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.
