Teaching psychodynamic psychiatry during medical school and residency: specific skills and beyond.

S years ago, during a workshop that focused on the integration of psychotherapeutic and psychopharmacologic treatment, a young woman patient was presented who had problems with both severe manicdepressive illness and borderline personality disorder. She was extremely sensitive to medications, but even during times of stability of her manic-depressive illness, management was difficult. Following a presentation of a videotaped psychotherapy hour of a resident and the patient, a residency director in the audience raised his hand and said, “I don’t know why you showed this videotape. This woman has manic-depressive illness and needs medication, and that’s that.” Although this may seem a caricature of the emphasis on biological psychiatry in the last several decades, the question was asked by an experienced residency director who had been in his position for many years. Too many clinicians believe that good psychopharmacology practice requires only knowledge of dosages, side effects, drug interactions, and indications for the medication. To me, however, the essence of good psychopharmacologic management is how one responds when a patient comes into the office and says, “Dr. Tasman, you know that medication you prescribed. Well, I’m not going to take it any more.” Dealing with issues of resistance and treatment compliance, even in a busy medication clinic, an emergency room, or an inpatient unit, requires psychotherapeutic skill and knowledge.