Psychodynamic Concepts and Their Application – A Curriculum for Fourth Year Medical Students

1. Psychodynamic Concepts and Their Application – A Curriculum for Fourth Year Medical Students Robert F. McFadden, MD Alexandra H. Sawicki, PGY1 Emory University Nadia H. Sawicki, PGY1 Emory University

2. Abstract: We report on a four-week curriculum developed to teach psychodynamic concepts to fourth year medical students. The course will provide students entering the field of psychiatry the conceptual foundation for doing a psychodynamic evaluation and developing an elementary case formulation. Introducing such an interactive curriculum would alter the make-up of current faculty by bringing analytically and psychodynamically-oriented faculty into contact with students earlier in the students’ psychiatric training. Currently, residents usually experience training in psychodynamic concepts late in their residency. However, creating a curriculum for medical students that will satisfactorily outline the topic, be usable in residency, and encourage further interest while maintaining an achievable breadth is a significant challenge with little precedent. Follow-up with students who took this independent study course is a future consideration. In developing this four-week curriculum we identified the following learning objectives: 1) Acquire a strong, basic foundation in psychodynamic concepts and dynamic formulation 2) Apply psychodynamic principles in the evaluation and diagnosis of patients at a local arts college and develop treatment and disposition planning. 3) Encourage students’ interest in mental processes and support this interest with faculty involvement. Once these goals were outlined appropriate texts for the course were selected.

3. Methods: Overall Purpose – Design a Psychiatry Elective in Psychodynamic Concepts Set Specific Goals for the Course 1) Read, discuss, and develop a strong, basic foundation in psychodynamic concepts 2) Learn to apply psychodynamic principles to clinical work even early in residency. 3) Learn to write a dynamic formulation. Record Details of Course – Time spent, teaching methods, etc Review Course – Evaluate what succeeded and what could be changed to improve the course for the future

4. Background: Challenges of teaching Psychodynamics to medical students: • NBME exam focuses on diagnosis • Educational goals unclear • Medical students’ negative stereotypes1 • Traditional focus on symptomatology2

5. Background: Importance of teaching psychodynamics to medical students • Psychodynamics are a basic science within Psychiatry2,3 • Early imprinting3 • Increases competence in all patient-physician relationships • Attracts students to Psychiatry as an 1) interesting and challenging area of medicine 2) a field in which they can tangibly help patients4

6. Background: How have educators taught psychodynamic concepts in the past? • Active supervision • Case discussion • Observing an experienced psychotherapist conduct a psychodynamic interview • Didactics on psychodynamic theory • Examples from film used as clinical cases5

7. Results: Course Design Length of course: 4 weeks Participants: 1 instructor, 2 students Meetings: 1-3 hours daily 1) Weekly observation of an attending physician conducting intake interviews 2) Daily discussion of readings Readings: 2 core books + 1 chapter

8. Where the course fits in the curriculum MSIV elective, Psychiatry Department Not counted as a sub-internship “By Departmental Arrangement” Offered 1-2 months of the year Consider requiring a case write up/application

9. Characteristics of Participants Instructor: • Interest and skill in psychodynamic psychotherapy • Trained in multiple types of psychotherapy • Skillful teacher • Ability to make concepts accessible Students: • Optimal # of students = 2 • Interest and enthusiasm for learning psychodynamic principles • Self motivated

10. Time Allocation During the Course

11. Learning methods used in the course Apprenticeship6 Supervision Discussion of the readings Lectures Self-directed reading and research

12. Readings

13. Readings Concise Guide to Psychodynamic Psychotherapy7 • accessible in its format • basic concepts of psychotherapy • stimulated thought and conversation • Sample Chapters: The Focus, Setting, and Technique of Psychodynamic Psychotherapy, Psychodynamic Listening, and Resistance and Defense Psychodynamic Concepts in General Psychiatry8 • We read Chapters on “Basic Concepts” and Chapters on “Clinical Settings” (ie inpatient unit, emergency room, medical hospital etc) • Facilitated discussion of the transition from medical school to residency Psychoanalytic Case Formulation9 • We read Chapter One, “The Relationship between Case Formulation and Psychotherapy” • We discussed eight areas she says should be addressed in a psychodynamic formulation. Then we discussed a method for writing simple formulations which could be applied to work during early residency.

14. Readings added when clinically relevant Akhtar, Salman. The Damaged Core: Origins, Dynamics, Manifestations, and Treatment. Lanham, MD: Jason Aronson, 2009, 113-146 (Chapters 7&8, The Analyst’s Office and Listening) Akhtar, Salman. New Clinical Realms: Pushing the Envelope of Theory and Technique. Northvale, NJ: Jason Aronson, 2003, 179-210. (Chapters 8&9, From Schisms through Synthesis to Oscillation and Mentorship) Akhtar, S. and Samuel, S. The Identity Consolidation Inventory (ICI): Development and Application of a Questionnaire for Assessing the Structuralization of Individual Identity. The American Journal of Psychoanalysis: 69, 53-61, 2009. Cohen M., Kay A., Youkaim JM, Balacius JM. Identity Transformation in Medical Students. The American Journal of Psychoanalysis: 69, 43-52, 2009. Coltart, NE. The Assessment of Psychological-Mindedness in the Diagnostic Interview. British Journal of Psychiatry (1988): 153, 819-820. Marguiles, A. and Havens, LL. The Initial Encounter: What to Do First? American Journal of Psychiatry 138:4, 421-428, April 1981. Williams, Gianna: Reflections on Some Dynamics of Eating Disorders: ‘No Entry’ Defences and Foreign Bodies.International Journal of Psycho-Analysis 78: 927- 939 (1997). Additional Chapters from Psychodynamic Concepts in General Psychiatry ed. by Harvey Schwartz. Chapter 18- The Depressed Male Homosexual Patient and Chapter 21- The Patient with Bulimia Excerpts from: Get Me Out of Here by Rachel Reiland

15. Products Book Notes • Made by instructor and students while reading • Used in meetings to facilitate discussion • Provide a record of outstanding questions Discussion Notes • Both students kept notes from daily meetings • Students compiled and typed notes each week, thereby consolidating information • Notes were submitted to course instructor for proof reading • Proofreading allowed instructor to identify topics for clarification, reinforcement, or further investigation at the next meeting. • The final version of the discussion notes represents a carefully revised record of all literature and clinically driven topics discussed in daily meetings. Autobiographical Statement • Proposed for future courses

16. Discussion • Our objective was to design a course to emphasize psychodynamic concepts early in psychiatric training (before residency). • Both participants in the course gained a working knowledge of psychodynamic concepts that they could apply early in residency.

17. Discussion Topics We Learned Best: • Introduction to Types of Psychotherapy • Dreams • Basic Principles of Psychodynamic Psychotherapy • Psychodynamics of common psychopathologies • Resistance and Defense • Psychodynamic Listening and Empathy • Psychodynamic Principles Across the Lifecycle • Principles of How to Teach

18. Discussion:Additions and Changes • Add Autobiographical statement writing for students • Add To Love and to Work, by Leonard Kapelovitz -more case-based learning for those who have limited opportunity to observe psychodynamic interviews. • Apprentice-style learning was a valuable, unique experience. The more observed psychodynamic interviews the better.

19. Future Considerations Reintroduce dynamic concepts to medical schools’ psychiatry clerkships. 1) Expose potentially interested students to intellectually challenging topics within psychiatry 2) Give future doctors in all specialties basic information about psychotherapy 3) Improve future physicians’ understanding of psychodynamic aspects of the patient-physician relationship

20. References • McWilliams, N. (2000) On Teaching Psychoanalysis in Antianalytic Times: A Polemic. The American Journal of Psychoanalysis, Vol 60:4, 371-390. • Goin, M.K. (2006) Teaching Psychodynamic Psychotherapy in the 21st Century. J. Amer. Acad. Psychoanal., 34:117-126. • Tasman, A. (1999) Teaching Psychodynamic Psychiatry During Medical School and Residency. J. PsychotherPract Res, 8:3, 187-190, Summer 1999. • Abramowitz, M.Z. and Gofrit, D.B. “The Attitudes of Israeli Medical Students toward Residency in Psychiatry” Academic Psychiatry 29: 92-95, March 2005. • Miller, F.C. (1999) Using the Movie Ordinary People to Teach Psychodynamic Psychotherapy with Adolescents. Academic Psychiatry, 23:3, 174-179, Fall 1999. • Brooks, M.A. (2009) Medical Education and the Tyranny of Competency. Perspectives in Biology and Medicine: 52:1, 90-102, 2009. • Ursano, R. Sonnenberg, S. and Lazar, S. (2004) Psychodynamic Psychotherapy – Principles and Techniques of Brief, Intermittent, and Long-Term Psychodynamic Psychotherapy 3rd ed. Arlington, VA. American Psychiatric Publishing. • Schwartz, H., et al. (1995) Psychodynamic Concepts in General Psychiatry, Washington, D.C.: American Psychiatric Press. • McWilliams N. (1999) Psychoanalytic Case Formulation, New York: The Guilford Press, Inc.