiatric diagnoses, but I don't like the rejection of psychodynamic, etc viewpoints in return. They're just additional conceptualizations, as much as a biological/medical one is. It seems, at least at the programs I'm looking at (all Midwest), I either get therapy (Wisc-Madison and MCW for my list) or "biological" (Iowa, etc.). I was hoping the presence of STEPPS was a good indicator, but seemingly I didn't learn enough about its origins.

I think that the orientation of the program tends to be an oversimplification. Programs are more similar than they are different. I've seen faculty members who came out of more "old school" programs who have no idea how to think about teh patient's thoughts and spray everybody wtih Depakote, and I've seen the converse from people who come out of WashU. I think that the focus you're describing is largely based ont he self-fulfilling prophecy that I described earlier... obviously MCW will generate more therapists because they probably recruited residents who already wanted to be therapists.


Have any of these "biologically" oriented places come up with a proposed treatment for antisocial PD? When they cure that, I'll start to believe that they know what they're doing.
The "biologically" oriented places recommend doing the same thing with sociopaths that every other place recommends. Also other personality disorders. Again this perception is a symptom of the misconceptualization that I described earlier. "Biologically oriented" doesn't mean that you can treat everything with biological treatments, just that you should have a strict understanding of the biology so that you can determine when it is and isn't appropriate.

How does this play out with ASPD? Well, I've had more than one patient who was diagnosed with ASPD elsewhere, and upon a more thorough evaluation, I learned that they actually had something else going on that made them look like a sociopath. With the appropriate regimen of drugs/therapy (I can't say which one worked and which one didn't because I did both), they didn't look like sociopaths anymore. The "medical model" dictates that you should look at every aspect of the patient's pathology, list the problems, and tackle them individually, just like the internists do. Oversimplifying that guy as a sociopath was not doing him any good, and was probably founded in a bit of race-related countertransference.


Truthfully, the "biological" psychiatrists are much better at insults/trolling:

""Here we meet everywhere the characteristic fundamental features of the Freudian trend of investigation, the representation of arbitrary assumptions and conjectures as assured facts, which are used without hesitation for the building up of always new castles in the air ever towering higher, and the tendency to generalization beyond measure from single observations. I must franky confess that with the best will I am not able to follow the trains of thought of this 'metapsychiatry,' which like a complex sucks up the sober method of clinical investigation." (E. Kraepelin "Frequency and Causes: Freudian Complexes, Dementia Praecox and Paraphrenia pp 250)

And from the Neo Kraepelinians:
"[Causes and mechanisms] will be discovered by scientific investigation, rather than by the use of nonscientific methods, such as pure discussion, speculation, further reasoning from the dictums of 'authorities' or 'schools of psychology' or the use of such pretentious undefined words as 'unconscious,' 'depth psychology,' 'psychodynamics,' 'psychosomatic,' and 'Oedipus complex,' and that fundamental investigation must rest on a firm clinical basis." - JJ Purtell, Eli Robins, Mandel Cohen. Observations on Clinical Aspects of Hysteria. JAMA 1951. (Mandel Cohen was the lone NON analyst at MGH/McClean in the middle part of the 20th century and constantly insulted his analyst colleagues- he was blacklisted from the Department and I think had an appointment in Neurology. Nevertheless, he was the Chief of the Consult Service at MGH, which today is one of the most respected in the world. Eli Robins was Cohen's protege who he encouraged to take a faculty position at Wash U, where he, Sam Guze, and George Winokur laid the foundation for diagnostic/biological psychiatry to become the norm in academia in America.)

Kraepelin is my favorite troll.
 
well you do realize that psychosomatic medicine was founded by analysts, the psych consult service at MGH that you so highly regard was founded by an analyst, and had historically been very psychodynamically oriented. The head of the psych consult service at Columbia/NYPH Philip Muskin is an analyst. I'm not a big fan of analysis but the idea that a psychoanalytic psychiatrist can't manage these problems is ridiculous.

consultation-liaison psychiatry lends itself very well to a psychodynamic approach, even the delusions of delirium can be detoxified with psychodynamic interpretations. This kind of thinking can be integrated into a more medical approach, they are not mutually exclusive. it's not good to be dogmatic. As the statistician George Box said "all models are wrong, but some are useful"

Can't really speak about the contribution of analysts to psychosomatic medicine, but the only way to justifiy a model is if it's backed up by data and has predictive power. It's good to be dogmatic if that's your measuring stick. We expect these sort of standards from every other medical specialty and we like to believe that medical practice is guided by science.
 
Last edited:
this is a joke right?! there is no way you guys have more psychotherapy training as PGY-3s than residents at columbia or anything close
Sorry, I wrote that wrong - I meant more lectures, not more training. I don't know about the other parts of their training.
 
Can't really speak about the contribution of analysts to psychosomatic medicine, but the only way to justifiy a model is if it's backed up by data and has predictive power. It's good to be dogmatic if that's your measuring stick. We expect these sort of standards from every other medical specialty and we like to believe that medical practice is guided by science.

The reason psychodynamic training is so helpful in C-L psychiatry is not because you are psychoanalyzing your consult patients, but because good supportive psychotherapy, which is at the heart of actually helping medically sick patients cope with their illnesses, requires a thorough understanding of things like defenses and primary and secondary gain (these are all psychodynamic concepts). Also, it helps to be able to understand the intrapsychic and interpersonal dynamics of the doctors who request the consults, especially since many of the problems with "difficult" patients on medical services are related to enactments of countertransference feelings by the primary doctors. The medical part of C-L is the easy part.
 
The "biologically" oriented places recommend doing the same thing with sociopaths that every other place recommends.

Which is what?

Also other personality disorders. Again this perception is a symptom of the misconceptualization that I described earlier. "Biologically oriented" doesn't mean that you can treat everything with biological treatments, just that you should have a strict understanding of the biology so that you can determine when it is and isn't appropriate.

How does this play out with ASPD? Well, I've had more than one patient who was diagnosed with ASPD elsewhere, and upon a more thorough evaluation, I learned that they actually had something else going on that made them look like a sociopath. With the appropriate regimen of drugs/therapy (I can't say which one worked and which one didn't because I did both), they didn't look like sociopaths anymore. The "medical model" dictates that you should look at every aspect of the patient's pathology, list the problems, and tackle them individually, just like the internists do. Oversimplifying that guy as a sociopath was not doing him any good, and was probably founded in a bit of race-related countertransference.

The example you give doesn't address the issue I raised. My comment earlier was not about patients who are misdiagnosed with ASPD, it was about the actual condition. Just because you discovered a patient who was misdiagnosed with ASPD does not mean it would not behoove society to find a cure for this appallingly bad disease, which has certainly caused as much suffering for humanity as cancer or even smallpox. In fact I would guess that ASPD is underdiagnosed in the population, since no patient ever books an appointment with the hopes of having their antisocial personality disorder understood and remedied. If they do make an appointment, they have an ulterior motive. So what are we supposed to do about people with ASPD? I see patients all the time who have antisocial traits at a minimum, and I have no idea what to do about it. My understanding is that it has a genetic component, and I therefore wish that the biological folks would come up with gene therapy or other treatment. So, why haven't they? If they adhere to a "medical" model shouldn't their agenda prioritize finding cures for disease?

I'm sort of just saying this to make a point, which is that it doesn't really seem from what you're saying about Wash U that "biological" psychiatrists are any different from other psychiatrists. All psychiatrists should be utilizing a medical approach, otherwise they need not go to medical school. It seems like a false dichotomy, a stupid fight that was originally perpetuated by the biological people against the analytical people.

Also, at places like Wash U, that claim to value evidence, do you guys question the sources of the evidence? Isn't most of the "evidence" in psychiatry tainted by pharmaceutical company influence?
 
Strangely, the above post comes off a bit antagonistic, but most of your points agree with most of what I was saying.

Which is what?
We all know that the answer to that question is more complex than what I can easily write in a little post here.

The example you give doesn't address the issue I raised. My comment earlier was not about patients who are misdiagnosed with ASPD, it was about the actual condition. Just because you discovered a patient who was misdiagnosed with ASPD does not mean it would not behoove society to find a cure for this appallingly bad disease, which has certainly caused as much suffering for humanity as cancer or even smallpox.
Yeah, I'd love to find a cure for ASPD. I'd also love to find a cure for schizophrenia, diabetes, CHF, COPD, and most other diseases in medicine. My point wasn't that biological psychiatry is "better" at treating anything - just that the way to handle ASPD is to do a detailed evaluation and treat it in a broad multi-dimensional way to the best of our abilities (which are obviously quite limited).

So what are we supposed to do about people with ASPD? I see patients all the time who have antisocial traits at a minimum, and I have no idea what to do about it. My understanding is that it has a genetic component, and I therefore wish that the biological folks would come up with gene therapy or other treatment. So, why haven't they? If they adhere to a "medical" model shouldn't their agenda prioritize finding cures for disease?
The reason we haven't come up with gene therapy for ASPD is probably the same as the reason why we haven't come up with gene therapy for most genetic diseases.

I'm sort of just saying this to make a point, which is that it doesn't really seem from what you're saying about Wash U that "biological" psychiatrists are any different from other psychiatrists. All psychiatrists should be utilizing a medical approach, otherwise they need not go to medical school. It seems like a false dichotomy, a stupid fight that was originally perpetuated by the biological people against the analytical people.
Yes, that was one of the first things I said in the post that you're citing. We should all be utilizing a medical approach rather than a wholly "biological" or "analytical" approach. It doesn't matter who started the fight or created the dichotomy, what matters is that we learn how to integrate things together in a scientific way.

You won't find anybody at WashU who thinks it's silly to learn psychoanalysis. You also won't find anybody who claims that everything can be explained by biology. You will find a general notion that it's silly to dichotomize psychiatry as "biological" vs. "analytical" because the issues are too complicated to fit into one of the two boxes. That's why we call it the "medical" model - moern medicine is about integrating multiple concepts from the different sciences and learning how to apply them to your patient.

Also, at places like Wash U, that claim to value evidence, do you guys question the sources of the evidence? Isn't most of the "evidence" in psychiatry tainted by pharmaceutical company influence?
Yes, of course... doesn't everybody do that? A critical part of medical training is learning how to critically evaluate literature. At our department specifically, we don't allow drug reps or drug company-sponsored talks. Any medical student can read an article and say "vitamin B6 is the cure for tardive dyskinesia," or "Latuda is the bee's knees."

There are several key components to implementing evidence-based practice. One is to make sure that the evidence is reliable, and there are several factors that go into that (good methodology, appropriate interpretation of results, drug company bias, etc... even non-pharma studies are often biased because the authors are tainted by their own grant funding, etc). Another is to ensure that it's generalizable to your patient. Another is to ensure that you're not conflating a lack of evidence with evidence of the lack of an effect. And several other factors.
 
Which is what?



The example you give doesn't address the issue I raised. My comment earlier was not about patients who are misdiagnosed with ASPD, it was about the actual condition. Just because you discovered a patient who was misdiagnosed with ASPD does not mean it would not behoove society to find a cure for this appallingly bad disease, which has certainly caused as much suffering for humanity as cancer or even smallpox. In fact I would guess that ASPD is underdiagnosed in the population, since no patient ever books an appointment with the hopes of having their antisocial personality disorder understood and remedied. If they do make an appointment, they have an ulterior motive. So what are we supposed to do about people with ASPD? I see patients all the time who have antisocial traits at a minimum, and I have no idea what to do about it. My understanding is that it has a genetic component, and I therefore wish that the biological folks would come up with gene therapy or other treatment. So, why haven't they? If they adhere to a "medical" model shouldn't their agenda prioritize finding cures for disease?

I'm sort of just saying this to make a point, which is that it doesn't really seem from what you're saying about Wash U that "biological" psychiatrists are any different from other psychiatrists. All psychiatrists should be utilizing a medical approach, otherwise they need not go to medical school. It seems like a false dichotomy, a stupid fight that was originally perpetuated by the biological people against the analytical people.

Also, at places like Wash U, that claim to value evidence, do you guys question the sources of the evidence? Isn't most of the "evidence" in psychiatry tainted by pharmaceutical company influence?

Is this a serious question?
 
Top