Should clinical training in long-term psychodynamic psychotherapy be mandatory in residency training? A debate.

I am Dr. Harvey Bluestone, Professor of Psychiatry at the Albert Einstein College of Medicine and Director of Psychiatry at Bronx-Lebanon Hospital Center, a major training affiliate of the medical school. I would like to welcome everyone to the debate on “Should Clinical Training in Long-Term Psychodynamic Psychotherapy Be Mandatory in Residency Training?” The crowded room in the face of exciting competing programs attests to the interest in this subject. The topic today highlights central issues, not only for training but for the future practice of psychiatry. We are dealing here with both current reality and our vision of the future. What is the psychiatrist of the twenty-first century going to look like? What kind of treatments will he be administering? What will be his model of pathology and treatment in the future? This debate would have been inconceivable when I was a psychiatric resident. At that time psychoanalytic treatment and theory dominated the field. Within a few short years the map of psychiatry has shifted so much that the old view feels almost prehistoric. There are many reasons for this shift: The development of new biological forms of treatment for specific illnesses. The biological revolution in technology such as brain scans. The increase in emphasis on empirically validated outcome studies (aided by technological advances such as the computer). The DSM-III and its successors with their atheoretical stance. The rise of short-term therapies that appear to have empirical support. And last but not least, economic factorsespecially the rise of managed care, which stresses efficiency and cost containment. The net result is a new, more empirical and medically oriented psychiatry with emphasis on results and accountability. It is clear that psychoanalytic theory and practice with their emphasis on long-term therapy no longer dominates the field. The question, however, remains, “Should clinical training in long-term psychodynamic psychotherapy be mandated in residency treatment?” Since there is so much other material for residents to learn, should they be spending time on a difficult and time-consuming treatment? Are we moving forward to a more enlightened approach, or are we unduly influ-