"We have a psychoanalytic approach!"

[235750]

We had several hospitals visit our school recently to show off their facilities to the upcoming 3rd/4th years, and I had the chance to chat to a psych PGY1. As s/he described the site I was getting quite excited until s/he said, "we one of the only places left in the country that has a truly psychoanalytic concentration".

I think I did a pretty good job of not letting my jaw hit the floor.

As an MS1, I have been warned time and time again about the dangers of the psychoanalytic approach and how it will make me the Worst Psychiatrist Ever.

A few weeks ago we had an alum from our school, now a tenured psych prof at a top 5 school, talk about his research. When I asked him what advice he could give us regarding choosing a residency, he dropped his smile, pointed a finger at me and said with conviction: "Whatever type of psychiatrist you become, DO NOT go to a place that emphasizes the analytic approach!" His reasoning was that it was old and dated, and while there was no choice 50 years ago, psychiatry has evolved. It should be taught only from a historical perspective. Opting to focus on psychoanalysis was like a surgeon matching to a site where blood letting was taught. Again, all his words, not mine.

Now, I'm not trying to get into an argument about pyschoanalytics. I am only an MS1, but I understand all of psychiatry owes footnotes to Freud, and that it's difficult to measure these sorts of therapeutical approaches as one cannot standardize the therapist, etc. I personally think that it sounds fascinating. But, I'm not trying to waste your time asking what the basics of psychiatry/psychology, I can certainly read about it later.

Ultimately I want 3 things out of my residency, which bring me to my questions:

If I match at a site that emphasizes psychotherapy, will I

(1)...be a good medical doctor, ie psychiatrist? It seems like this particular concentration is meant for psychologists as biological systems (neurotransmitters, etc) are ignored. Despite how wonderful the psychoanalytic model is, isn't this a bad thing for someone who's spending 4 years in medical school? Should not my 'toolkit' be empirically based?

(2)...be able to get a job? I hope to work for the VA, or maybe the NHSC, I don't know yet, but does this harm my chances?

(3)...be able to get a fellowship later on if I am so inclined? It is of course an ACGME accredited site, but if the psychiatrists I meet are any indication of how PDs feel, then it would seem like psychoanalysis is the wrong way to go. Which leads me to my last qusetion....

(4)(Would you have done)/(Did you do) a residency in that focused on psychotherapy? Why or why not? On top of this, lets say that the location of this site is REALLY attractive for your family...would that change your mind?

Oh yes, and when the resident was pressed, s/he said, "psychotherapy is stressed during the last two years of training" at this site, and didn't have any specifics.

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[Doc Samson]

We had several hospitals visit our school recently to show off their facilities to the upcoming 3rd/4th years, and I had the chance to chat to a psych PGY1. As s/he described the site I was getting quite excited until s/he said, "we one of the only places left in the country that has a truly psychoanalytic concentration".

I think I did a pretty good job of not letting my jaw hit the floor.

As an MS1, I have been warned time and time again about the dangers of the psychoanalytic approach and how it will make me the Worst Psychiatrist Ever.

A few weeks ago we had an alum from our school, now a tenured psych prof at a top 5 school, talk about his research. When I asked him what advice he could give us regarding choosing a residency, he dropped his smile, pointed a finger at me and said with conviction: "Whatever type of psychiatrist you become, DO NOT go to a place that emphasizes the analytic approach!" His reasoning was that it was old and dated, and while there was no choice 50 years ago, psychiatry has evolved. It should be taught only from a historical perspective. Opting to focus on psychoanalysis was like a surgeon matching to a site where blood letting was taught. Again, all his words, not mine.

Now, I'm not trying to get into an argument about pyschoanalytics. I am only an MS1, but I understand all of psychiatry owes footnotes to Freud, and that it's difficult to measure these sorts of therapeutical approaches as one cannot standardize the therapist, etc. I personally think that it sounds fascinating. But, I'm not trying to waste your time asking what the basics of psychiatry/psychology, I can certainly read about it later.

Ultimately I want 3 things out of my residency, which bring me to my questions:

If I match at a site that emphasizes psychotherapy, will I

(1)...be a good medical doctor, ie psychiatrist? It seems like this particular concentration is meant for psychologists as biological systems (neurotransmitters, etc) are ignored. Despite how wonderful the psychoanalytic model is, isn't this a bad thing for someone who's spending 4 years in medical school? Should not my 'toolkit' be empirically based?

(2)...be able to get a job? I hope to work for the VA, or maybe the NHSC, I don't know yet, but does this harm my chances?

(3)...be able to get a fellowship later on if I am so inclined? It is of course an ACGME accredited site, but if the psychiatrists I meet are any indication of how PDs feel, then it would seem like psychoanalysis is the wrong way to go. Which leads me to my last qusetion....

(4)(Would you have done)/(Did you do) a residency in that focused on psychotherapy? Why or why not? On top of this, lets say that the location of this site is REALLY attractive for your family...would that change your mind?

Oh yes, and when the resident was pressed, s/he said, "psychotherapy is stressed during the last two years of training" at this site, and didn't have any specifics.

The PGY-1 you spoke to is clueless. Their residency program is not training reisdents in psychoanalysis, they're teaching them psychodynamic psychotherapy (which, BTW, is quite valid and well worth learning). The attending you spoke to is also clueless - psychodynamics and psychoanalysis are both vibrant areas of active research - certainly not stagnant and dated. My advice is always to find broad based traingin that will give you exposure to a variety of therapeutic modalities so that you can develop your own approach to your patients. Learning psychopharm at the exclusion of psychotherapy or vice-versa are just as likely to make you the Worst Psychiatrist Ever.

 

[dl2dp2]

I'll tell you that on the interview trail this year, the only program that is very psychodynamically oriented is Cornell, and they even de-emphasize it. If you go to any solid residency program the core of your training will be solid psychopharm + a few evidence based therapy modalities (i.e. CBT). Or else you won't pass the boards! Just because a program has a lot of opportunities for therapy training--or even analytic training--doesn't mean that it will overshadow the core.

There is a big difference between modern evidence-based psychotherapy (i.e. CBT, psychodynamic, DBT, insight-oriented, motivational interviewing, etc.) and classical psychoanalysis (i.e. 5 times a week for 1 hrs, no set end point). I would say to the extent that classical psychoanalysis is practiced, some theories are incorporated into brief therapy techniques, etc., but the vast majority of practicing psychiatrists don't do psychoanalysis. I think of psychotherapy as mostly a "brain training" activity, just like how physical therapy is more like "body training". And the neuroscience of psychotherapy is becoming clarified, especially for CBT.

Classical psychoanalysis is not reimbursed by medicare or the vast majority of private insurance, which means that it's only sustainable in a few metro centers. In order to practice psychoanalysis you theoretically have to join an institute and get further training and enter analysis yourself for years.

The main problem of classical analysis is that it's very expensive, and not very effective for things psychiatrists treat on a daily basis.

Psychiatry is a MEDICAL specialty. Most psychiatrists do what every other doctor does: see a patient, assess the symptoms, make a diagnosis, prescribe medicine or refer for allied therapy. It's not very mysterious.

 

[nancysinatra]

I'll tell you that on the interview trail this year, the only program that is very psychodynamically oriented is Cornell, and they even de-emphasize it.

Did you interview at every program in the country? If not, how would you know?

 

[masterofmonkeys]

A strong psychodynamic orientation was one of my main criteria in evaluating programs back when I was on the interview trail.

There are very few mediocre programs that have a strong psychodynamic orientation. Most are among the top in the country. And none of the ones I interviewed at had poor psychopharm training. In fact, in particular Cornell seemed to have an excellent and well-structured psycopharm course that at least on paper seemed to be more thorough than anything other residency training programs offered.

But the 'biologically oriented' (god i hate that) programs frequently did NOT have good psychotherapy training.

Furthermore, I'd argue that to be an effective psychopharmacologist, you have to know your therapy as well. This really struck home when I was working with an attending with a reputation as an excellent psychopharmacologist. He definitely was. But he was also all over the psychodynamic and cognitive-behavioral aspects of our patients. We went into more depth in those areas than I had with any of my other attendings this year. He believes that it's important to be able to tell symptoms from behaviors, and that an effective psychopharmacologist manages symptoms but does not 'treat' behaviors, the latter of which will almost definitely make a patient with a significant component of acting out or characterological issues worse.

I'm skeptical of any program or any individual who denies the importance of inner life and external stressors in treatment. And will always remain so.

 

[HMSPSYCH]

Furthermore, I'd argue that to be an effective psychopharmacologist, you have to know your therapy as well.
.

I wonder when did psychiatrists started being called psychopharmacologists? Are we pharmacists or chemists? The term is misleading and does not fully describe what we do. And possbily empowered some to marginalize psychiatry further.

 

[snarfer]

I wonder when did psychiatrists started being called psychopharmacologists? Are we pharmacists or chemists? The term is misleading and does not fully describe what we do. And possbily empowered some to marginalize psychiatry further.

I agree. It is indeed a misleading, perjorative term.

 

[235750]

I'll tell you that on the interview trail this year, the only program that is very psychodynamically oriented is Cornell

Again, I am only an MS1, but I know of a few others sites besides Cornell. This would be such a site. This one is probably very 'medicore' in most peoples' eyes, although I don't really give much weight to rankings. I am most concerned about my original questions!

If you go to any solid residency program the core of your training will be solid psychopharm + a few evidence based therapy modalities (i.e. CBT). Or else you won't pass the boards!

OK, that makes sense! I didn't think to look at their pass rate, which according to the ACGME website is 99%. So, they must be teaching enough psychopharm, right?

You add as a precondition that the site has to be 'solid', and I don't really know what that means, except to say the residents seemed happy and got the usual perks (meals/CMEs paid for, decent salary [for a resident], etc) and call seemed typical (eg crazy during PGY1 for medicine and easing up to nothing in PYG4). The facility (again looking at it through my inexperienced eyes) is pretty awesome, inpatient unit for children, addiction, etc, although it has no big name to back it up. Thoughts?

From everyones' posts, it seems as though I should not be afraid of the psychoanalytic concentration. It does strike me as odd that all the responses here are positive, and yet the dozen or so psychiatrists I have talked to in real life have all been negative, or at best condescending.

Even though your thoughts are positive, can anyone confirm/deny that some psychiatrists are against such training? Will that create bias for me later on? Like for example (just making this up), do child psychiatrists tend to be more pharm and less analytic, or vice versa? Or does the concentration one has in residency not effect chances for fellowship opportunities later?

Does anyone think the residency concentration will effect questions (3) or (2)? Do hospitals care about what concentration you had in residency, or do they just want someone who's board eligible/board certified?

Thank you to everyone who has taken time to respond!

 

[235750]

The PGY-1 you spoke to is clueless. Their residency program is not training reisdents in psychoanalysis, they're teaching them psychodynamic psychotherapy (which, BTW, is quite valid and well worth learning).

I am not knowledgeable enough about psychiatry to respond to you Doc Samson, but I am looking at their pamphlet right now and it says in bold, all caps, "WE HAVE A PSYCHOANALYTIC FOCUS" "The psychoanalytic curriculum begins in the first year...you will become more familiar with the world of the unconscious."

I obviously need to read more about CBT, psychoanalysis, etc. and for that I apologize. However, if you look at my questions, my main concern (and my reason for starting this thread) is prevailing attitudes amongst psychiatrists/hospital administrators about the analytic approach. At the end of the day I just want to be a decent psychiatrist that can land a job! Will the 'concentration' or 'focus' of a residency effect my job/fellowship prospects?

Thanks again!

 

[dl2dp2]

I am not knowledgeable enough about psychiatry to respond to you Doc Samson, but I am looking at their pamphlet right now and it says in bold, all caps, "WE HAVE A PSYCHOANALYTIC FOCUS" "The psychoanalytic curriculum begins in the first year...you will become more familiar with the world of the unconscious."

I obviously need to read more about CBT, psychoanalysis, etc. and for that I apologize. However, if you look at my questions, my main concern (and my reason for starting this thread) is prevailing attitudes amongst psychiatrists/hospital administrators about the analytic approach. At the end of the day I just want to be a decent psychiatrist that can land a job! Will the 'concentration' or 'focus' of a residency effect my job/fellowship prospects?

Thanks again!

Although I do think that psychoanalysis per se is no longer the core of psychiatric practice in most situations, as long as your residency program as mentioned is ACGME accredited and makes you board eligible, I don't think there's a big problem finding a job even if you decide to take on the "psychoanalytic concentration." I think you are safe--they just have a program that allots more time for more Freudian stuff. As I said, if a program fulfills all the ACGME requirements, theoretically you should be well trained in the core stuff. Of course, as made obvious by a previous poster, I didn't go to interview at every single program in the country, so perhaps there are ACGME accredited programs that are so shady that they only train exclusively psychoanalysts--I hope not--but from a small batch of programs I've seen this is the impression I got.

As far as attitudes from the admin etc, it seems that the job market right now is such that there is a dire lack of community psychiatrists, so unless you attempt to treat schizophrenics and bipolars with exclusively psychoanalytic techniques, admins will probably not care that much. Remember the BREAD and BUTTER of community psychiatry consists of severe depression, schizophrenia, children requiring ADHD/antipsychotics, and opioids etc. There is a huge need for people to prescribe meds appropriately.

The need for psychoanalytic "treatment" is just not there. Insurance doesn't reimburse it. Patients don't usually get it. Unless you are in a few metros with a body of extremely rich people you won't develop enough of a client base to survive exclusively on psychoanalysis. And hospital administrators don't deal with people who do psychoanalysis. I would say that psychoanalysis is NOT really part of the US healthcare system at large.

 

[mishavrach]

I am not knowledgeable enough about psychiatry to respond to you Doc Samson, but I am looking at their pamphlet right now and it says in bold, all caps, "WE HAVE A PSYCHOANALYTIC FOCUS" "The psychoanalytic curriculum begins in the first year...you will become more familiar with the world of the unconscious."

Fortunately, I have enough knowledge to respond to Dr. Samson. There is no appreciable difference in psychoanalytic and psychodynamic approaches. Both came from Freud loins, both are misguided and misleading. It's a well established myth that one needs psychoanalyt/dynamic training to practice psychiatry. Trust me, you don't. I won't be getting into debate, but share an analogy. If a psychoanalyst drives a car and realizes that the tire is blown, he'll go back to 5 miles to find the nail that probably did it. A cognitive -behavioral psychologist or psychopharmacologist would fix the tire.

I will also refer you to Peter Kramer's book from Eminent Lives Series titled Freud, Inventor of the Modern Mind - fascinating reading, not the type Dr. Samson would approve, though. ..

 

[Doc Samson]

I am not knowledgeable enough about psychiatry to respond to you Doc Samson, but I am looking at their pamphlet right now and it says in bold, all caps, "WE HAVE A PSYCHOANALYTIC FOCUS" "The psychoanalytic curriculum begins in the first year...you will become more familiar with the world of the unconscious."

I obviously need to read more about CBT, psychoanalysis, etc. and for that I apologize. However, if you look at my questions, my main concern (and my reason for starting this thread) is prevailing attitudes amongst psychiatrists/hospital administrators about the analytic approach. At the end of the day I just want to be a decent psychiatrist that can land a job! Will the 'concentration' or 'focus' of a residency effect my job/fellowship prospects?

Thanks again!

I WOULD actually be troubled by a residency that advertizes itself as psychoanalytic, since realistically it cannot hope to provide psychoanalytic training. It terms of limiting job prospects - not really, but a limited residency (whether it be limited to analysis or psychopharm) will limit your options for treating your patients.

 

[Doc Samson]

Fortunately, I have enough knowledge to respond to Dr. Samson. There is no appreciable difference in psychoanalytic and psychodynamic approaches. Both came from Freud loins, both are misguided and misleading. It's a well established myth that one needs psychoanalyt/dynamic training to practice psychiatry. Trust me, you don't. I won't be getting into debate, but share an analogy. If a psychoanalyst drives a car and realizes that the tire is blown, he'll go back to 5 miles to find the nail that probably did it. A cognitive -behavioral psychologist or psychopharmacologist would fix the tire.

I will also refer you to Peter Kramer's book from Eminent Lives Series titled Freud, Inventor of the Modern Mind - fascinating reading, not the type Dr. Samson would approve, though. ..

It seems that any voice of support for psychodynamic psychotherapy or psychoanalysis (which BTW ARE different modalities, but, yes, they both originate from Freud's theories) will be taken by you as an assault on other forms of treatment. If you read back over my posts, you'll see that I advocate exposure to as many treatment modalities as possible so that an individual eclectic treatment approach can be developed. You don't HAVE to train in psychodynamics to be a psychiatrist, but you do look sort of silly when one of your colleagues wishes to discuss a psychodynamic issue of a shared patient with you and you either (a) cannot or (b)just dismiss it as "misguided" (which in my experience tends to be camoflage for option (a)). Why would you wilfully limit your vocabulary?

 

[nancysinatra]

If a psychoanalyst drives a car and realizes that the tire is blown, he'll go back to 5 miles to find the nail that probably did it. A cognitive -behavioral psychologist or psychopharmacologist would fix the tire.

And they'll keep fixing it over and over every day if they drive the same route to work, is that right? Or they'll go out of their way to find some new, circuitous route. Since they have zero interest in finding and removing that nail.

I'm only following your analogy. I could be wrong since I don't know enough about the two types of therapy. But I wouldn't want only a fixer-upper type form in my toolbox, I guess.

 

[mishavrach]

It seems that any voice of support for psychodynamic psychotherapy or psychoanalysis (which BTW ARE different modalities, but, yes, they both originate from Freud's theories) will be taken by you as an assault on other forms of treatment. If you read back over my posts, you'll see that I advocate exposure to as many treatment modalities as possible so that an individual eclectic treatment approach can be developed. You don't HAVE to train in psychodynamics to be a psychiatrist, but you do look sort of silly when one of your colleagues wishes to discuss a psychodynamic issue of a shared patient with you and you either (a) cannot or (b)just dismiss it as "misguided" (which in my experience tends to be camoflage for option (a)). Why would you wilfully limit your vocabulary?

The original post, may I remind you, was about role of psychoanalytical training in psychiatric post-graduate education. Your position is that these instructions are useful, my position is that they are useless and wasteful.

Now, you are advocating familiarity, in your words, "exposure" to psychoanalysis. I won't argue that. There is a huge gap, IMO and I hope in yours, between training and exposure. I am all for exposure, to psychoanalysis, accupuncture, EMDR, witchcraft, etc. But I don't believe psychiatric program's philosophy should be based on any of those.

It's easy to become well versed in psychoanalytical lingo and I would encourage anyone who is curious to learn an expression or two. As for a colleagues who wish to discuss psychodynamic issues, I usually listen to them with the same restrained civility an internist would reserve for a well-meaning homeopath. We ought to be collegial.

 

[mishavrach]

And they'll keep fixing it over and over every day if they drive the same route to work, is that right? Or they'll go out of their way to find some new, circuitous route. Since they have zero interest in finding and removing that nail.

I'm only following your analogy. I could be wrong since I don't know enough about the two types of therapy. But I wouldn't want only a fixer-upper type form in my toolbox, I guess.

Keeping with the analogy, we never travel the same route in our life journey. As Heraclitus said "You can't step into the same river twice." Physicians, not philosophers, are car mechanics and those who bring to us their problems expect us to take care of them and not discuss pitiful state or provincial roads.

There are several problems with looking for the nail. First, no one knows what causes tires to blow, sometimes they sell defective tires. Second, nail-seekers always find the nail and then try to convince you that all your car problems stem form it. They also waste a lot of your time and your car insurance doesn't cover nails on the road. In addition they universally blame your family for planting the nail and that is far from innocent.

I hope you would agree that we should leave car fixing to the mechanics and keep driving instructors away from it.

 

[OldPsychDoc]

Keeping with the analogy, we never travel the same route in our life journey. As Heraclitus said "You can't step into the same river twice." Physicians, not philosophers, are car mechanics and those who bring to us their problems expect us to take care of them and not discuss pitiful state or provincial roads.

There are several problems with looking for the nail. First, no one knows what causes tires to blow, sometimes they sell defective tires. Second, nail-seekers always find the nail and then try to convince you that all your car problems stem form it. They also waste a lot of your time and your car insurance doesn't cover nails on the road. In addition they universally blame your family for planting the nail and that is far from innocent.

I hope you would agree that we should leave car fixing to the mechanics and keep driving instructors away from it.

You seem very interested in nails penetrating tires...

Would you care to talk about that?

 

[235750]

Ok, now I'm really confused.

So, Dr. Samson, this site that brags about having a psychoanalytic focus: this is a poor option because they couldn't possibly teach psychoanalysis well enough in a psychiatry residency...is this what you're saying? And you said it wouldn't really hurt my job prospects by matching there, but you didn't sound very convincing

Will 'focusing' on psychoanalysis not hurt my job/fellowship prospects because of the psychiatrist shortage? If suddenly there were enough docs in the US, would the analytically trained go to the bottom of the lists? That's what several people (sluox, Samson) have insinuated, that it doesn't really matter the focus due to the short supply. So, it is a handicap that is overcome by demand?

If so, that still does not sound good to me. And, I don't understand why a technique which is not reimbursable through insurance is stressed in a residency. That really part really confuses me

a limited residency (whether it be limited to analysis or psychopharm) will limit your options for treating your patients.

Many places brag about having a concentration or focus. Does that mean they are 'limited'?

It seems like a gimmick, a way to differentiate themselves from other sites, as to me looking at their on call schedule, rotations, etc, they all look the same. Maybe one has an extra month in addition, another has more geriatric. I mean, I'm looking at 8-10 sites around me, and honestly I can't tell most of them apart except some have obviously spent more money on the pamphlets...and their focus of course. I was hoping this 'focus' business would help me widdle it down

Thanks again for everyone's words of wisdom.

 

[mishavrach]

You seem very interested in nails penetrating tires...

Would you care to talk about that?

Quite the opposite, I don't believe in nails. But I'll talk to you.

 

[billypilgrim37]

This thread reminds me so much of my dinner the night before my Cambridge interview, where I had the audacity to basically ask what the difference was between psychodynamics and psychoanalysis. The Yale kid and the Harvard kid sitting at the table almost spit their wine everywhere. Seriously. It was clear they were offended and that they thought I was the dumbest hick applicant that could have dared enter the state of Massachusetts for a visit.

"Come on," I said, "I went to med school in the midwest, where psychotherapy goes to die."

2.5 years later at one of those pesky "biological" programs, and I sleep with my Gabbard book underneath my pillow half the time. You never know.

 

[Doc Samson]

The original post, may I remind you, was about role of psychoanalytical training in psychiatric post-graduate education. Your position is that these instructions are useful, my position is that they are useless and wasteful.

Now, you are advocating familiarity, in your words, "exposure" to psychoanalysis. I won't argue that. There is a huge gap, IMO and I hope in yours, between training and exposure. I am all for exposure, to psychoanalysis, accupuncture, EMDR, witchcraft, etc. But I don't believe psychiatric program's philosophy should be based on any of those.

It's easy to become well versed in psychoanalytical lingo and I would encourage anyone who is curious to learn an expression or two. As for a colleagues who wish to discuss psychodynamic issues, I usually listen to them with the same restrained civility an internist would reserve for a well-meaning homeopath. We ought to be collegial.

While I'm not sure of the evidence base of witchcraft, there is evidence supporting psychoanalysis, accupuncture, and EMDR for the treatment of various conditions (similar for the "evidence" of using Paxil for depression). I agree that limiting a training philosophy to any one of them would produce an "incomplete" psychiatrist.

I'm sure your patients and colleagues are thrilled that you would be capable of displaying "restrained civility" if you were to collaborate with the majority of the attendings at Harvard, Yale, Brown, Columbia, Cornell, Northwestern, UCSF, etc.

My recommendation to trainees is this: train in EVERYTHING. Get as much exposure to as much as you can - then you can decide if you want to practice psychodynamics, CBT, DBT, IPT, EMDR, ECT, TMS, whatever. If you don't train in it, you won't have the choice.

 

[Doc Samson]

Ok, now I'm really confused.

So, Dr. Samson, this site that brags about having a psychoanalytic focus: this is a poor option because they couldn't possibly teach psychoanalysis well enough in a psychiatry residency...is this what you're saying? And you said it wouldn't really hurt my job prospects by matching there, but you didn't sound very convincing

Will 'focusing' on psychoanalysis not hurt my job/fellowship prospects because of the psychiatrist shortage? If suddenly there were enough docs in the US, would the analytically trained go to the bottom of the lists? That's what several people (sluox, Samson) have insinuated, that it doesn't really matter the focus due to the short supply. So, it is a handicap that is overcome by demand?

If so, that still does not sound good to me. And, I don't understand why a technique which is not reimbursable through insurance is stressed in a residency. That really part really confuses me



Many places brag about having a concentration or focus. Does that mean they are 'limited'?

It seems like a gimmick, a way to differentiate themselves from other sites, as to me looking at their on call schedule, rotations, etc, they all look the same. Maybe one has an extra month in addition, another has more geriatric. I mean, I'm looking at 8-10 sites around me, and honestly I can't tell most of them apart except some have obviously spent more money on the pamphlets...and their focus of course. I was hoping this 'focus' business would help me widdle it down

Thanks again for everyone's words of wisdom.

You will be able to get whatever fellowship area you want regardless of residency program. Location of that fellowship may be limited based on residency (and also - and I'm assuming based on your screen-name - due to having a DO rather than an MD).

My worry about a residency advertising analysis is this:

1) They can't really train you as an analyst in residency, so it seems dishonest (they could train you in psychodynamic psychotherapy - but they don't say so).

2) I'd worry about any program that needed a gimmick to sell itself (whether it be psychoanalysis, meds, or anything else).

 

[235750]

Thank you Doc Samson for your explanation, although I'm still not sure why you claim a residency couldn't teach the analytic approach. You seem to accept it as a tautology which I don't comprehend. But, I'm sure that is due to my ignorance on the subject. I certainly have my summer reading cut out for me!

You will be able to get whatever fellowship area you want regardless of residency program. Location of that fellowship may be limited based on residency (and also...due to having a DO rather than an MD).

I would disagree that having a DO rather than an MD limits one in terms of residency opportunities when it comes to psychiatry. Does it limit matching in dermatology? sure. Rad onc? absolutely. But psychiatry? I'm not too sure about that. Plenty of DOs I've spoken to in real life and in this forum did very well in the match, in this year and years before.

Looking at last year's match results, it seems that if you're an AMG (MD or DO) with a decent step score (and good recommendations I'm sure), you will match at one of your top picks in psych.

I am far from the top of my class. I know I'll never match at your sort of institution Dr Samson, but I don't think that has to do with my degree initials. I do not excel in standardized exams. From talking to attendings in psychiatry though, it seems as this is one of the few specialties that look beyond numbers. That's one of the reasons I feel comfortable in this field.

I hope I do not come across as rude. I am grateful for your responses and have learned plenty from this thread.

Thanks again for everyone's input, I need to read more about psychoanalysis in order to determine if this program is a good fit for me personally, now that I know it won't limit me professionally.

 

[billypilgrim37]

I'm still not sure why you claim a residency couldn't teach the analytic approach.

Because the residency isn't a ten year program. Analytic training takes many years ON TOP OF a psychiatry residency.

 

[Doc Samson]

Thank you Doc Samson for your explanation, although I'm still not sure why you claim a residency couldn't teach the analytic approach. You seem to accept it as a tautology which I don't comprehend. But, I'm sure that is due to my ignorance on the subject. I certainly have my summer reading cut out for me!



I would disagree that having a DO rather than an MD limits one in terms of residency opportunities when it comes to psychiatry. Does it limit matching in dermatology? sure. Rad onc? absolutely. But psychiatry? I'm not too sure about that. Plenty of DOs I've spoken to in real life and in this forum did very well in the match, in this year and years before.

Looking at last year's match results, it seems that if you're an AMG (MD or DO) with a decent step score (and good recommendations I'm sure), you will match at one of your top picks in psych.

I am far from the top of my class. I know I'll never match at your sort of institution Dr Samson, but I don't think that has to do with my degree initials. I do not excel in standardized exams. From talking to attendings in psychiatry though, it seems as this is one of the few specialties that look beyond numbers. That's one of the reasons I feel comfortable in this field.

I hope I do not come across as rude. I am grateful for your responses and have learned plenty from this thread.

Thanks again for everyone's input, I need to read more about psychoanalysis in order to determine if this program is a good fit for me personally, now that I know it won't limit me professionally.

As BP said, psychoanalysis requires many years of training, including seeing patients 5x/week for years - impossible to complete in residency.

As far as the MD/DO issue - realistically there are residencies and fellowships that never have, and likely never will, taken a DO candidate, no matter how competitive (in fact, they don't even grant interviews to DOs). I'm not saying this is justified - just reporting the facts.

 

[235750]

As far as the MD/DO issue - realistically there are residencies and fellowships that never have, and likely never will, taken a DO candidate, no matter how competitive (in fact, they don't even grant interviews to DOs). I'm not saying this is justified - just reporting the facts.

I'd be interested to hear which universities don't interview DOs as a matter of policy. We have alumni who matched and now teach at 'top' places, including UPenn and Hopkins. Per my OP, listening to one of those professors is what started my concern re: psychoanalysis

 

[nancysinatra]

"Come on," I said, "I went to med school in the midwest, where psychotherapy goes to die."

Ugh--try going to med school in NYC, where it is socially unacceptable to not be aware that analysis occurs on a couch. Everyone in New York has a therapist. I would definitely not say that it seems to have helped, not on any socio-cultural-interpersonal-epidemiological level.

 

[mishavrach]

While I'm not sure of the evidence base of witchcraft, there is evidence supporting psychoanalysis, accupuncture, and EMDR for the treatment of various conditions (similar for the "evidence" of using Paxil for depression). I agree that limiting a training philosophy to any one of them would produce an "incomplete" psychiatrist.

I'm sure your patients and colleagues are thrilled that you would be capable of displaying "restrained civility" if you were to collaborate with the majority of the attendings at Harvard, Yale, Brown, Columbia, Cornell, Northwestern, UCSF, etc.

My recommendation to trainees is this: train in EVERYTHING. Get as much exposure to as much as you can - then you can decide if you want to practice psychodynamics, CBT, DBT, IPT, EMDR, ECT, TMS, whatever. If you don't train in it, you won't have the choice.

Interesting choice of "EVERYTHING". Why not also include neuropsychology, clinical neurobiology, neurogenetics, developmental neuroscience, advanced psychopharmacology, and neuroimaging? Why old school instead of new (TMS notwithstanding)?

We can't study "EVERYTHING" for various reasons. There is not enough time in psych training and someone has to pay for psychodynamic Tx education. I can safely assume that pharmaceutical company won't. Philosophically, neurobiological and psychoanalytical approaches are not well compatible. The latter finds origin of psychopathology in earlier experience and describes it in form of "formulation", while the former looks at evolutionary genetic and inborn vulnerabilities and describes them in form of psychiatric diagnosis.

Teaching both equally and uncritically clashes to visions: 1) something was done to the innocent you vs. 2) you were born this way, now learn to live with it.

I am not big fan of EBM (evidence based medicine) either. The idea was highjacked and exploited by powerful interest groups (government and pharm. companies). It's only matched by dishonesty of "evidence supporting psychoanalysis, accupuncture, [and] EMDR" and neurofeedback.

Psychoanalysis and EMDR are probably the worst culprits. The first has vested ideological interest, the second is there for money.

Lastly, alleged psychoanalytical "majority of the attendings at Harvard, Yale, Brown, Columbia, Cornell, Northwestern, UCSF, etc." is quickly turning into minority. Psychoanalysts are dying breed not protected by Endangered Species Act of 1988 (the year Prozac was marketed in the USA).

 

[mishavrach]

"Come on," I said, "I went to med school in the midwest, where psychotherapy goes to die."

2.5 years later at one of those pesky "biological" programs, and I sleep with my Gabbard book underneath my pillow half the time. You never know.

And why not as long as your residency program doesn't mandated it. Personally, I enjoyed reading Freud's Interpretation of Dreams as much as Swift's Gulliver's Travels. But what do these fine books have to do with treatment of psychiatric disorders?

 

[Doc Samson]

Interesting choice of "EVERYTHING". Why not also include neuropsychology, clinical neurobiology, neurogenetics, developmental neuroscience, advanced psychopharmacology, and neuroimaging? Why old school instead of new (TMS notwithstanding)?

We can't study "EVERYTHING" for various reasons. There is not enough time in psych training and someone has to pay for psychodynamic Tx education. I can safely assume that pharmaceutical company won't. Philosophically, neurobiological and psychoanalytical approaches are not well compatible. The latter finds origin of psychopathology in earlier experience and describes it in form of "formulation", while the former looks at evolutionary genetic and inborn vulnerabilities and describes them in form of psychiatric diagnosis.

Teaching both equally and uncritically clashes to visions: 1) something was done to the innocent you vs. 2) you were born this way, now learn to live with it.

I am not big fan of EBM (evidence based medicine) either. The idea was highjacked and exploited by powerful interest groups (government and pharm. companies). It's only matched by dishonesty of "evidence supporting psychoanalysis, accupuncture, [and] EMDR" and neurofeedback.

Psychoanalysis and EMDR are probably the worst culprits. The first has vested ideological interest, the second is there for money.

Lastly, alleged psychoanalytical "majority of the attendings at Harvard, Yale, Brown, Columbia, Cornell, Northwestern, UCSF, etc." is quickly turning into minority. Psychoanalysts are dying breed not protected by Endangered Species Act of 1988 (the year Prozac was marketed in the USA).

Again, you insist on confusing psychoanalytic with psychodynamic. Regardless, I disagree with your assessment of clashing visions. It is well proven at this point that experience changes neurobiology. You can thus quite easily blend an eclectic model including neurobiological predisposition and neurobiological changes brought about by experience. Since we can all agree that neurobiology can be influenced negatively by experience (e.g., trauma resulting in PTSD), then it can also be influenced positively by experience (i.e., psychotherapy).

 

[mishavrach]

Ugh--try going to med school in NYC, where it is socially unacceptable to not be aware that analysis occurs on a couch. Everyone in New York has a therapist. I would definitely not say that it seems to have helped, not on any socio-cultural-interpersonal-epidemiological level.

Not surprising. Honest and smart analysts will tell you that analysis has nothing to do with medicine, and I will add that it has hardly anything to do with anything else practical or relevant. Great though for philosophers, moviemakers, and writers.

 

[nancysinatra]

Not surprising. Honest and smart analysts will tell you that analysis has nothing to do with medicine, and I will add that it has hardly anything to do with anything else practical or relevant. Great though for philosophers, moviemakers, and writers.

I don't think anything could fix the socio-political-interpersonal problems of NYC. Nobody for 100 years has even managed to fix the sidewalks.

I have met several "honest and smart" analysts, and they've never said anything like what you mentioned. And I'm not really looking to be indoctrinated into a camp of anti-this or anti-that, but thanks anyway.

 

[mishavrach]

I have met several "honest and smart" analysts, and they've never said anything like what you mentioned. And I'm not really looking to be indoctrinated into a camp of anti-this or anti-that, but thanks anyway.

You are welcome and here is an example of "honest and smart" who said it : Elio Frattaroli, M.D. You can even find excerpts from his book on
http://www.eliofrattaroli.com/Author.asp

 

[mishavrach]

Again, you insist on confusing psychoanalytic with psychodynamic. Regardless, I disagree with your assessment of clashing visions. It is well proven at this point that experience changes neurobiology. You can thus quite easily blend an eclectic model including neurobiological predisposition and neurobiological changes brought about by experience. Since we can all agree that neurobiology can be influenced negatively by experience (e.g., trauma resulting in PTSD), then it can also be influenced positively by experience (i.e., psychotherapy).

I am afraid that confusion is all yours. Experience indeed changes neurobiology within biological limits. I see no evidence, however, that normal life experience creates psychopathology and this notion is at the core of etiology and treatment of mental disorders. You can't blend two models, one which says your psychiatric disease is from earlier conflicts and must be treated by recognizing and resolving these conflicts and the other that states that inherent biological deviation or defect caused harmful dysfunction and we can repair these damage or deviation by understanding the nature of underlying neurobiological processes.

The evidence is less compelling for trauma causing PTSD than presence of strong biological vulnerability as the main cause. Otherwise, it would be impossible to explain why 2 individuals going through the same traumatic experience have differential responses and why those who have never experienced major traumatic event, manifest full-blown PTSD psychopathology (example: the personnel on the base who never saw military action had similar or higher rate of PTSD as the military who were exposed to it).

 

[masterofmonkeys]

The evidence is less compelling for trauma causing PTSD than presence of strong biological vulnerability as the main cause. Otherwise, it would be impossible to explain why 2 individuals going through the same traumatic experience have differential responses and why those who have never experienced major traumatic event, manifest full-blown PTSD psychopathology (example: the personnel on the base who never saw military action had similar or higher rate of PTSD as the military who were exposed to it).

A couple of words from old school biology "Necessary" and "Sufficient". If an inherent biological vulnerability is the 'main cause' of PTSD, then there are people walking around with PTSD who had never suffered appreciable trauma in their lives. Which is interesting. If you don't actually get exposed to or anticipate major trauma, do you just manufacture one from your past? "Man I've got wicked bad PTSD from that time I viciously stubbed my toe. I thought about how I could have had hemophilia, and then I could have bled to death. It's this damned strong biological vulnerability!"

Sure, there is a neurobiological predisposition, but that really doesn't mean jack. It fails to recognize how malleable our brains and bodies are. How responsive they are to stress, and how stress can both strengthen and weaken an organism depending on dosage, frequency, and rest periods.

The brain is a changing organ, eloquently summed up in what Donald Hebb said so long ago: "Nerves that fire together wire together". A statement made long before the dawn of 'biological psychiatry' and sadly ignored in the pathetic excuse for a biological synthesis our field claims to be headed toward. Our stress endocrine systems are also highly responsive to a) training b) nutrition c) experience and d) stress load. etc etc etc etc.

It always horrifies me at how many physicians, psychiatrists or otherwise, do not recognize the immense capacity of the human body for adaptation, both negative and positive.

A physician who fails to incorporate the tools to help his or her patients adapt their bodies in beneficial ways is woefully incomplete, and is doing an extreme disservice to their patients. 'Let's not worry about trying to be stronger and healthier, you're biologically predisposed to get sick, so we'll just symptomatically manage the illness without trying to counterbalance that biological predisposition with beneficial adaptation'

 

[Evidence Based]

Two things:
1) Neuroplasticity:
It occurs. Your brain changes, whether it's through drugs, experience, or psychotherapy.

2) The diathesis stress model.
Any position that holds that psychopathology is determined exclusively or almost exclusively from either biology or experience is simply foolish.

And I have so little experience. Yet I feel like these things should be self-evident... Any undergrad in an Abnormal Psych (heck, even Intro Psych) could spit this back to you.

 

[dl2dp2]

I am afraid that confusion is all yours. Experience indeed changes neurobiology within biological limits. I see no evidence, however, that normal life experience creates psychopathology and this notion is at the core of etiology and treatment of mental disorders. You can't blend two models, one which says your psychiatric disease is from earlier conflicts and must be treated by recognizing and resolving these conflicts and the other that states that inherent biological deviation or defect caused harmful dysfunction and we can repair these damage or deviation by understanding the nature of underlying neurobiological processes.

The evidence is less compelling for trauma causing PTSD than presence of strong biological vulnerability as the main cause. Otherwise, it would be impossible to explain why 2 individuals going through the same traumatic experience have differential responses and why those who have never experienced major traumatic event, manifest full-blown PTSD psychopathology (example: the personnel on the base who never saw military action had similar or higher rate of PTSD as the military who were exposed to it).

So your points are valid but it's kind of irrelevant to the discussion at hand. Environmental triggers are always part of medicine, even though in psychiatry they influence the disease process in such a complex way that it can't be easily evaluated by Koch's postulates.

The fundamental "incompatibility" is this: "mainstream" psychiatry has evolved such that it emphasizes scientific, data-driven, evidence-based approaches, even if it is still limited in scope and practice, especially in questions bordering social science and social neuroscience. Psychoanalysis is not scientific. It has never attempted to make itself a scientific discipline. it is based on the critical exegesis of individual experiences. I personally think that things that aren't science still have tremendous value, both practical and theoretical: you can't argue that concert pianists and philosophers have no role in this society. However, the appropriateness of inclusion of psychoanalysis in a psychiatry RESIDENCY program is very questionable. Indeed, in most Midwestern programs it's just NOT THERE. But I don't personally think it is or should be interpreted as an ideological position, and I really don't think that a psychiatrist trained at such a program is any less qualified in handling the vast vast majority of psychiatric scenarios.

Furthermore, you have to look at the cutting edge of neuroscience, where ideas appropriated from psychoanalytic literature, such as "theory of mind", transference, values and rewards, the subconscious etc. are now beginning to be approached scientifically. Neural representations are Beginning to be uncovered. Freud had some good ideas, but it was just not possible at the time to quantitatively evaluate these phenomenology and properly analyze the data. One would hope that in another hundred years, we'll have psychotherapy that is more rationally designed, circuitry based, pharmacologically and somaticallly assisted, etc. So perhaps spending a few hours getting acquainted with these historic ideas can be beneficial in a possible future where the field comes to a final synthesis.

What is also interesting to me, on a more practical note, is that in theory even if you've never trained at an analytic institute, but only have board certification in psychiatry, you COULD attempt to get analysis clients and just do analysis on them. And for all practical purposes if you went through a "top" residency (whatever that means) in a major metro, you'd get at least a few clients, it seems. Analytic training seems to fulfill a certain strange philosophical utility that doesn't have any practical consequences. Also, I can imagine you easily spinning your short-term well-off psychodynamic "worried well" patients into cash cow analytic clients. Or perhaps there are way too many analysis candidates out there for this to actually happen in reality? Or perhaps psychoanalysis in practice is just too painful for the analyst without proper "training".

 

[cleareyedguy]

Fortunately, I have enough knowledge to respond to Dr. Samson. There is no appreciable difference in psychoanalytic and psychodynamic approaches. Both came from Freud loins, both are misguided and misleading. It's a well established myth that one needs psychoanalyt/dynamic training to practice psychiatry. Trust me, you don't. I won't be getting into debate, but share an analogy. If a psychoanalyst drives a car and realizes that the tire is blown, he'll go back to 5 miles to find the nail that probably did it. A cognitive -behavioral psychologist or psychopharmacologist would fix the tire.

..

Modern psychoanalysts would not go back and find the nail. That is naive. The analyst would focus on the present but might also explore or at least be curious about issues surrounding the blown tire (how did it feel to be out of control? did the driver contribute to the blown tire in some way? did s/he have a spare tire available? ie, the analyst might look for self defeating behavior, or panic, or whatever, but would also try to vigorously empathize with the plight of the driver). The analyst might also be curious about the way in which the story was recounted (eg, was the analysand pulling for pity for his plight, for praise for handling an emergency, for fatherly advice on where to buy a new tire). The analyst would have learned to see where the story went and help encourage curiosity and look at the shifting relationship between the two of them and would try to relentlessly empathize with the patient's perspective while also shifting his perspective to assess reality and the relationship.

This is hard work, has been shown in many studies to be effective, and is simply not done well by people who haven't studied therapy (or extensively done it) after residency; as is argued elsewhere in this thread, no residency will train anyone to be an analyst, but some programs will more thoroughly introduce dynamic principles and therapy to residents. Some programs may decide not to offer much dynamic education, but some of that decision stems from the lack of qualified teachers within some programs and some locations; Cornell may be mentioned for its dynamic therapy training, but that's partly because it has dozens and dozens of FT and voluntary faculty who are analysts--it wouldn't be so well regarded if its residency were in Ithaca.

Anyway, I don't think you need to do analytic trianing to be a good psychiatrist, but I do think you will be a better therapist if you have a serious experience in therapy. And, by the way, my bias is that most psychopharmacologists are just substandard and biased psychiatrists.

 

[Sneezing]

my bias is that most psychopharmacologists are just substandard and biased psychiatrists.

Out comes the right hook, and a take down! The crowd leaps to their feet!

 

[Doc Samson]

Well said, all of you. After mishavrach's last post I was just going to post this:

 

[mishavrach]

Modern psychoanalysts would not go back and find the nail. That is naive. The analyst would focus on the present but might also explore or at least be curious about issues surrounding the blown tire (how did it feel to be out of control? did the driver contribute to the blown tire in some way? did s/he have a spare tire available? ie, the analyst might look for self defeating behavior, or panic, or whatever, but would also try to vigorously empathize with the plight of the driver). The analyst might also be curious about the way in which the story was recounted (eg, was the analysand pulling for pity for his plight, for praise for handling an emergency, for fatherly advice on where to buy a new tire). The analyst would have learned to see where the story went and help encourage curiosity and look at the shifting relationship between the two of them and would try to relentlessly empathize with the patient's perspective while also shifting his perspective to assess reality and the relationship.

This is hard work, has been shown in many studies to be effective, and is simply not done well by people who haven't studied therapy (or extensively done it) after residency; as is argued elsewhere in this thread, no residency will train anyone to be an analyst, but some programs will more thoroughly introduce dynamic principles and therapy to residents. Some programs may decide not to offer much dynamic education, but some of that decision stems from the lack of qualified teachers within some programs and some locations; Cornell may be mentioned for its dynamic therapy training, but that's partly because it has dozens and dozens of FT and voluntary faculty who are analysts--it wouldn't be so well regarded if its residency were in Ithaca.

Anyway, I don't think you need to do analytic trianing to be a good psychiatrist, but I do think you will be a better therapist if you have a serious experience in therapy. And, by the way, my bias is that most psychopharmacologists are just substandard and biased psychiatrists.

You are wrong.

 

[mishavrach]

Well said, all of you. After mishavrach's last post I was just going to post this:

You are also wrong.

 

[Sneezing]

I like Mishavrach and his fresh view on things. I think it is awesome more attendings are popping up on the forums recently. I hope things don't get too nasty and no one gets scared off.

 

[Doc Samson]

You are wrong.

Prove it.

 

[Doc Samson]

You are also wrong.

You lost me here...

Am I wrong that the other posters wrote well, or wrong that I was shocked by your beliefs about mental illness?

 

[mishavrach]

You lost me here...

Am I wrong that the other posters wrote well, or wrong that I was shocked by your beliefs about mental illness?

Neither. You were wrong assuming that your reply mattered.

 

[mishavrach]

I like Mishavrach and his fresh view on things. I think it is awesome more attendings are popping up on the forums recently. I hope things don't get too nasty and no one gets scared off.

Thanks, I don't get scared easily, but if Samson-boy wants to pound his chest and get territorial, he can have it for himself anytime.

 

[OldPsychDoc]

Thanks, I don't get scared easily, but if Samson-boy wants to pound his chest and get territorial, he can have it for himself anytime.

Whether you were trained to love or hate psychodynamics, somewhere along the way you should have learned that your statements in an anonymous forum will carry more weight if you contribute positively and refrain from ad hominem attacks. It's particularly not seen as a sign of maturity and good judgment to attack a moderator when one is a fairly new member of a forum.

 

[loveoforganic]

Out comes the right hook, and a take down! The crowd leaps to their feet!

Right hooks are frowned upon unless you're roy jones jr.

http://www.youtube.com/watch?v=gexazLr6pSY

 

[kohut]

The bizarre antipathy toward psychoanalysis seen among many psychiatrists has always puzzled me, and it seems to be more the result of a hebetude of the understanding than a rational aversion. The enmity between analytic psychiatrists and pharmacology-oriented psychiatrists is examined quite nicely in Christoper Lane's book on shyness (and screed against modern psychiatry). While Lane's tone is almost comically acerbic and his text is left seriously wanting in scientific rigor, I do think he makes a valid point that psychiatry's epistemological shift from analytic to pharmacologic had a lot to do with economic factors/easy insurance billing embodied by the anti-analytic DSM.

Psychopharmacology is the dominant treatment modality nowadays, and well it should be for so many reasons, however to cavalierly disregard psychoanalysis and its progeny (Bowlby, Klein, Kohut, etc.) as irrelevant is troubling on many levels.