Abstract
In the wake of their heightened role in addressing the emotional challenges of United States soldiers during World War II, American psychiatrists increasingly argued that their knowledge of human nature, based on interpretation of unconscious processes, was a powerful tool in effecting changes in society. As they turned to training an adequate supply of psychiatrists to meet expanding demand, educators in psychiatry residency programs faced questions about whom to entrust with the power of psychiatric interpretation, how educators’ knowledge about trainees’ own unconscious processes should be harnessed, and how much to adhere to strict psychoanalytic doctrine in training. During the 1970s, social and cultural upheavals outside and inside psychiatry began to dismantle the grand claims of the postwar generation of psychiatrists, while shifts in the 1980s led educators to focus more on seemingly objective educational measures. Trainees’ and critics’ serious questioning of authority and structures in American society, and within psychiatry training programs, was perhaps as much of a factor – if not more – in the shift away from an emphasis on the interpretive power of psychoanalysis in favor of more eclectic and ultimately biological approaches in academic psychiatry.
The Group for the Advancement of Psychiatry (GAP), which was founded in the United States right after World War II to promote an activist approach to the field, took up as one of its earliest projects the issue of medical education. For these psychiatry leaders, many of whom had been involved with the experiences of American servicemen and their neuropsychiatric ailments during the war, psychiatry was not just a medical specialty. As they explained in a report in 1948, psychiatry was in fact fundamental to medical education as a whole. ‘The problem of medical education is not simply to train more doctors’, they explained, ‘but to train doctors who can help men and women to understand and live with themselves at a time when man's lack of understanding of himself and his misuse of his own powers has become a threat to civilization’ (Grob, 1986; Group for the Advancement of Psychiatry, 1948: 1). The answer to the problem of unthinking and destructive human action lay in the power of psychiatric knowledge to uncover the hidden elements of human nature itself.
But in claiming that their particular expertise could effect global change, educational leaders in psychiatry grappled for decades with what that meant for training. Their knowledge was not of the kind that could merely be transmitted through direct instruction. Instead, it involved an initiation of sorts into the mysteries of understanding and interpreting humans and their interactions. Psychiatrists worried about how best to train, but also focused on the potential risks of bringing the wrong people into the field. They worked hard to recruit medical students to join the specialty, but then questioned the motives of those who would choose it. Educators emphasized the power of interpretation through psychoanalytic methods, but never settled on whether general psychiatry trainees (outside psychoanalytic institutes) could ever fully master them. Educational leaders also insisted that their assessment of a trainee's potential was more important than demographic elements (such as race, sex, or religion), but then assumed norms in training based on White, male physicians.
During the 1970s, social and cultural upheavals outside and inside psychiatry began to dismantle the grand claims of the postwar generation of psychiatrists. Critics poked holes in psychiatrists’ interpretations of human behaviors while arguing that psychiatric assumptions about normality had missed major issues in society. Resident physicians in psychiatry programs started to speak up and complain about the power structures in their training, and psychiatrists who were not White or male pointed out the ways in which their education had assumed a singular kind of provider. By the 1980s, psychiatric leaders had shifted away from justifications for the field based on superior knowledge of human nature or the insights of psychoanalysis, and were instead focused on the seemingly more objective disease criteria of the third edition of the Diagnostic and Statistical Manual (DSM; American Psychiatric Association, 1980) and medication therapy.
Ellen Herman has described the extraordinary influence of psychological experts in American society in the decades after World War II. These professionals, who ranged from academic psychologists to social scientists to clinical psychiatrists, strove for authority to guide policy and direct the nation on multiple levels. The insights of these experts were drawn from a range of theories about development and human nature (Herman, 1995). In these decades, psychiatrists shared their expertise regarding ideal human development through popular media, parenting manuals, and their frequent presence within intellectual circles (Hale, 1995). But behind the public pronouncements about such elements as the id, the ego, and the superego, American psychiatrists struggled to redefine and expand their medical specialty from its origins in the state mental hospital movement. This meant, among other things, that they needed to develop new and different ways of recruiting and training practitioners for the expanding field.
Many historians have described American psychiatry's dominance by a psychoanalytic framework in the middle of the 20th century, as well as the eclipse of that perspective with the emergence of interest in medications and diagnostic criteria by the 1980s and 1990s (Grob, 1994; Harrington, 2019; Shorter, 1997). Much of this literature has centered on professional structures and theoretical approaches. Discussions about training, though, offer a means to explore emerging and contested professional issues under active discussion. Several historians have pointed out the ways in which changes in medical education were used to shape the profession as a whole (Barr, 2018; Markowitz and Rosner, 1973). An analysis of the methods psychiatry educators used to transmit the powerful secrets of the profession is especially revealing, as it helps to explain not only the success of psychiatry’s infiltration into many aspects of medical education but also the dominance of the psychodynamic approach to the field. Even more, conflicts around the power dynamic at the heart of training, the supervisor–trainee relationship, help to explain the ultimate decline of psychoanalysis in American psychiatry by the 1970s and 1980s. Trainees’ and critics’ serious questioning of authority and structures in American society was perhaps as much of a factor – if not more – in the shift away from an emphasis on the interpretive power of psychoanalysis in favor of more eclectic and ultimately biological approaches in academic psychiatry.
Postwar psychiatric education
American experiences during World War II convinced many – especially in psychiatry – that services aimed at maintaining and supporting mental health, as well as treating mental illness, were going to be critical as the nation entered its postwar recovery. American psychiatrists, a significant proportion of whom served in the military, were acutely aware of the number of men who had been excluded from service for neuropsychiatric reasons and the high degree of mental strain and injury incurred during the war (Grob, 1990). The sheer scale of the destruction of people and property during the war and the magnitude of the Nazi extermination of whole populations, as well as the destructive power of antisemitism in Germany and other nations, shook many in the field. Further, a significant number of Jewish psychiatrists from Europe had fled the Nazis and helped to develop psychoanalytic training structures in the US (Leff, 2014). Although the psychoanalytic institutes could help inform the field, American psychiatry educators looked toward expanding adult psychiatry residency training programs as the primary method to meet what they identified as future manpower demands.
As historian Kenneth Ludmerer has described, residency training by this period had become the accepted and expected route for those who graduated from medical school to obtain specialty instruction. The Council on Medical Education of the American Medical Association (AMA) was the arbiter of what counted as an acceptable residency program (Ludmerer, 1999). For psychiatry, the residency – which typically consisted of three to four years of labor in hospitals or busy clinics – was a legacy of the specialty's origins in the asylum (state hospital) movement in the 19th century. While, as Elizabeth Lunbeck has pointed out, by the 1940s psychiatrists were much more interested in treating neurotic patients outside the hospital (Lunbeck, 1994), the psychiatry residency training structures were slow to accommodate this shift in the emphasis of the specialty. For the decade before the war, educators within the National Committee on Mental Hygiene tried to make sense of the landscape of training options and make suggestions for improvement. 1 Much of psychiatric instruction at this point was a hodgepodge of training positions at state mental hospitals; some positions in academic programs, such as that at the Boston Psychopathic Hospital; and educational opportunities available in mental hygiene spaces (Ebaugh, 1944). All of this seemed removed from the concerns of the war, and the training process was too lengthy for the urgency of the postwar need (Rymer, 1945). Karl Menninger, one of the influential members of the family who had created a psychiatric clinic in Topeka, Kansas, stepped into this gap and negotiated the creation of the Menninger School of Psychiatry (MSP) at the Veterans Administration (VA) hospital in Topeka (Friedman, 1990a, 1990b). Karl explained in 1945 that the field required new kinds of training: ‘Psychiatry has become a complex specialty. Its extra-mural applications are far more numerous in point of patient and far more complicated in point of social relationships than was the case with exclusively hospital psychiatry’ (Menninger, 1945: 42). The Menningers created a new kind of training program to match their expansive view of psychiatry's role in the modern world.
The approach of the MSP reflected and reinforced concerns on the national level. The Menningers were highly regarded at the American Psychiatric Association (APA) – William became president in 1948 and served as the public face of the organization (even making it on the cover of Time magazine that year). William was also a staunch advocate of centering psychiatry training in medical centers, outside dedicated psychoanalytic spaces (Plant, 2005). Karl's assessments regarding the breadth and extent of what was needed in psychiatric training was captured in the 1946 APA update on education: The objectives are to equip the graduate with a body of knowledge, certain techniques or skills, and a spirit or attitude characteristic of psychiatry. The methods should include assigned reading, work with selected cases, group and individual conferences, seminars and didactic lectures, and the formulation of an autobiography. The content should include the history of psychiatry; presentation of psychiatric symptoms and syndromes; orientation in psychotherapy; counseling and working with general practitioners, social agencies, industrial representatives, teachers, and workers in the allied fields of anthropology, education, religion, criminology and public health. (Rymer, 1946: 549; emphasis in original)
As they weighed the responsibility of the nation's mental health and pondered how they were going to share their insights about unconscious processes and their effects on world events, leaders within the APA and the GAP debated what to teach, how to convey information, and how to expand the field while emphasizing that not everyone would be suited for the role. As Florence Powdermaker, chief of the division of psychiatric education in the VA neuropsychiatric service in Washington, DC, explained in 1947, the need was for men of ‘quality’ who could handle the challenges of becoming actively engaged with psychiatric material. She explained that ‘psychiatry is the possessor of an enormous and rapidly increasing body of experimental and experiential observations and facts, for the most part ill-digested and poorly integrated’. As a result, what was required for trainees was active discussion, careful observation, and increased learning by both teachers and students (Powdermaker, 1947: 471). The art of trainee selection became a key element of the expanding mission of postwar psychiatry.
Student and resident selection and evaluation
The lessons of the evaluation of servicemen during the war were immediately incorporated into medical student management by academic psychiatrists. At institutions such as Harvard University and the University of Michigan, psychiatrists played key roles in selecting students for admission to medical school and in assessing their emotional stability for medical practice (Dienstag, 2016; Waggoner and Zeigler, 1946). Not surprisingly, psychiatry educators were equally interested in the need to carefully choose students for positions in psychiatry residency programs. In fact, the study of how best to do this occupied a number of educational investigators over the decades. One group, which represented a collaboration among training directors at VA hospitals around the country in 1949, emphasized the seriousness of selecting applicants for the important work of psychiatry. In addition to reviewing a candidate's credentials, they reviewed ‘his entire life history and his personal, professional, cultural, and general social adaptations’. They also recommended putting residents on a temporary contract and not letting them see patients until they had been prepared with a series of lectures about psychiatry. They emphasized that this would help orient residents to the field so that they had a realistic idea about what was involved in the practice of psychiatry, and also keep them from the inevitable failure of trying to work with patients when they did not know what they were doing (Masserman et al., 1949: 362–3).
In 1952, psychiatry educators held a national conference on residency education at which participants discussed not only the essential elements to include within training programs but also the selection of trainees. Karl Menninger remarked that the character of residents was as important as their intellectual capacity. As a summary of the conference explained, Menninger ‘emphasized that the psychiatrist is the “good” physician, with a broad cultural background, an open-minded, friendly, yet inquiringly scientific approach to problems’ (Ebaugh and Barnes, 1953: 539; Whitehorn, 1953). But while Menninger was confident that he would know a good psychiatry resident candidate when he saw one, the broader community was less sure about what they were looking for. A 1955 GAP report complained that ‘the ideal psychiatrist has not been adequately defined, especially in view of the many roles he may be called upon to fill. Nor have the personality characteristics been specified which best fit him for these roles’ (Group for the Advancement of Psychiatry, 1955: 3). The GAP report suggested further study in this area.
Embedded in the investigation into resident personalities was the assumption that psychotherapeutic interactions with patients involved an intimate and powerful dynamic, one that was entirely different from the physical management of patients in large mental institutions. In psychotherapy encounters, the trainees were using their own emotional reactions, along with their intellect, in interpreting and guiding patients to change. By definition, the interpretations involved information not accessible to patients’ consciousness, and psychiatrists needed to learn when and how to share that information with patients. Educators viewed the psychiatrist–patient dynamic with regard to unconscious processes as much more interactive and meaningful for patients than what educators characterized as the crude management of patients within institutions. In fact, educators worried that the population demands in large hospitals could lead to a potentially authoritarian abuse of power. At a time when some were comparing the conduct of state psychiatric hospitals toward their patients to that of the Nazis toward Jews in concentration camps, it was critical to assess how psychiatrists viewed and used their power (Halliwell, 2013; Staub, 2011). A group of psychiatry researchers obtained funding from the National Institute of Mental Health in the late 1950s to look at the inner workings of a state mental hospital. This project included exploration of the residents working at the hospital. Myron Sharaf and Daniel Levinson from Harvard developed a scale to assess the extent to which residents were oriented toward psychotherapy (believing only in this intervention) versus the extent to which they were invested in a ‘sociotherapeutic’ view (seeing all aspects of hospital care as potentially valuable). Sharaf and Levinson further assessed the residents based on how they felt about custodial care and their authoritarian tendencies using a scale developed from work that Levinson had done with Theodor Adorno and his team on authoritarian personality (Adorno et al., 1950; Roiser and Willig, 2002). The investigators concluded that the residents were more humanistic than other members of the hospital staff (therefore less likely to be authoritarian or to want to continue custodial care), especially as they progressed through the residency and became more invested in psychotherapy (Sharaf and Levinson, 1957).
For psychiatry educators, a psychotherapeutic perspective, especially one seeped in psychoanalytic theory, was an important bulwark against the gross misuse of power involved in containing and controlling patients in the institutional setting. Although later critics would point out that interpretation of patients’ thoughts, feelings, and behaviors involved a psychiatrist exerting significant power over patients by defining their reality, researchers in the 1950s viewed psychotherapeutic interactions as much more personalized and helpful than the alternative. Sharaf and Levinson went on to collaborate with two other Harvard researchers to explore whether authoritarianism was more common among psychiatry residents who were learning to use medications in treatment. While they found that psychiatry residents were on the whole less authoritarian than surgical residents, they also noted that the psychiatrists who use drug therapy frequently tend to value assertive and decisive behavior more than their colleagues who use drug therapy to a lesser extent. They also place relatively greater value upon manifest status differences, sense of duty, and self-control than the psychiatrists who are low drug users. (Klerman et al., 1960: 114)
But psychoanalysis and medication were not necessarily antithetical, as interpretations could be used to enhance medication effects and medication could be seen as part of the dynamic encounter (Sadowsky, 2006). One of the authors on the Harvard study was Gerald Klerman, a major figure in the development of psychopharmacology, so the characterization of residents who used drugs in the treatment of patients was a puzzle to be solved (Healy, 2002: 299–300). The authors of this study went on to suggest that the residents who did not use drugs in treatment were insecure about their psychotherapy technique, and that in this insecure position, they may perceive the use of drugs as an indication of the failure of their psychotherapeutic efforts. We observed that their aversion to acting in an assertive or directive manner was laden with emotion, indicating that this was an area of conflict for them. It may be that these concerns relate to their resistance to accepting the learning of techniques in drug therapy as part of their psychiatric skills.
The challenge with evaluating candidates for residency positions was that the typical methods by which students had been selected for school – such as their grades – did not reveal the inner character of the person. Psychiatry educators explored a number of proxies for the qualities they were looking for in residents, particularly the capacity to learn to sit with patients and interpret their innermost thoughts and feelings. Faculty from the Albert Einstein Department of Psychiatry examined residents to look for qualities such as creativity and self-awareness, and also inquired about their emotions and values. The psychiatry applicants scored higher on emotional stability and insight, which the faculty said correlated well with success in psychiatry (Plutchik, Conte, and Kandler, 1971). There was the potential, however, that some who might seem suited to psychiatry were actually pursuing the field to address their own emotional needs (Sharaf and Levinson, 1964). It was imperative for educational leaders to manage this risk through continued selection of applicants and well-designed training programs.
Therapy instruction and supervision
One of the central aspects of psychiatry training during this period was in the technique of psychotherapy. A difficulty with therapy training, though, was that not everyone agreed on what it meant to learn – or to do – psychotherapy. Some used the term to mean some kind of interaction with patients that took place one on one. Others specifically meant that psychotherapy was psychoanalytic in nature and that it followed the rigid rules for those interactions. But though the term was vague, it was serious business for psychiatrists. During the postwar decades, therapy instruction was a major issue for a variety of fields (Capshew, 1999). As one participant in a training conference in psychology in 1949 was said to have quipped, ‘Psychotherapy is an undefined technique applied to unspecified problems with unpredictable outcome. For this technique we recommend rigorous training’ (Raimy, 1950: 93).
It seemed self-evident to psychiatry educators in the postwar decades that psychiatrists would be the primary ones performing therapy. Although there were active disputes within and around psychoanalytic circles about whether nonphysicians could be trained for analysis (Buchanan, 2003), the specialty of psychiatry was by definition limited to physicians. At a time when psychiatrists were arguing that psychotherapy was the central method of intervention for the field and that demand for psychiatry was enormous, it meant that there were serious manpower problems (Rymer, 1948). Further, not all training sites were capable of providing appropriate patients for teaching therapy. At the state hospitals, for example, the seriously and chronically ill patients were seldom considered good therapy candidates. Psychotherapy patients were generally middle-class, White, usually neurotic but able to live in the community, and almost always able to pay for individual therapy. When asked about what they wanted in residency programs, trainees said that they wanted access to patients who would get better – which in the parlance of the time was translated to patients who were well enough to come in to an office for therapy and invested enough in the treatment that they were willing to pay for services (Ebaugh and O’Hearne, 1951).
While therapy had a clear class base, there were few other defining characteristics within the psychiatry literature. The essence of therapy was time spent with just the patient and therapist. The content of the interaction might or might not follow the more rigid rules of psychoanalytic treatment, including the practice of remaining neutral or silent while patients expressed emotion (Koch, 2017), or just be generally informed by psychodynamic principles. Educators were not in agreement about how deeply residents in psychiatry training needed to become immersed in what the purists in the field identified as psychoanalytic method. At the 1952 psychiatry educator conference, participants agreed that state hospitals were not appropriate places to learn the key elements of therapy, but they also concluded that the role of explicit psychoanalysis was only a part of the broader consideration of psychiatric treatment (Whitehorn, 1953). At the same time, though, educators insisted that the teaching of method was complex and required time and theoretical preparation. As a report on the 1952 conference explained, ‘Too often, even in graduate training, psychotherapy is treated as a “commonsense” procedure that one just “picks up” in contacts with patients. Psychotherapy has to be approached with a firm grasp of psychodynamics and applied through close supervision of the psychotherapeutic process’ (Ebaugh and Barnes, 1954: 540). A 1955 GAP report called out problems with consistency and quality in the relationship between psychiatric and psychoanalytic training (Group for the Advancement of Psychiatry, 1955). And a 1957 educational report noted that programs that were too immersed in psychoanalysis seemed to be so narrow in their approach that it was harming the quality of education (Ebaugh and Barnes, 1957). All continued to agree, however, that therapy training was the central feature of psychiatric education.
The importance of a supportive teacher was a constant theme in the psychiatry education literature. Educators were particularly focused on the teacher–student relationship within supervision, the structured relationship in which residents discussed their cases in detail with the faculty member ultimately responsible for the patient's care. The 1952 report said that graduate training ‘should focus on the dynamic approach and should provide an intimate relationship between teacher and student’.
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The description of the ‘intimate relationship’ echoed elsewhere in the psychiatry education literature. As a 1955 GAP report explained, Because the emotional interplay between physician and patient is an integral part of the subject matter of psychiatry, the resident's subjective attitudes and emotional reactions are of prime importance in his residency adaptation. This distinguishes psychiatric residency experience from other specialty training. It requires teachers and supervisors to be alert to, and understanding of, the changing emotional reaction of the resident as he proceeds in his training experience. This necessitates intimate supervision and sometimes includes the recommendation for therapeutic assistance. (Group for the Advancement of Psychiatry, 1955: 5)
The supervisory relationship was clearly complicated. Since supervision was modeled on the psychiatrist–patient encounter, the supervisor–trainee relationship revealed some of the same issues addressed in treatment (Group for the Advancement of Psychiatry, 1955). Some insisted that this was not a problem because it was essential for the supervisor to help residents understand their own emotions so that they could function effectively. Since it was in the service of making a more effective psychiatrist, the fact that supervisors were acting as therapists was part of the job (Ebaugh, 1950). Not everyone was comfortable with a slide into what could be considered therapy, however. New York psychoanalyst Lewis Wolberg was cited in the APA Committee on Education’s annual report in 1952 as pointing out that both trainees and supervisors had feelings about each other that needed to be managed. However, ‘Lest this sound like therapy, he cautions that learning is more an educational than a therapeutic process and that the focus in supervision is on the therapist's work, not on his problems. If therapy for the trainee becomes necessary, he recommends referral to someone other than the supervisor’ (Ebaugh and O’Hearne, 1952: 548). No one was ever clear about what it meant to cross the line into therapy or when the psychiatry trainee should manage issues outside the supervisor relationship.
Whatever the specifics of the relationship with trainees, psychiatry educators held up the role of the faculty supervisor as central to psychiatry teaching. The objective for the supervisor was to be a supportive authority figure who would help trainees manage patients through a therapeutic use of self. For psychiatry educators, this was not a reciprocal relationship but rather one in which the faculty member had the responsibility to identify areas in which the trainees needed help both for patient care and for themselves. The supervisor's job also included attesting to the residents’ readiness to practice independently. It is a mark of the penetration of the shared assumptions regarding psychiatry training that for decades this power dynamic went virtually unquestioned in the literature.
Identity and personal analysis
The dynamic between the all-knowing supervisor and the trainee who was at the mercy of (usually) his interpretations (and assessment of his job performance) was especially prominent in training programs that leaned into psychoanalytic frameworks. Many psychiatrists in the postwar decades agreed that the most powerful tool to uncover unconscious processes and reveal truths about human nature was psychoanalysis. Some educators used the term loosely to refer to any approach toward patients that involved a consideration of unconscious processes. There were more discrete standards for psychoanalytic training, though, and these were located primarily within training institutes. During this period, there was extensive discussion about the role of the institutes, especially their relationship to general psychiatry resident training. Though there was not much consensus on the general question of how much psychoanalytic instruction or exposure would be useful to all trainees, the psychoanalysts were among the elite of the profession and their proclamations about training carried a great deal of weight. Among psychoanalysts, the supervision of residents’ emotional reactions required more explicit management through the trainees’ personal analysis. A training analysis, in which a trainee engaged in individual psychotherapy with a supervisor, was never mandatory for general psychiatry residents outside psychoanalytic institutes. But for many, it was the process by which trainees fully learned the inner workings of the unconscious by understanding their own.
As Columbia University psychoanalytic training director Sandor Rado outlined in 1948, a personal analysis revealed a trainee's identity: ‘In his personal analysis, the student undertakes a penetrating psychological study of himself. He is expected to explore resolutely and thoroughly the unconscious reaches of his mind, trace his development back to the formative experiences of his childhood, and arrive at a better knowledge and realistic appraisal of himself as an individual and as a product of a given period and culture.’ This process, Rado explained, would help the trainee overcome his psychological difficulties and become more mature. With the intensity of the personal examination, along with clinics and courses, a trainee would master the insights and skills needed to become a psychoanalyst (Rado, 1948: 113; Tomlinson, 2010). The assumption in psychoanalytic education, which was based on Freud's self-analysis, was that all analysts had some neurotic traits that needed to be resolved so as not to interfere with the clinical work they did with others (Jackson, 2001).
The personal analysis functioned as a kind of rite of initiation into the secrets of the profession. Those who had undergone personal analysis spoke confidently of the lessons they had learned about their characters. As part of that introduction to the mysteries of the field, trainees entered into a treatment relationship, often with someone at the same institution. As Maimon Leavitt later recalled about training at the Menninger Foundation right after the war, the personal analyses among trainees and faculty in the small program led to some blurring of boundaries. Leavitt put a positive spin on what he identified as the heightened emotion from these relationships during the training program and said it had led to better learning (Leavitt, 1990).
Training analysis in some ways upended the traditional distance between analyst and patient, particularly the deliberate avoidance of knowledge of the analyst's personal attributes. Instead, trainees and supervisors acted as patients and doctors in some contexts and as provider colleagues in others. Supervisors did not necessarily switch how they treated trainees, however. Some psychiatry educators tended to interpret their trainees’ behaviors as they might those of patients. Much of this appeared to be accepted by residents as part of the training process. For the residents immersed in the ethos of psychodynamic interactions, interpretation – even of their own reactions – was part of the transition from learners into faculty. Lewis Merklin, who was a resident at the Institute of the Pennsylvania Hospital, presented a paper at the APA annual meeting with faculty member Ralph Little, interpreting the emotional phases of resident life as the trainees adjusted to the role of psychiatrist. They compared the ‘transient neurotic, psychosomatic, and behavioral changes’ of training to the process of growing up. Emotional problems were to be expected in psychiatry residents: It is widely accepted that the development of a psychotherapist is related to his capacity for intrapsychic growth and emotional maturation. A rapid phase of growth, with its attendant personality changes, often occurs early in the course of formal psychiatric training. Although distressing, these changes are essential experiences to be worked through by the new psychiatrist. How he handles this initial stress may later be reflected in his potential to treat the emotional problems of others.
The relationship between trainee and faculty supervisor relied heavily on the concept of transference. In therapy, transference was the way in which a patient would associate the therapist with a key person from the past, especially a parent, around whom the patient had developed unconscious conflicts. The interactions between patient and therapist could provide opportunities to work through those conflicts, and this transference relationship was a mark of success in therapy. It was obvious to psychiatric educators that the relationship between trainee and supervisor revolved around the ways in which the trainee (child) reacted to the faculty member (parent). As with therapy with a patient, the goal of analytic interpretation was to help overcome residents’ resistance to change. A group of faculty from the New York Medical College in 1966, in fact, commented that a benefit to combining general psychiatry training with psychoanalytic instruction was that residents could encounter psychoanalysis at an earlier stage of their education when they were at their ‘most formative and malleable’ (Kaplan, Freedman, and Nagler, 1966: 808).
Psychiatry educators were often explicit that supervisors should act in the role of parent while the trainees functioned as children. In a manner consistent with child-rearing literature of the time (Hulbert, 2003), the father-figure supervisors strove to instruct and support. While they did not take on a dictatorial role, they intended to exert influence on the trainees by virtue of their modeling of expertise and maturity. As University of Pennsylvania faculty Philip Escoll and Howard Wood explained, the problem of confusion and chaos with the different schools of thought in the field could be managed with the example of the preceptor: ‘The supervisor should be a mature psychiatrist who has made his own personal integration of a specialty in which conflicting schools of thought still abound but who retains flexibility and open-mindedness’ (Escoll and Wood, 1967: 188). For psychiatry educators, the faculty were embodiments of the ability to assimilate knowledge, resolve internal conflicts, and guide the next generation. They were intended to be seen as powerful figures to emulate and follow.
But what did it mean for trainees to want to emulate wise father figures? Myron Sharaf and Daniel Levinson, who continued their work exploring the characters of psychiatry trainees through the late 1950s, identified the promise of future power as a contributing factor to what they identified as trainees’ ‘quest for omnipotence’. Through the training process, ‘the admired teacher is apperceived not simply as a person having great skill and understanding, but as an omnipotent, charismatic figure who may, if all goes well, bestow his treasures upon the resident’. Since psychiatry training involved what educators had called the ‘therapeutic use of the self’, Sharaf and Levinson pointed out that the long and painful journey to transform the self led residents to seek the position of all-knowing, all-powerful psychiatrist (Sharaf and Levinson, 1964: 136).
The idealized figure of the psychiatrist was firmly based in cultural ideas of White men from the period. Sharaf and Levinson explained that masculinity was associated with maturity and that residents wanted to strive toward being strong men (Sharaf and Levinson, 1964). Most of the psychiatric literature, like other public and professional writing of the time, used the default language of White men, along with assumptions about appropriate masculine behaviors (Kimmel, 1996). The question of how the race and gender of a psychiatrist would affect either patient care or the supervisory relationship was seldom addressed. In 1949, Herbert Erwin of St. Louis presented at the APA annual meeting and pointed out that while the APA had admitted Black psychiatrists to the organization for a while, there were few places to train and only a dozen or so who had been admitted to the psychiatry specialty board. A commentator to Erwin's presentation noted the benefits of including Black trainees with regard to the others in training, but offered no methods to increase numbers: The very presence of Negro physicians in psychiatric training facilities makes for an increased awareness by psychiatrists of one of America’s major social problems – intergroup tension. Intergroup tension has frequently been called the greatest of our social ills. Certainly psychiatry has a greater responsibility toward the solution of this and other social problems than it has demonstrated in the past. (Erwin, 1950: 627)
Though psychiatrists at mid-century saw the world – and their role in it – in broad terms, their training reinforced conformity to mostly traditional roles. This was nowhere more evident than with a personal analysis. Psychiatrist Barbara Young recalled that she had gone to an analyst while she was in medical school at Johns Hopkins University in the 1940s to address some anxiety. She explored the transference of her feelings about her father to her analyst, explaining that being cared for and respected by this remarkable man anchored me in a solid reality and improved my self-esteem so much that I could dare to investigate the source of my self-doubts and masochistic underminings. And increasingly, I discovered the joy of being a woman in my relationship with a former naval officer. (Young, 2004: 237)
The other effect of the emphasis on personal analysis and the therapeutic use of the self was, as educators pointed out in the early 1960s, that it led a generation of trainees to an almost exclusive focus on private practice. While postwar psychiatrists had emphasized the potential of the psychodynamic perspective to illuminate all human relationships, psychoanalytic training narrowed the scope of psychiatrists’ worldview to the therapist–patient relationship. As Johns Hopkins University psychiatrist Leon Eisenberg pointed out in 1962, trainees in psychoanalysis learned this not only from the content of their instruction but also through their own financial challenges in undergoing a personal analysis (which limited income and opportunities to move and look for better positions) and the time investment in a form of treatment only applicable to private practice. The psychodynamic perspective missed the bigger picture of the mental health needs of the nation (Eisenberg, 1962). Educators also noted that psychodynamic training led to a certainty about answers to complex problems, when the reality was that the world and human interactions were more complicated (Conference on Graduate Psychiatric Education, 1964). As the training director for the UCLA psychiatry program pointed out in 1966, part of the challenge was that residents followed role models who were immersed in psychoanalysis and dismissive of other approaches. He said that residents had prejudices and issues to overcome, but the answer was not a personal analysis but rather good supervision and learning about the world from other fields such as anthropology and sociology (Woods, 1966).
Dissent and rebellion in the 1960s and 1970s
Although psychoanalysis clearly dominated the profession during this period, especially within the leadership of academic departments and the APA (Grob, 1991), psychiatry educators became increasingly concerned about the narrowness of the psychodynamic perspective and its effects on the profession. However, educators who were immersed in psychoanalytic training structures simultaneously pushed the more orthodox elements of training. By the middle of the 1960s and into the 1970s, educators with a broader perspective on the profession increasingly struggled with more traditional psychoanalytic figures around not just the content of training, but also the certainty with which analysts presented their ideas. Some educators – and increasingly residents – framed the conflict in terms of lingering concerns about authoritarianism. Now, instead of authoritarianism being viewed as a risk of resident treatment of patients, critics within psychiatry education began to identify psychoanalytic interpretation as part of authoritarian practice.
As early as 1955, Johns Hopkins psychiatrist John Whitehorn pointed out the risk of psychoanalytic principles in training that led trainees to adopt doctrinaire positions. He suggested that with opportunities to learn and read broadly in psychodynamic concepts, trainees might have the opportunity to avoid overly rigid adherence to any one specific school of thought (Whitehorn, 1957). Whitehorn’s cautious perspective on the value of psychoanalysis as a whole may have been shaped by his position in the psychiatry department at Johns Hopkins University, which never fully embraced a Freudian framework (Lamb, 2014). Psychiatry department leaders outside Johns Hopkins over the following decade confronted the increasing separation between psychoanalytic institutes and academic psychiatry programs. In the late 1950s, the American Psychoanalytic Association became more insistent that psychiatrists who applied for psychoanalytic training meet a higher standard of training in terms of hours, types of cases, and supervision. Although the biggest challenge to the organization appeared to be the threat posed by the more flexible and inclusive American Academy of Psychoanalysis, the effect on psychiatry residents was to make analytic training increasingly rigid, expensive, time-consuming, and inaccessible to many. 3
Not only did the standards for psychoanalytic training become more challenging, but also psychiatric educators started to question some of the central tenets of psychodynamic interactions in residency training. One potential problem was the issue of trainees’ personal analysis. As analyst and fierce psychiatry critic Thomas Szasz pointed out in 1960, personal analysis by definition violated confidentiality, as the trainee would be undergoing analysis with a member of the training faculty who was part of the group evaluating the resident in his work with patients (Szasz, 1960). Another issue was the role of the supervisor. In 1962, Seymour Halleck and Sherwyn Woods addressed vulnerabilities of psychiatry residents to their own emotional problems. While a resident's supervisor could be helpful, the relationship could also be detrimental. They noted that when a supervisor was acting as a ‘quasi-therapist’, the resident was revealing his conflicts, defenses, and issues. This might not be a safe space in which to do so, however: ‘If the resident exposes himself and deals with his anxieties, he must at the same time face the realistic absence of the securities inherent in a truly therapeutic alliance. He has no assurance of confidentiality and knows that his supervisor exercises much power over the ultimate success or failure of his residency’ (Halleck and Woods, 1962: 343). Halleck and Woods interpreted this in terms of the resident's emotional state (heightened guilt from consciously or unconsciously withholding information), but there were also potential consequences for the resident's job and future prospects in the profession.
Though critics pointed out issues with the practice of essentially treating trainees as patients, some psychanalysts continued to emphasize the central role of personal growth in training, even into the 1970s. Noted educators and textbook editors Benjamin Sadock and Harold Kaplan explained in 1970 in the American Journal of Psychiatry that new methods in group therapy meant that for residents, ‘a personal group psychotherapeutic experience should be undertaken by those who would utilize this technique. The resident will thus achieve therapeutic benefits and also be sensitized to group processes.’ They described a group they had been running for residents for several years at the New York Medical College Metropolitan Hospital Center that, while voluntary, had included most of the residents in their program. In terms of rules for the group, Sadock and Kaplan said that if a resident was going to participate, he had to be honest and forthcoming and ‘allow all aspects of his functioning to be probed by the therapist when the latter thinks it is appropriate’. Sadock and Kaplan further elaborated that the group functioned by developing character sketches of one resident a week and then discussing commonalities as a group. The end result was a resident with ‘a deep understanding of the human condition’ that would make him a better therapist (Sadock and Kaplan, 1970: 1139, 1143). Sadock and Kaplan’s description of intensive group psychotherapy used much of the older language of personal growth, while maintaining a dynamic in which residents were instructed to share personal information not only with the faculty group leader but also with fellow residents.
While, decades before, Sadock and Kaplan's resident group psychotherapy program might have fit with other discussions of faculty-directed and psychoanalytically inspired resident programs, by the 1970s there were other alternatives. In the same year within the American Journal of Psychiatry, two residents from Johns Hopkins described a different kind of group in which residents met to process their experiences. Although this group included a chief resident to represent hospital administration, members freely discussed issues among themselves and did some creative problem-solving. They noted that there was one instance in which a resident shared too much personal information and they worried that he would become a patient within the group. They asked him to stay quiet for a while to reduce this risk. The intent of this group, the residents explained, was to ‘abandon the traditional dependency model on which most doctor-staff relationships are based and develop an evocative leadership role’ (Sherman and Hildreth, 1970: 372). Although the residents were clearly influenced by at least some of the language of psychodynamics, they did not take on the language of the certainty of interpretation that had become characteristic of psychoanalytic writings. In insisting that they had some expertise of their own and that they did not want to be interpreted and treated as patients, residents argued for a very different power dynamic than existed in traditional psychoanalytic training.
Psychiatry educators in the late 1960s and 1970s recognized the enormous social changes that were happening in the world around them and the role of generational conflict. Some psychoanalysts tried to insist that the problems facing psychiatry actually reflected a power grab by community-minded psychiatrists who wanted to abandon the profound knowledge base of the profession centered on human processes and unconscious factors as revealed in the physician–patient dyad in favor of social engineering (Bandler, 1970). Others interpreted problems in terms of the question of authority. As California psychoanalyst Jurgen Ruesch commented in the American Journal of Psychiatry in 1967, ‘While in the older system the leader was identified with an authoritarian, heroic, or romantic character surrounded by his kinsmen, family, and aides, in the newer system a management group takes his place.’ Ruesch said that while the younger generation was looking for alternatives to both authority and soulless management, psychiatrists could help with social adaption (Ruesch, 1967: 226). But though trainees and the younger generation within psychiatry from previous decades may have been willing to share in the interpretations of training faculty, by this period they were looking to speak up for themselves and use their own frameworks. Recent UCLA graduate Sheldon Kardener worked with a research team to ask residents what they wanted out of their training. The surveyed residents from nine different training programs rejected a psychodynamic interpretation of the need for supervision (Kardener et al., 1970).
The fundamental inequalities in psychiatric training power relationships were particularly apparent to Black psychiatrists, who began to speak out in the late 1960s and early 1970s. Training positions for Black psychiatrists had been few and far between for most of the century, while those who were able to find a way told stories of having to cobble together opportunities in ad hoc settings (Prudhomme and Musto, 1973). Even when Black trainees were able to get positions in regular programs, they ran into the disconnect between the assumptions embedded in psychiatry and the needs of the Black community. Several Black psychiatrists who had recently finished training in psychoanalytically oriented, entirely White programs presented at the APA annual meeting in 1969. They complained that the focus on intrapsychic conflict ignored essential issues for Black patients, and that institutionalized racism within the program itself was palpable. They articulated ways in which Black residents experienced pressures to assimilate, the circumstances in which they received exaggerated or perhaps undeserved praise, and the clear expectations for them to show restraint and not react to racist ideas. These recent graduates did some interpretation of their own, and suggested that the fact that they were not criticized in supervision was due to ‘likely reactions to latent anti-black sentiment’ (Jones et al., 1970: 799).
The recent trainees observed that none of them had encountered a Black supervisor. Indeed, the number of Black, trained psychoanalysts was very small nationwide. One of them, Charles Pinderhughes, a professor at Boston University, articulated some of the failures of White psychiatry in relationship to Black patients, especially around power dynamics, in a talk he gave in 1970. He explained that one major failure among White psychiatrists was unconscious racism toward the few Black patients who were accepted into psychoanalytic treatment: One problem area for many patients lies in the unconscious needs of many psychotherapists to be in helping, knowledgeable, or controlling roles. Unwittingly they wish to be initiators and have patients accommodate to them or to their style or approach. More Black patients than White perceive in this kind of relationship the basic ingredients of a master-slave pattern. (Pinderhughes, 1973: 104)
Psychiatry seemed to be out of touch where race issues were concerned in the early 1970s, as well as the particular challenges faced by women in training in the field (Benedek, 1973; Bradshaw, 1978). These areas in fact highlighted the ways in which psychiatrists, with their focus on intrapsychic conflicts in middle-class patients, seemed to be falling well short with regard to the need of a rapidly changing society (Gurel, 1975). While leaders in the profession had argued in the immediate postwar years that they were leading the management of social change through their ability to know and understand fundamental human interactions, the newer generation of trainees and professionals by the 1970s saw the insistence on dynamic issues as hopelessly old-fashioned. As Yale resident Donald Apostle pointed out, too much training had been organized around individual issues rather than the broader social and community problems. He said that this was not preparing the young psychiatrist to do what needed to be done in the community, since ‘to a large degree he has been taught what to think and how to intervene in a traditional role’ (Apostle, 1971: 470). In the context of the questioning of authority that was so characteristic of the younger generation in the 1960s and 1970s (Gitlin, 1987), it became apparent that psychiatric tradition was narrow and hierarchical. Stanford residents Robert Taylor and E. Fuller Torrey were more pointed in their complaint in 1972: ‘The teacher knew what to teach – just pay attention and listen! And thus it has continued unchanged until the present, with medical and psychiatric education moving swiftly forward into the 14th century’ (Taylor and Torrey, 1972: 1116).
Some educators were willing to acknowledge that the younger generation wanted different things from their training. Others, though, continued to interpret those who were undergoing psychiatric training in terms of stages of child development. Gary Tischler from Yale described the process of residents as they figured out that the doctor–patient relationship was different in psychiatry than in the rest of medicine and the methods they used to bolster their self-esteem while realizing that they knew very little. Tischler explicitly invoked the language of defense mechanisms to interpret how the residents approached patients, especially regarding what he considered lower-order defenses. He described residents’ tendency to see mental illness as solely organic and treated only with chemical means as a regressive defense, one that indicated that they had not yet progressed to understanding the true nature of patient issues. Tischler also said that residents constructed a façade of scientific interest as a barrier between self and patient and displayed something he called ‘therapeutic megalomania’, or the belief that everything could be explained in psychodynamic terms (Tischler, 1972: 1103). (Of course, it was only over the top when the residents were doing it. Established psychoanalysts had been describing all world interactions in psychodynamic terms for decades.) Residents in training did not necessarily disagree that they went through stages during their education, but they increasingly articulated their resentment at being interpreted (Scanlan, 1972).
But even as residents became more vocal about what they wanted in their education, some of the senior leaders in the field continued to describe them as children who needed to grow up and framed the training experience in these terms. As Roy Grinker Sr. explained in 1975, the resident, as he evolved into a practicing psychiatrist, ‘should have the experiences of suffering, succeeding, and losing his adolescent narcissistic self-evaluation and his grandiose idealism. Only by attaining his own lifestyle and a stable self-system is he able to help others within a mutually trusting and respecting therapeutic alliance’ (Grinker, 1975: 259). The training directors continued to take the position of all-knowing parent figures who had the power to interpret residents and their growth in the program. Further, some training directors doubled down on the idea that psychoanalytic tools could be broadly helpful. O. Eugene Baum at the Medical College of Pennsylvania published an article in 1975 in which he explained why his psychoanalytically based training program, which he admitted was going against the tide, could address contemporary issues. He claimed that ‘psychoanalysis epitomizes the lifting of repression intrapsychically; thus its development parallels the lifting of repression of peoples’, and could not function under totalitarianism. For Baum, interpretation and development could apply to the field as a whole (Baum, 1975: 1281).
The quest for objectivity in the 1970s and 1980s
By the mid-1970s, psychiatry educators could agree about one thing: training in the field was all over the place. There were numerous standards, multiple approaches, and little agreement on what should be taught, how information should be conveyed, or the extent to which residents were like children who needed to grow as they learned. Some educators responded to the chaos with calls for structure and educational objectives for training. Joel Yager and Robert Pasnau at UCLA outlined a residency training program in 1976 that included specific tasks for the residents to complete every year of training, along with what they should be focusing on for approaches to patient care. The concrete structure, Yager and Pasnau argued, would help bring order to the field and help residents and faculty know what they were supposed to be doing (Yager and Pasnau, 1976). Harvey Weinstein and Michael Russell in San Francisco also published on specific competencies that residents should be able to demonstrate with their training. At a time when psychiatry as a field was still struggling to define what it meant to act as a psychiatrist, it should be possible, Weinstein and Russell pointed out, to demonstrate that residents could function in core areas with performance objectives and knowledge assessment (Weinstein and Russell, 1976). The authority for training would be in the specific tasks and skills psychiatrists should acquire before they graduated, an approach they now shared with other medical specialists (Ludmerer, 2015: 287–8, 306).
At the same time that educators in psychiatry were looking beyond psychodynamic interpretation to assess progress in trainees, research psychiatrists were attempting to shift the field as a whole away from what they saw as the old-fashioned subjectivity of psychoanalysis toward a more objective and presumably scientific specialty, helped along by broader critiques of psychiatrists’ claims to interpretive authority (Grob, 2011). The main location for this work was in the creation of specific psychiatric diagnoses with symptom criteria in the 1980 third edition of the DSM. New York State Psychiatric Institute psychiatrist Robert Spitzer, who led the transformation in diagnostic methodology, was explicit about his intent to expunge psychoanalytic interpretations from diagnosis (Decker, 2013). He and his colleagues also focused on how to transmit this approach to the next generation of psychiatrists. They designed extensive, concrete training modules for residents to make sure that they learned the new system (Skodol, Spitzer, and Williams, 1981). Though some later worried that this form of training would reduce residents to unthinking mechanics who only checked boxes instead of assessing patients (Tasman, 2002), Spitzer and others argued at the time that this was a step forward for objectivity in psychiatry training (Williams, Spitzer, and Skodol, 1985).
By the 1970s and 1980s, analytic interpretation carried significantly less weight in the profession. Instead, both residents and faculty increasingly started to gather information from colleagues in the field to reach consensus on what were the most important things to learn. For example, John Drucker, who was a resident unhappy with his supervisor in training, collaborated with a consultant in his state's health department as well as a junior faculty member from his program to assess resident evaluations of their supervision. They flipped the assessment from the ways in which faculty typically evaluated residents. Instead, the residents were asked about ‘the supervisor’s attendance, interest in supervision, empathy for patients, ability to elucidate psychodynamics, ability to use alternate conceptual models of therapy, encouragement of the resident's capacity for self-observation, and other areas’ (Drucker, Klass, and Strizich, 1978: 1517). Although Drucker did not have specific recommendations for his training program, he (and the journal that published his work) assumed that the data presented about resident feedback was important.
Surveys were useful tools to try to make sense of the mass of material that could be included within psychiatry training programs. Within its first decade, the American Association of Directors of Psychiatric Residency Training (AADPRT) created a task force to survey residency programs about what they thought were the most important elements of training. They asked about everything, within a survey instrument they explained would likely take 4–10 hours to complete. The task force then made recommendations based on items deemed important by at least 50% of the training programs. The goal, the task force members explained, was to create a reliable curriculum with clear objectives. The data, they elaborated, could be used to further define the profession – what it was and what it was not (Bowden, Humphrey, and Thompson, 1980).
One area of collision between older and newer definitions of psychiatry came in the question of how (or whether) to assess for mental health problems among all trainees. By the 1970s, there was much more awareness of the vulnerability of physicians in general to problems, especially in the area of drug and alcohol abuse. The AMA worked with a group of psychiatrists to create a report and make recommendations to states to help impaired physicians rather than just punish them (Council on Mental Health, 1973; Sargent, 1985). Against that backdrop, the scrutiny of psychiatry residents fit with the general surveillance of physicians and students but also reflected older concerns about what special challenges might be faced by psychiatry trainees.
In 1982, Baylor psychiatrist Harvey Campbell described the importance of screening students and residents prior to admission to a program in an article in the American Journal of Psychiatry. He also said that those who had personal problems were more likely to be attracted to psychiatry, and that ‘the stresses inherent in the process of becoming a psychiatrist have a potential for exacerbating or reactivating latent conflicts in the resident, thus contributing to the development of overt psychopathology’. He suggested that many aspects of psychiatry training might address these issues: Almost all psychiatric residents can benefit from various training program interventions directed at greater self-understanding. Personal or group psychotherapy, didactic supervision, and/or supportive relationships with faculty preceptors are effective interventions. Personal psychotherapy as a part of professional training may enhance the development of skill as a psychotherapist by helping to resolve personal emotional conflicts that often surface in the process of training. (Campbell, 1982: 1407)
Another indication of how much things had changed regarding expectations for training on substantive content rather than emotional processes was conflict around a 1990 report by members of the Association for Academic Psychiatry and the AADPRT on psychodynamic psychotherapy in training programs. The authors of the report acknowledged that their conclusion, that this form of therapy remained central, might seem old-fashioned, but they argued for a way of framing the past as critical for guiding the future: We are clearly at a historical scientific watershed, but should the psychiatrists who teach psychodynamic psychotherapy be viewed as the medieval alchemists and astrologers, only grudgingly giving way to the Newtons and Galileos of neurobiology, or should they be regarded as the medieval monks carefully preserving the writings of Aristotle lest the wisdom be lost? (Mohl et al., 1990: 7)
By the 1990s, in fact, psychiatry training had moved well beyond psychodynamic psychotherapy. Although it was still listed as an aspect of training to which residents needed to be exposed, the field as a whole had moved solidly toward more biological interventions (including medications). Residents were instructed in techniques for determining appropriate drugs for concrete diagnoses as outlined in the DSM. The APA published a volume in 1987, Training Psychiatrists for the ’90s, that outlined what residency programs should address in the future. The section on psychotherapy was very small (and included a chapter entitled ‘Psychotherapy Will Not Be Central in Psychiatric Education’), while there were significantly more chapters on scientific knowledge, research, economic issues, academic medicine in general, and the centrality of content and knowledge rather than process (Nadelson and Robinowitz, 1987; Scully, Robinowitz, and Shore, 2000).
Conclusion
In his contribution to the volume on Training Psychiatrists for the ’90s, New York psychiatrist Zebulon Taintor explained that future residents would need to move beyond the limited knowledge of one particular supervisor. Taintor commented that ‘the field is growing faster than individual faculty learning, thus defining the limits of individual supervision and emphasizing the need to consider new teaching alternatives for the 1990s and beyond’. These innovations could include peer instruction, group supervision, and even the use of technologies such as computers (Taintor, 1987: 71). The emphasis was on pieces of information that were presumed to be objective, cutting-edge, and beyond the authority of any particular individual. The worry was not that residents’ characters were inappropriate for psychiatry, but rather that they might not have all the information they needed to practice.
While the possibility of new technology, including computers, could seem modern and powerful, this was a very different way of imagining both the training process and the mystique and authority of psychiatry than in the heady days of psychoanalysis after World War II. For decades, psychoanalysis seemed to offer a way for initiates in the field to see and understand what others could not: the unconscious factors that led to human behavior. Psychiatrists who wanted to mobilize the power of interpretation tried to mold generations of trainees to use this knowledge to help patients and society. However, with the rise of generational questioning of authority and the rights movements in the 1960s and 1970s, the power of interpretation seemed less true and more arbitrary and controlling. General psychiatry training programs for the most part shifted away from psychoanalytic methods and toward a focus on content. Psychoanalytic institutes did not die out, and in fact continued to train the select few who could afford to undergo the lengthy education and personal analysis that remained a critical part of initiation into the exclusive group of psychoanalysts. But psychoanalysis became just one of many kinds of interventions residents needed to learn as part of their education in general psychiatry programs. Trainees were no longer promised access to the secrets of society's inner workings. Even more, psychiatry faculty did not claim to understand more about their residents and their unconscious motives than the residents themselves.
For the generation of residents and faculty grappling with the structure and content of psychiatric training in the 1970s and 1980s, it seemed increasingly difficult to accept the model of all-knowing, analytically informed supervisors retaining all the power to interpret, judge, and control residents. At a time when educational sites in all areas of the country were experiencing conflicts from activist students, psychiatry faculty members’ claims to ultimate authority could not be sustained. When residency training programs increasingly had to compete with other kinds of medical specialties to attract applicants for a growing number of empty training positions, educators needed to be more mindful of adapting programs to the wishes of the newer generation.
While postwar psychiatrists emphasized the value of the field in understanding human interactions and international power dynamics, psychiatry by the 1980s was, along with the rest of medicine, increasingly shaped by financial concerns (Frank and Glied, 2006). The older model of private practice psychiatry relied on fee-for-service payments by more affluent patients. The newer model of third-party insurance meant that psychiatrists had to explain what they were doing to companies that had the economic power to shape practice, and this influenced the types of patients whom residents saw in their training (Rudy, 1971). Medications were much more concrete for insurance companies to measure, as well, as psychiatry shifted more toward prescriptions and away from therapy. The knowledge base of psychoanalysis did not really change, though the generation of psychiatrists willing to make grand claims about what it could reveal faded over the decades and retreated into psychoanalytic institutes. Instead, psychiatry leadership and educators stressed the power of reliability of diagnosis and pharmaceutical interventions. Historians have pointed out that the shift in American psychiatry toward specific diagnoses and medications leaped well beyond the validity of the scientific claims of the time (Harrington, 2019; Healy, 2002). It has seemed self-evident to scholars in hindsight to see the demise of psychoanalysis in that context (Shorter, 1997). However, there was nothing inevitable about the dominance of the DSM over the field. By the time that specific diagnoses arrived on the scene, many psychiatry educators had begun to reject the premise that supervisors had the power to interpret and judge trainees as part of the initiation process to dynamic knowledge. It may be that the repudiation of the power of psychoanalytic knowledge was as much a factor in the rapid changes in psychiatry in the 1970s and 1980s, beyond the claims of the merits of diagnosis and medication.
Footnotes
Declaration of conflicting interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.
