Paul H. Ornstein

Sorcerer's apprentice: The initial phase of training and education in psychiatry

Summary Societys demands for increased and more varied services and the expansion of the field of psychiatry from within, coupled with the information explosion, have put considerable strain upon psychiatric training and education. In spite of fundamental insights into training and educational needs, no pedagogic methods have been developed to increase teaching and learning efficiency and effectiveness. A narrow, pragmatic view and a shift toward an eclectic orientation from a psychoanalytic-theoretic base led to considerable neglect of the core curriculum and the basic skills. Instead, the residents are expected to have experience in all newly developing areas of our field, rather than achieve depth in the core curriculum and the basic skills. This smorgasbord-type of training leads to a “Jack-of-All-Trades, Master of None.” This training is supplemented by formal instructions, the educational part of the residency experience, which also strives to be all-inclusive and eclectic rather than truly integrated. We have redefined the basic skills and the core curriculum and have suggested that experience with learning in the initial phase of psychoanalysis and psychotherapy can serve as guidelines for a systematic pedagogy for training and education in psychiatry. We have reasserted that the diagnostic-therapeutic “instrument” is the doctors personality, his “mental apparatus.” His methods and skills are observation, evocative listening, empathy, intuition and introspection. The folk tale of the “Sorcerers Apprentice” provided us with clues and parallels for the examination of the climate and methods of teaching and learning. We concluded that some methods of teaching and some climates for learning play into the trainees “Apprentice Complex” and contribute to the development of his learning blocks. We suggested a method to deal with the problems of learning, presented by the proneness to the “Apprentice Complex” and by the nature of what is to be learned. The method has to avoid an excessively didactic and overly supportive approach by the teacher. The initial phase of training and education for the psychiatrist has to involve primarily his immediate use of himself and his skills in a dyadic relationship, without introducing artificial barriers to learning in the form of premature theoretical studies. The emphasis is on the word “premature,” since we do not propose an anti-intellectual climate or a training and education devoid of the necessary acquisition of information, accumulated knowledge and theory. As a matter of fact, our approach is designed to prepare the ground for their better assimilation rather than mere registration. In case seminars and in individual supervision, our method involves helping the trainee reflect upon the workings of his diagnostic-therapeutic “instrument.” Focus upon each individual skill and then especially upon those leading to emotional understanding, represent techniques to “break in” the instrument for its task. Allowing the beginner to discover his own mode of thinking and feeling in his professional experiences is the crucial learning task of the initial phase. It has to be the core experience of a core curriculum, if what he is taught is not to be for the resident “empty words of incantation” or be what Fenichel calls “dynamically ineffective knowledge.” We have postulated that to expand training and education in depth and breadth from such a solid base will guard against the kinds of devastating experiences the “Sorcerers Apprentice” had. We have finally reviewed some of the difficulties encountered in our teaching and suggested that empathy for the residents predicament and certain specific changes in the teachers posture might further improve the chances of good teaching and good learning.

Toward a conceptual scheme for teaching clinical psychiatric evaluation

Summary We presented the physician as the instrument of clinical psychiatrie evaluation and (1) observation, (2) evocative listening, (3) empathy-intuition-introspection as his primary functions. His evaluative work consists of a descriptive and an interpretive synthesis of the intra- and extra-interview data. Though in actuality all of the work occurs simultaneously, with the different evaluative functions intermingled, for the sake of clarity and convenience we dealt with them separately. We have seen the patient bring to the diagnostic situation his (a) behavior, (b) experiences, and (c) somatic phenomena, as modes of expressing his way of reaching out to the doctor and overtly or covertly communicating his wishes and expectations of him (Fig. 1). When the patient reaches out and the doctor responds so that meaningful communication is established between them to the extent that their individual idiosyncratic barriers permit, a two-person system is established. This is essential for obtaining the kind of data we need for a comprehensive psychiatric evaluation. Such intra-interview data, supplemented by extra-interview data, permit a descriptive synthesis leading to (1) clinical diagnosis and an interpretive synthesis, leading to (2) dynamics and (3) genetics of the patients behavior and symptoms; a formation of (4) the patients idiosyncratic response to and barrier against the communication with the physician; and, finally, a formulation of (5) the physicians idiosyncratic response to, and barrier against, the patient. These data should permit specific statements about (6) treatment possibilities. This is essentially Levines six-point diagnosis (Fig. 2). We then presented a didactic model of the mental apparatus with its three subsystems (Fig. 3) in order to enable us to understand clinical-descriptive data in meaningful functional relationships to each other. We described briefly and only in general terms the three subsystems, their relationship to the stimuli impinging upon them, the resultant behavioral responses, and then their relationship to each other. The cognitive-intellectual functions listed are more or less individually “testable” in addition to an overall assessment in an ordinary conversation. The affective-emotional responses are not in the same sense “testable,” but primarily perceived through observation, empathy and introspection, and at times by inference, in the context of the ordinary conversation. The interpersonal adaptive-defensive behavior requires the same modes of perception and inference. The intrapsychic adaptive-defensive mechanisms, however, representing theoretical concepts of internal events, are formulated primarily by inference. A descriptive synthesis aims at presenting the data obtained so as to indicate how the observed “functions” (by necessity viewed as if truly separate or separable) coalesce into a coherent personality. Such a descriptive synthesis, documenting the form and content of what transpired in the interview, serves as the basis for a clinical diagnostic label and also provides the “raw data” for the interpretive synthesis. An interpretive synthesis aims at identifying the interpersonal and intrapsychic forces at work (dynamics); their early innate or experiential precursors (genetics); the manner in which the patient treats the doctor (transference and other feelings); and finally the manner in which the doctor treats the patient (countertransference and other feelings). The interpretive process was delineated from the process of interpreting. Understanding and explaining were presented as two consecutive and interrelated steps in arriving at an interpretation. The latter may either be diagnostic or therapeutic in intent and use. This will depend upon the needs of the immediate situation, and the doctor may keep the interpretation to himself (diagnostic interpretation) or communicate it to the patient (therapeutic interpretation). The models that best condense interpretively the clinical material are those of the focal conflict and nuclear conflict. Their use enables us to express our understanding more precisely and in such a fashion that our diagnostic formulations contain definite guidelines for treatment. The focal conflict represents the problem and its attempted solution that is foremost in the patients mind and explains most of the data at any one time. Crucial to such formulation is a knowledge of the precipitating circumstances that brought the problem to the fore. Identification of the focal conflict permits the diagnostician to get hold of the red thread of the doctor-patient transactions, which he needs in order to listen and intervene more skillfully. His listening and his interventions are also aided by his formulation of the nuclear conflict (which is a formulation of the deeper roots of his conflicts) by putting current problems into “genetic” context.

An experimental approach to the psychoanalytic theory of dreams and conflicts

Summary We have presented a method for the implantation of conflict using structural-conflict models. This method of hypnotic implantation is followed by a free-associative interview in which the interviewer has no knowledge of the implanted conflict. The subject, who may or may not recall a hypnotically induced dream, then dreams in a Dream Laboratory which enables the research group to collect several dreams of the night of the experiment. The data are then utilized for studying: o 1. the problems of consensus 2. the method of clinical inference 3. the teaching of focal conflict formulation 4. the comparison of hypnotic and night dreams 5. the influence of implanted conflict on early memories 6. the differential effect of male and female interviewers on the interview 7. the interrelationship of the artificially induced conflicts with the subjects own naturally occurring conflicts The advantages of a technique which stimulates the subject to focus on certain areas of his current experiences, and further triggers unconscious processes which unite with these experiences, are clearly of great value in studying psychological mechanisms of dreaming and conflict formation.

On the metapharmacology of psychotropic drugs

Summary We have proposed psychoanalytic metapsychology as a useful explanatory tool for investigation of drug effects upon the psychic apparatus. All six metapsychological points of view: (1) genetic; (2) dynamic; (3) topographic; (4) structural; (5) economic; (6) adaptive, were brought to bear upon the psychic events in connection with drug use. Psychopharmacology can be seen as composed of two major divisions: A. Pharmacology —site, mode of action, etc.; and B. Metapharmacology —the application of the above six metapsychological points of view to the phenomenology and interpretation of drug response. This approach provides an overlapping frame of reference for psychopharmacology and psychoanalytic psychiatry, and permits the psychoanalytic psychiatrist to use his skills in an integrated approach to treatment.

On the process of becoming a psychotherapist: An outline of a core-curriculum for the teaching and learning of psychoanalytic psychotherapy

T 0 CONTEMPLATE the process of becoming a psychotherapist-in isolation from current trends in psychiatric training, in general, and from the political and economic pressures upon our field, in particular-would be short-sighted and unrealistic. Faculty and residents are involved in a rapidly changing service delivery system; they have to cope with an expanding fund of pertinent biological and psychological knowledge, and a “pluralism” of therapeutic modalities. Funds for residency training programs are now more frequently supplied by local sources which steadily increase the demand both for accountability and for service. Such demands, along with the economic pressures, have led to questioning the cost-benefit ratio of psychoanalytic psychotherapy. Therefore, a major challenge, if not the major challenge for psychiatric education today, is to reexamine the value of the teaching of psychoanalytic psychotherapy as the central aspect of residency curriculum. This challenge should be welcomed. It should stimulate us to rethink the problems related to the teaching and practice of psychoanalytic psychotherapy, which should benefit from a new look at our pedagogic methods. We can then bring the results of our reevaluation into our clinics and into academia-the open market place of conflicting ideas and approaches-where they can be tested and compared for the benefit of our patients and trainees and for the benefit of our science as well. It is entirely in the spirit of this open exchange with other approaches that we will now limit our discussion to the process of becoming a psychoanalytic psychotherapist. We have selected some problems of pedagogy related to the teaching of psychoanalytic psychotherapy as the central theme for this discussion, carrying one step further a previous consideration of similar issues which will make some repetition of earlier expressed ideas unavoidable.’ Three questions will bring these pedagogic problems into focus. (1) How to teach psychotherapy in a manner that will permit the immediate translation of what is learned into actual patient care. (2) What methods are there at our disposal to help the future psychiatrist (short