Letter to a Young Psychiatrist: Confessions of a Psychodynamic Attending

(There is a need to address the growing "generation gap" in our field between older psychiatrists, who have had substantial training in traditional psychodynamic psychotherapy, and their younger colleagues [the profession's heirs], whose education has been predominantly biomedical. The following was a response by Dr. Genova to an article critical of psychodynamic psychiatry and its practitioners, written by an articulate psychiatric resident, that appeared in a local newsletter. Some of the resident's objections are summarized in italics for the sake of clarity-Ed.)

Dear ________,

I liked the energy, courage, critical thinking and fine writing style of your piece on psychodynamic education in residency. I encourage you to write more; the profession needs articulate voices desperately. I do, however, need to dis-abuse you of some of your notions about the cushy and complacent life of a psychodynamic psychotherapy-oriented psychiatrist in the year 2000!

(The resident questioned the relevance, for his high-pressure world, of the perspective of certain psychodynamically oriented attending physicians who appear to practice in "clean" and insular outpatient settings, and who appear to be less than rigorously scientific in their thinking-Ed.)

Recalling the hard and often thankless work of psychiatric residency, and the ethereal world some of the attendings seemed to inhabit while we house officers dealt with (as you so well describe it) the "dirt, smell and unpredictability" of emergency room and hospitalized patients, I can easily identify with some of the resentment expressed in your article. Unfortunately, your anger is misdirected at a caricature of psychodynamic psychotherapy as it should be practiced and its faded status in psychiatry today, and also at a mistaken idea of how most of us attendings apportion our time. More important, its conception of the sorts of mental rigor necessary to begin to understand patients is overly narrow.

The (unfair) fact is that medical training is a hierarchical system and residents are at the bottom of it. This is as true of the other specialties in a tertiary setting as it is in psychiatry. The mental health care system, in particular, often throws its least experienced people at the hardest cases in the middle of the night. This resembles, as a teacher of mine who died a few years ago put it, "Learning to paint by starting with the Sistine Chapel." Although I might not have your physical stamina anymore, I know that I would certainly do a far better and more efficient job in the ER or on the ward now than I did as a resident...if I could stay awake. It is a lot harder to come up with a way to change the perennial initiation rite (or blood sacrifice!) of training young doctors than it is to get angry at those of us who are a few rungs higher on the ladder and can choose our battles and when we fight them. Someday soon, a young resident will resent you for the same reason. Try to find a way to help him or her.

(The resident imagined that most psychodynamic psychiatrists have little or no contact with severely ill patients-Ed.)

What is life for a psychodynamically oriented attending like? Most of us today spend a good deal of time doing medically oriented work with people with major mental illnesses, either in clinics (as I do) or as part of their private practices. I have always worked in such settings, feeling that 1) the perspective thus gained is invaluable for treating anybody; 2) my medical skills need to be maintained, again, for use in treating anybody; 3) my own personality just does not "fit" well enough, in the intimate context of traditional psychotherapy, with all patients; and 4) I would have nothing left over emotionally for my family if I did therapy all day, every day.

(The resident also has the mistaken impression that doing psychodynamic psychotherapy today is an easy way to make a lot of money-Ed.)

If I were interested in a lucrative psychiatric career, I would close my therapy practice now. I estimate that it costs me 20,000 to 30,000 a year to not do a routinized, prescription-driven, managed-care-friendly practice or simply take a full-time job (psychiatrists from other regions may give different figures). The psychiatrists I know who still seriously practice traditional dynamic psychotherapy, especially outside the few major cities where psychoanalysis remains strong, confirm my experience. They also confirm my conviction that it is worth every penny to do work that we love.

(The resident complained that some of his compatriots are eager to get through psychiatric training so they can call themselves "therapists" and leave medicine, and the need to keep abreast of the current medical literature, behind-Ed.)

In contrast to your perception, I do not find that most residents today really want to learn psychodynamic therapy. I have a hard time scraping up one per year from our local program who is willing to read some of the classic primary texts (there are more than a "handful" of such texts, by the way) or even newer books, to bring in process notes or tape recordings, or to really look at their own personal issues and how they influence the therapy process. It's sobering to find out that you've done all this science- and technology-oriented training, you have your M.D. or D.O., and none of it equips you to understand individual life stories and how they unfold; how personality develops, normally and pathologically. You may consider these latter concerns to be outside your chosen domain. They are often necessary concerns in effective psychiatric treatment, nonetheless.

And if one does want to do anything other than procedural psychotherapies (imitative of other procedures in medicine)-like the manualized ones whose studies you are willing to endorse-and med checks, one has to understand these things. Double-blind evidence is of very little help. So, if one wants to do this sort of work, in which preconceived notions take a back seat, one begins at the beginning again. If you happen to find any residents who are interested, send them my way!

(The resident cited the so-called "Woody Allen syndrome" of excessive dependence upon therapists among the more affluent social classes and wonders whether psychodynamic psychiatrists cultivate such dependence as a means of maintaining a comfortable work life-Ed.)

Few people where I live can afford the 2,000 to 6,000 per year out-of-pocket investment that traditional psychotherapy typically represents (again, local figures will vary) just to maintain an "umbilical bond" indefinitely. They want to get better, too, and leave when they do. (In my own practice, this is typically anywhere from six months to three years after starting, and some will then "check in" every few months in an ongoing way.) I may miss seeing them, but I am happy for them and for having done my job well. The kind of improvement they experience is often cost-effective in terms of reduced future expense on medical and/or psychiatric treatment, as offset studies have apparently shown (and as my personal experience of 15 years practicing in one place has definitely shown). This is because underlying factors behind the superficial syndrome-and-symptom presentation, or intertwined with a major psychiatric illness, have been addressed more definitively.

The phrase "worried well" has always struck me as a particularly compassionless insult to highly functioning patients and psychiatrists who treat them. Sure, there are a few narcissists out there with the resources to purchase ego-bolstering services on demand, indefinitely, from dishonest therapists. Precious few in this area, I fear, and none of them in my practice-at least, not for very long!

Highly intelligent, productive people who earn good incomes can be abjectly miserable, too-and psychiatrically ill (about 50% of my private therapy patients are on psychotropic medications). When their lives go better, the world becomes a better place for their children, their employees, their patients, their clients. The decisions they make affect all of us. And their problems aren't so different from those of clinic and hospital patients, just the resources they have to deal with them. Sometimes, their resources and their class privilege even get in the way of appropriate treatment.

As a once-famous psychodynamic psychiatrist (Harry Stack Sullivan) said, "We are all more human than otherwise." And since you speak of smells and needing to endure them, I might venture the question of which smells worst: a homeless psychotic patient in the ER, or a wealthy businessman who refuses to take any personal responsibility for his out-of-control teen-ager and comes seeking "stress management" to help him cope with the result of his neglect? The ugliness we sometimes encounter transcends outward appearances.

(The resident opined that controlled clinical trials should be the gold standard not only in psychopharmacology, but in choosing and conducting any form of psychiatric treatment-Ed.)

If Sullivan was right, then we psychiatrists need to be human and to understand humans. The sort of intellectual rigor we need in thinking about the human condition goes far beyond that of clinical trials on "pure" forms of syndromic illnesses in academic settings. Evidence comes in many forms, and it falls to us practitioners to decide which kinds are relevant to the practice we choose to pursue. I read a lot of mainstream journal-article stuff and continually read in many other areas as well (a "handful of texts" isn't sufficient for any physician or therapist). Science also comes in many forms: from the double-blind trials that dominate academic psychiatric thinking today to the naturalistic observational tradition of Charles Darwin, Donald W. Winnicott (pediatrician/psychoanalyst), Daniel Stern (infant researcher/psychoanalyst) and Oliver Sacks (neurologist/writer). All of it is useful to me. Clinical trials have no special monopoly on the high intellectual road and certainly not on the truth about suffering people. Novels, philosophy, anthropology, sociology and economics are all useful to me in daily practice.

Do I ask every psychiatrist to always consider all of this or to think like a psychodynamic therapist? No, and I don't even ask this of myself at all moments. But any psychiatrist does need some awareness of just how complicated people can be, and some perspective on the limitations of his or her own preferred way(s) of thinking about, and working with, human beings. That is what is best for our patients.

Dr. Genova practices in Maine and is clinical associate professor of psychiatry at the University of Vermont. His book The Thaw: 24 Essays in Psychotherapy (Dorrance, 2000) is available at online booksellers.