Psychiatry residency training programs are in danger of turning out psychiatrists well trained in diagnostic categories and medication but lacking in basic therapeutic skills, according to APA President Allan Tasman, M.D.

He spoke last month at the annual meeting of the American Association of Directors of Psychiatric Residency Training (AADPRT) in Puerto Rico.

For example, a psychiatry resident supervised by Tasman, who chairs the department of psychiatry at the University of Louisville School of Medicine, asked him to see a patient who had not improved for several months. She had a diagnosis of delusional disorder and was taking an antipsychotic.

When Tasman interviewed the patient with the resident, he explored the patients’ recurrent extreme anxiety about strangers breaking into her house and killing her and her children. He asked her about any recent crimes in her area, and the patient responded that a drive-by shooting had occurred on her front porch, killing a neighbor girl who had been playing with her children.

"I quickly knew this woman didn’t have a simple psychotic disorder, but was traumatized. Rather than continue her medications, I decided she needed to talk about how she was feeling," said Tasman.

He concluded that the resident lacked the basic therapeutic tools to do the job fully. "When we underemphasize the role of empathy as a way of listening for the psychological aspects and symbolic meanings in a patient’s presentation of his or her concerns, we lose essential data to fully understand our patients," said Tasman.

Despite the tremendous gains in clinical diagnoses represented by DSM-IV, the manual "doesn’t enhance our understanding of the role of psychological conflict or developmental distress in the symptoms we see," said Tasman.

In his role as an examiner for the American Board of Psychiatry and Neurology (ABPN), Tasman said he increasingly encounters young psychiatrists well trained in diagnosis and medications. But "they don’t understand or see as part of their job dealing with anything more than the most concrete and surface manifestations of illness and somatic interventions."

For example, when he asked a recent candidate for the board exam why he omitted psychosocial and psychotherapeutic issues from his treatment plan, "he responded that those aspects of the patient’s problems were the responsibility of a social worker," said Tasman.

Even if residents are working in a busy inpatient unit, emergency room, or medication clinic, they should have the psychotherapeutic skills to deal with patients who are resistant to treatment or noncompliant with medication, common problems among psychiatric patients, said Tasman.

"How can we deal with these problems if we don’t feel comfortable in understanding or intervening around the sources of resistance?," asked Tasman.

He recommended that residents receive training in psychodynamic psychotherapy for the following reasons, which were first listed in an article he cowrote in the January 1990 American Journal of Psychiatry.

• The psychological and social concepts are relevant to all doctor-patient relationships.

• The resident learns how to manage other dyadic relationships within psychiatry involved in supervision, consultation, and mental health administration.

• The resident gains expertise in interviewing by observing the long-term course of psychopathological and normal mental phenomena.

• The resident learns about patient resistances, strengths, and opportunities for change, which are applicable to treatment planning for all psychiatric disorders.

• By observing complex pathological and normal mental functioning over time, residents can observe similar phenomena in inpatient, consultation, and emergency room settings.

• Residents learn to manage their feelings and reactions to patients, which enhances their ability to anticipate, analyze, and avoid ethical dilemmas and transgressions.

• Practicing psychotherapy requires intellectual rigor and discipline in observing behavior, developing hypotheses, and analyzing theories and data.