Today, there is broad agreement regarding the value of an integrated (biopsychosocial) approach toward treating psychiatric patients. Psychiatrists are expected to treat the whole person, by assessing biological, psychological, and social factors that contribute to mental health problems (1). However, there is still tension between biological and psychological tendencies. Social scientists have observed that psychiatrists continue to operate according to a mind-brain dichotomy (2). Teaching methods that directly or indirectly favor this lack of integration have usually presented these approaches in different lectures, by different teachers, associated with different patients, and in different settings (3, 4). In such contexts, residents are taught how to “switch between distinct hats according to settings” (5), instead of developing an effective, unified approach toward patients.
To address these issues, we designed a 16-session course for first-year psychiatric residents that includes seminars about psychodynamic concepts and a biopsychosocial interview with their own outpatients who have been treated by psychopharmacotherapy.
We hypothesized that watching patients being interviewed with this focus and having the opportunity to discuss the pharmacological, the psychodynamic, and the social characteristics of the same patient might make it easier for residents to perceive the complementary nature of these approaches.
All 18 first-year psychiatric residents at the Institute of Psychiatry, University of São Paulo, participated in the course. They ranged from 24 to 32 years old (mean=26.3); 72% were men (n=13).
After a complete description of the study to the residents and patients was recorded on video, written informed consent was obtained. The institutional review board of the University of São Paulo, approved all study procedures.
The weekly sessions consisted of one practical activity and one theoretical activity, lasting 1.5 hours each. For the practical activity, each resident in turn chose to bring an outpatient who was attended with a pharmacological focus for a biopsychosocial interview conducted by the supervisor. After the interview, the group postulated differential diagnoses and psychodynamic formulations and discussed implications for treatment, including aspects of the doctor-patient relationship (6–9). Suggestions were also made for different approaches and interventions that residents could utilize for subsequent attendance of the patient.
For the theoretical activity, each resident in turn presented a paper selected by the supervisor on the doctor-patient relationship, intrapsychic conflict, ego defense mechanisms, transference and countertransference, paranoid-schizoid position, depressive position, manic defenses, good-enough mother, false self and true self, transitional space, and transitional object.
On the first and penultimate days of the course, residents watched a video of an outpatient interview conducted by the supervisor. Three videos (A, B, and C) were selected. Six residents watched video A at the start and video B at the end; six watched video B at the start and video C at the end; and six watched video C at the start and video A at the end. They then took a test (available upon request from the authors) consisting of five questions. Three questions (one discursive and two testing) were conceptual, to assess residents’ knowledge. Two discursive questions were related to the patient on the video, to assess residents’ skills. For example, residents were asked to identify the patient’s main defense mechanisms and the influence of these on the treatment and to correlate the patient’s psychodynamic functioning with the diagnosis (10–12). The total score of the test was 10 points, and each question received a value of 2 points. Two faculty members independently judged the discursive questions and were blind regarding the residents’ identities and the time when the test was done (at the start or end). In addition to the tests, residents received a form with two questions: Are you doing or have you done any coursework on psychodynamics? Are you doing or have you done any personal psychotherapy?
On the last day of the course, each resident was interviewed individually. The interview was recorded on audiotape and consisted of seven questions investigating residents’ thoughts about the course and assessing whether psychodynamic concepts had been incorporated into their attitudes in daily practice. The residents’ declarations were transcribed and grouped in accordance with the collective subject discourse methodology (13). The interview questions are available from the authors.
We tested significance using analysis of variance (ANOVA) with repeated measurements. Nonparametric tests were used when necessary (14). The agreement among the judges was tested using intraclass correlation coefficients between the scores given before and after the course, for each judge. They demonstrated a high level of agreement (minimum r=0.90). The significance level adopted was 5%.
For the three conceptual test questions, ANOVA with repeated measurements was performed. There were significant differences between the means for the scores at the start (0.55, 0.49, 1.56) and end (1.18, 1.13, 1.97) of the course, such that the final mean was greater than the initial mean (p=0.002, p=0.000, p=0.016, respectively).
For questions relating to the patients on the videos, ANOVA with repeated measurements was performed; the scores could depend on whether the video was seen before or after the course and on which video was watched. The difference between the scores at the start and end depended on which video was watched initially. Only the residents who initially watched video B had a significant increase in the mean score at the end of the course.
The analysis of the variables “doing or already done other coursework on psychodynamics” and “doing or already done personal psychotherapy” did not suggest that these had any influence on the residents’ total scores. Some extracts from the interviews conducted with the residents are shown in Appendix 1.
The teaching methodology presented in this study is original in that it uses patients whom the residents have attended using a pharmacological approach to teach psychodynamic principles. This emphasizes an integrated view of patients while at the same time focusing on problems encountered in the daily routine of the outpatient clinic.
Psychodynamic concepts are so interlinked with medication-related conflicts that Mintz (15) devised a course using psychopharmacology to teach psychodynamics. However, there are not many references in the literature to teaching programs with similar concepts. The neural systems-based neurobiology and neuropsychiatry course taught within the National Capital Consortium Psychiatry Residency Program (16) can be highlighted. This course aimed to integrate biology, psychodynamics, and psychology, describing a new format for teaching psychodynamics that would use metaphors for neuronal functioning (17). Most teaching methods directed toward learning psychodynamic theories do not have an integrated focus between “biological” and “psychological” psychiatry (18–21).
The intention of our course was not to train psychotherapists but to demonstrate the applicability of psychodynamic thinking to psychiatric consultations (22, 23). Extended interviews with outpatients is very useful for this purpose (24).
Responses to theory questions in the test showed that the residents achieved significant learning of the psychodynamic concepts addressed in the course. All the residents started the course with similar levels of knowledge and, on average, all obtained the same growth in learning by the end of the course.
For questions relating to the patients on the videos, analysis of the residents’ progress showed that only those who watched video B initially had a significant increase in mean score at the end. This suggests that video B presented a greater degree of difficulty than the others. Although the interview with the patient on video B was held using the same format as the others, there was one striking feature: the patient’s intense degree of suffering and dramatic life story. Every time this video was shown to the residents, there were a lot of emotional comments expressing sadness, pity, and disgust.
The patient in video B had a depressive disorder with significant somatic and psychotic symptoms, while the patient in video A had a chronic depressive disorder with conversive symptoms, and the patient in video C had a mild depressive disorder with obsessive symptoms and very infantile behavior. Thus, perhaps exactly because of the dichotomy between the biology and the psychodynamics, it was more difficult for the residents to learn about the psychodynamic functioning of the patient in video B in between so many symptoms that rapidly fulfilled the diagnostic criteria needed for a known explanation. These symptoms could easily be attributed to neurobiological causes, which according to Miresco and Kirmayer (2), makes doctors judge that patients have no responsibility for their problems and have more pity for such patients. On the other hand, the more that behavioral problems are seen as originating in “psychological” processes, the more the patients tend to be viewed as responsible and blameworthy for their symptoms.
The residents who watched video B at the start probably initially learned to observe patients better, including their psychodynamic characteristics, in addition to looking for diagnostic criteria, and/or they learned to deal better with countertransference such that it did not interfere with their assessments.
Facing psychic sorrow moves one toward experiencing specific projective and identification anxieties (9). Teaching psychodynamics enhances residents’ skills to deal with unconscious feelings of countertransference, which became a highly important source of a comprehensive diagnostic evaluation and treatment planning. These feelings can provide insight into the disease dynamics underlying symptomatology. However, if they are not monitored carefully, the consequence could be a wrong diagnosis and inadequate treatment (25).
A significant number of residents began to undergo personal psychotherapy during the course. The most likely explanation must lie in the degree of closeness to their patients that they attained during the course. The long interviews, which deepened relationships, and the discussions emphasizing transference and countertransference favored conscious identification by the residents with their patients and an attitude of introspection and reflection. These patients became people who could be like the residents themselves or anyone within their circles of relationships. This experience, which was repeated several times during the course, brought questioning and anxieties, and the residents went looking for resources for this task.
Fogel et al. (26) reported that psychiatric residents believed that their training programs explicitly encouraged personal psychotherapy and that they saw this as a respected and valued educational and therapeutic experience. The residents’ interviews showed that they valued the course and emphasized the learning acquired. Their comments on how they were managing to treat their patients in a broader manner, and including psychodynamic characteristics in their assessments, showed that integration occurred between what was learned in the course and their attitudes in outpatient practice.
This initial study indicates that the described educational method can effectively promote psychodynamic knowledge, skills, and appropriate attitudes among residents for managing psychiatric outpatients. However, we cannot say how consistent this learning was and how durable these changes to the residents’ attitudes will be. There are also clear limitations to this study, which was conducted among a single group of residents, with a limited sample size, in one institution. Consequently, the conclusions drawn may not apply to other residency programs. Thus, this study should be repeated among new groups of residents and with consecutive evaluations over a longer period.
Because it is very difficult to repeat a qualitative evaluation like this every academic year, the next residents’ evaluations should be made based only on the data obtained through the written tests. An easier method that could be feasible in each group of residents, like the Psychodynamic Psychotherapy Competency Test (27) would be desirable to measure changes in residents’ attitudes.
Despite these limitations, we believe that this course is a potentially useful starting point in integrating biological and psychodynamic approaches in patient care and resident education.
At the time of submission, the authors disclosed no competing interests.