Teaching Psychotherapy in Contemporary Psychiatric Residency Training by articles

yrů + , ů t, ů z*ů q k n*~s ů uů o{}l ů Ç ķů ů × ů ů GØ ũů d`aů ( 4 ĞÙA Jů ů ů È ů & ů Úŭ ů ů ů #Ę> ů ů ů Ř; ğů ů ? ů ă Wů É @ ů ¥ Ûŕ ĸů ÜĠ ů Ê Ýġů ¾ ů ń F ů Ņ ů ņř ů ůš Ģ Ś ů Ň ů ůě 5 &Ūů ů ů Þ1 ň ů ů Ëß ů % ů ů ŉÌ ů ¿ ů ů ů Í ů ů Îś ąů ģ 6ēĆ Xů p ý ćů ů A ô ů ů ?ů2à ¦á õ ů ů¡ Ĉů °ů @ů% ů ů+ I ů ó ů Ĥ7 â=ö ĹYů ĉ ů ů Ãĥ ů Ĕ»ůvm-ů Ċů bhfgů ů ů Ï Ţ ů Ŧ Ħ ů§÷ (ů F Ŋ ů !¨ ů % ħů 5 ů ů C4Ĩ : ãĺ Ků ¢ $ D Lů ŋ Mů Ļ äļ å Nů E ĩ Oů ø ( Ī Pů Ŝī Qů ū Ð 8 Ō Rů Ľ H Ä Sů © $ů Ĭ ĭ Tů 0 ů G ů ů ů ! )ů Ñæ Uů ů Zů w ů ţ ů ů® ç ŝ ů Ů Į Ąů ¼ů ŧ į ů İ è ů ů ´ů #ęþÿ ů iů |[ ĕů ªĖĀā «ōů <3ů .Ĝ ı/éľµů Ŀ7ÅċêÀ¬/ĒŖů 3.Ŏ ů ë<ů ŏÒ¶ů Á·:±ŀ

& $ % & & ! & & # & "

c\ ů Ť ! D ů ů Ő ů "ů ő ů 2 ť¸ù ů ů Ũů j e] ů 0 ú ů Œ ů û ů CÓŞ ů ìČ ²ů #ĚĲů ů =ĵ H í ů ů; č üů Ô ů "ů ů ÕE ů > $ î Ď ^ x -ů Łů ů 8 " ů Ķ ş )ů ů łů ĳ œ ů &¹ ů 'Ö ů ¯ ĝėŃï'ºů Â ³9ďÆBů Đ ů ð 9 đBů ½ů 6' ů £ Ĵ ů Vů !ñ ů ¤Ŭů òŔ ů ů 1 ŠĂŗ _ů

2 7

7 ,6 #/ ( &37 7 $ 0 '%( )47 -5 1* 7 . 67 + ! " 7

( # ! $( ( " %( & '

a |gĭ s rt h ĭ ' b} ~ xĭ A(Ĉĭ ¿ 5ġÞ( ¯,ĭ )ĩĭ ĭ i çĬ Ê ĝ ĭ ìĭ Ä 8 Pĭ ' ĭ 5°è ĉĭ ¹ĭ 0 ĭ ª é Ë = ĭ ĭ Ì Ğ Bĭ ß1Ċ= -ĭ à AQĭ Å ĭ ù:ĭ ºĭ> ±ĭ Ĕ/ ĭ %c ĭ * 9ĭ Ħ 4åĭ ċĭ Í>Î6í áĭê ¡²úČÆÏôĭ¥ ĕ 7 Ð³9ĭ -ĭ¦Ģ û Ėĭ «ĭ ėĭ ¾§ ĭ »ĭy# Cĭ ü ĭ 4Ý Ę´,ĭ îĭ õ8 ĭ ]`O^_Rĭ

. / 04 $ 4 3'%"* 4

Ñ ĭ ĭ ö ĭ j z ģ÷ĭ Àýĭ ę. ĭ #¬@ ï¨ òğĭ ; *.Ò þĪĭ $ ĭ Sĭ č ¢â Dĭ " Eĭ kÇ 0ÿ Ď ðĭ

7 µK © b²]©z µ µ µ 9 µP ^{ |ª}_U µ FpV le µ µµ ; µGqZ me µ ~ µ TqW«µ L¡µ « µ Edµ QV³lr¬µ µ µ = µHqX ne¢µ µ Mes b µ jµ ReY`t mµ !µ µ > µHqZ of£µ µ ®ueµ Oe¤ ce ¯ µ " #$ % &% 'µ µ B µIvX mg¥µ µ °weµ Se[axe ¦µ ()*+ ,-. - /0 12µ µ C µN §\ ¨µ k µ ±yhµ J²±´ iµ 34 5% / 6µ µ

;µ ?µ 88µ 8Dµ :@µ ;7µ <Aµ

( +4 4 # 12 ,4 ! 4 )- &4

{ Ćīĭ e 1 Fĭ Tĭ uĤ ĭ fUĭ v ÓÁ 3: ñGĭ ! Vĭ £ ĭ Ô+ ã Hĭ W Xĭ d Āµħĭ ĭ 6āĂÕ<ó Iĭ &Yn!ĭ Zo ĭ 3ĭ Jĭ %2 ď¤ ĭ w æ Ĩ;ĭ È ć ĭ Ö Ě × Kĭ &[p\ĭ ĭ $Đ©/Lĭ "q ĭ

) ĭ Ø+ äđMĭ Nĭ ¶ @ ĭ ĭ l Ù ă ĭ ¼ĭ ·ĭ m ë2?ě ĭ ®ĥĄÚ Âĭ Û¸ąĭ <? Ã Ēĭ 7½ĭ ĜÉÜēĭ ø Ġĭ

INTRODUCTION

Training and supervised experience in conducting psycho therapy has long been a central theme of psychiatric resi dency programs, but the role that it plays has changed significantly in the last few decades. Thirty years ago the most respected teachers in psychiatric residency programs were clinicians who were practicing psychoanalysts, and "dy namic" psychotherapy occupied a virtually undisputed piv otal position in psychiatry. Today, in sharp contrast, this traditional centrality of psychotherapy in psychiatric edu cation is being challenged. Both friends and critics are questioning the rationale for teaching psychotherapy in mod ern psychiatric residency programs, along with the very definition of the profession and the goals of its educational programs. In fact, several current observers are so deeply concerned with the impact of a so-called "identity crisis" in psychiatry and its implications for the future of the profession and the nature of its therapeutic practices, that they have worried about the "survival" of the contemporary resident (and teacher) (Freedman & Gordon, 1973; Osmond, 1973; Yager, 1974; Eaton & Goldstein, 1977; Karasu & Hart, 1979). Thus, the changing role of psychotherapy in training and in practice cannot be divorced from consideration of the changing scope and context of psychiatry as a whole. Psy chiatry has a special place in modern medicine that reflects the ambiguous position it has long tried to occupy as a 3

;

$ ; 28 *5 . ,8; %; +&6 #-+. /8; 39 70 ; 4 ' :; 1 !(") ;

¹ ' E Ɲ O " Ɲ Ŭ Ɲ Bø a ' Ɲ Ɲ 9 ê ùAĤƝ k# 1Ɲ UƝ ë Ɲ # Ò 1ú Ɲ N ' Ɲ û ; [A; Ɲ : !2* 0Ɲ ` Ɲ # \ ; Ɲ 6¿Ƃ Ŝ pƝ .MH $A/ Ɲ Ɲ Ɲ .' ü =? Ɲ ÓƝ !ªĥƝ « ŭ ƃ Ɲ Ɲ . > Ɲ ¢ Ɲ ) Ɲ Ɲ 3 ì À!¬ ƓƝ Ɲ Ħ Ɲ / 8 &ý5®ĭ 3Ɲ B Ɲ # -Ɲ VƝ# þ Ů 34Ɲ p $ Ɲ Ɲ ! ( YƝ +Ɲ Ɲ ¯ŋ Ɲ Ō +& ƔƝ ]cģ Ɲ Ɲ ÿ 4Ɲ 9 ĮĞ 5° 4Ɲ ĸ Ɲ Ā Ɲ Xņō Ɲ Z Ɲ 1 Ɲ >ŎƝ " J Ɲ N %Ɲ å Ɲ 0 Ɲ !$Ɲ F Ň Ɲ ) . Ɲ / Ɲ ! Ƅş< Ɲ / Ɲ "ā Z* Ɲ ±Ĺ Ɲ Ńƅ ŠĂ RƝ )RƝ ăšÁĄň ą+ Ɲ ¨<ĳeĺQƝ y {Ɲ ÊÎŢÂŏĆºÏQƝ Ɲ r F E Ɲ ÝK IƝ @7 ć sƝ Ĉ Ɲ "í7 Ɲ Ĵ O%, Ɲ UƝ Ɲ , Ô ĉ ĻƝ ƊńÃ ů ƝƏ' ƝƋ $ Ɲ Ɲ Ő Ɲ Ɲ ÕƝ ƀ ħƝĊ Ɲ + Ɲ ' Ɲ I Ɲ £ŰƝ Ɲ ( Ɲ ÖƝ Ɲ ċ: C Č űő Ɲ n ƙ I% Ɲ Ɲ Ɲ }Ɲ \ Ɲ @ Ɲ %ƌ Ɲ #Ņ ţ B Ɲ = Ɲ/ Ɲ Ɲ Œč1 Ɲ ĎbƝ æ~Ɲ áĨ( ď Ɲ ËƝ -l Ɲ Ɲ ƝŲ Ɲ. Ɲ i Ɲ * Ɲ ļƝ t Ťƕ ] œ uƝ Ɲ Đ ĩe&ƖƝ ²c Ɲ ³5 d Ɲ ĢS đĽçƝ î6Ɲ 8 Ɲ ×Ɲ ųï Ɲ $ Ē aƝ #1 ð 9( 2Ɲ Ɲ " H Ɲ Ɲ Ŵñ Ɲ Ɲ . ? Ɲ ØƝ ò Ɲ:Ŕ Ù G Ɲ©!ĵm ? Ɲ ŕ &Ɲ = ē ľƝ Ɲ Ī Ɲ , Ɲ ğn Ɲ Ĕŵ Ɲ Ɲ Ɲ Ɲ ; Ɲ ÚƝ ? Ŗ Ɲ d Ɲ f Ɲ: $- <Ɲ^ Ɲ į )Ɲ g Ɲī Ɲ Ɲv ` ƝXK ƝƐ7 >2wƝ z¤ŗT bƝ xƝ ¥ h Ɲ ¡ | Ɲ g ä [ Ɲ M» _ Ɲ Ä Ɲ 0 Ɲ ßl +Ɲ, $ * &Ɲ Ɲƍ Ř* Ɲ Ɲ Ɲ ĕ Ɲ # ƚ ƆĬ F Ɲ Ɲ f P2* Ɲ ť ( ŦƝ WƝ Ɲ Ŷ Ķ , J Ɲ iƗ )Gƛ ! Ɲ ¦ Ɲ ř ^0&Ɲ Ɲ > 4Ɲ " Ɲ " Ɲ â Ɲ ! 8 Y Ɲ ŷó Ɲ ¼J Ɲ 7 9 H(ŸĠ 8Ɲ jƝ " İƝ ´jƝ ŧC_ (ã Ɲ ) +E Ɲ ÛƝ Ɲ ŹƝ h TƝ Ì Ɲ - Ɲ Ǝ Ɲ & S$ ı 3Ɲ àÐ 6 Ɲ <35ô µźŚġÉƝ ŝ¸ Ɯ Ė èƝ ÍƝ ŉ, P ėC Ɲ DL DÅ'¶ qƝ ŨqÆõ ŻöÑś Ƙ Ɲ §ĿƝ LƇ½LDŊƈ żƝ - 0 Ɲ o6Ɲ ƑĘ ĲƝ ƒ ŀ%Ɲ Ɲ ęķ Ɲ ÜƝ km Ɲ Ç Ł % Ɲ łƝ Ɲ È éƝ VƝ ÷ - ƝÞK ƝŽ %Ɲũ G žŪƝ WƝ@ ·ſƝ Ě Ɲ Ɲ ¾ Ɲ 2 M Ɲ "Ɲ ě=Ɲ Ɲ Ɖ Ɲ @ Ɲ Ş ūƝ Ĝ Ɲ Ɲ o Ɲ Ɲ ĝƁ Ɲ

! 7 04 '2 + )57 "7 '#3 *(, -47 06 3. 7 1 $ 47 / % & 7

+ ź ²>Q eź Ŭ - ź ź ¹õ fź ź ź ů& ôź .Ë gź -Àź # ź & # ź ź Ķ 1ź ³>0) ź Ġ+ ŉŢ 15hź Q ġ ź " %ź ű öź iź * ź ţ ź jź 7Jź ŵ Ģ ź ģ ź Ť Fź ź "ź Ĥ ź º ź ũ Č ź = ź = ĥź ź P ź ź ź 9! 4 7 ź ź ¶ ź / ) ź ª ź \% ź Ì 1 ź « ¡ 3ź ´+č ź ) ! ź ź + ź . ' Í ź Î Ï źĚ & W'C {ź ź ' ź'Ļļ+Ć ź \źÐ ! MR ź ŊÁ¤ź ĽťěĜB:ź ĕ¬ź ĝ[ ÂÑ ŋWÒ[Ōľź ŰĖ+ ¢ź Ŀė÷ŭ¥ź ōÃ ź ŀ Ę '¿ kź 7 lź #M Ă mźA źĦ S ź- ź ź Ä ź ź ŝ 7šź ź Ó ź ħ ź% ź źŎ. ź ź ź N ź ź ź Ô - Fź H ź ķ Ĩź 4 $ ź ź , 9 ź / · " ź ź ź Ů ć nź Õ ź Z ź` ź- ŏź ź ź ź & Ŷ |ź T!oź % ź Ď 0&^ ź A ź ; X ź ź ĩÖ Y P ź 4 J ø ź ® ¦Īź 8 ( ď ù 8×8pź ź ī /_ ź ź ó#Ø ź ź % 9 ź ? ź ź ' ź +IăN <ź ź ź ,qź 4? B Ŵ ź ź ź % ź ź ź 6 ź ź ¼,ź $ ź Ĭ ź !ĔŞ Ą :ź Ùą <ź ½ ź ` Őź ź ź ź Z §ź Ł 6 0rź T ź # ź L© ĭ úź <ź 0Ú ź Į& "'C sź ź # ź ź ź ź O # ) ź E łÛ 65}ź Sź @Ü ź Ń ş/ ź ź ő ź ¯ ûź 2 ( ź ź ] ź A Š B # ź E Ý ź Kź 5 .& 2 tź 9 ĸ Ĉ Œ üź »ŷ D ýź Ŧ " ź¾"ź 8 ÅÞ œ, ź ŧ *uź *£ź *źß à¸ į Đ ź ę ź ź þ ź ÿ aź µ İ ź Ŕŕ ŖŨ !ź I ź @ ź %ź + vź ı áD * ź )D 2 / ź Oa ź ŗ ź $ ( ź ź 3 z X0ź Ų 'Ř&Ĳ ź 5 Æ1 ź ź # %ź &ź !ź â ŪĀ ź Kź " ź ńã ~ź ] 6 ź ź¨ ź- ź , ź ° Uź ź : Çä , ź #E *åU ź ź ź ĳ æĉçđ ź Ņ ź $ " ź ? Ċ) ź ź -ź ź 3;ř/(ź $ " ź c ź bź wź Gd ź = .ź . ź 5$ Ĵź ųV ź ź Èè é ź$ ê ) ź ź ë ź xź É ź Ē " ì Rź ±źċ ź Ğ ŚĹ í ź ĺū ņź *ź Ê ź ā $!ź G ź ź î ź ź ē ź ź ï*ź ;Ÿ ĵ ź VY ( 2( yź _! 3 ź ) ź ś ź ;ź ź Ź 3 ð ź ğ Ŝ :ź 2 ź C1 ñ ź Ň ò ź H !ź 0 $ 4 ź ( , %ź ź @ ź ^ ź ( ňź L> $ ź 6 ź

ĉŤ Ť ĖŎ Ť ½ŤÌ Ť + ì ĺI ĊŤÂİ 2Ť c Ť$Į + .Í íŤ _Ļ îéš Î Ť f`Ť È Ť ² Ť ¾ŤFU ïŤ ę Ť Ť. Ť ü Ť ś ;Ť ¨ Ť Ã ý Ť Ť \ / ċ Ť Ť ŗ & * Ť Ŝ% J Ť DŤ ļ0 * Ť ðK Ť ı Ť ( ŝŤ A ŏ Ï TŤ VĲ^³G Ţ ^ Ð Ť G Ő Ť a¥ w Ĝ * L bŤ 3 Ñ Ť į Ť Ť x Ò Ť 6Ó| }gŤ Č QN dŤ É W* ~Ť ¡ Ť hŤ Ť 5 Ô Ť DŤ " Õ ő OŤÁė ą ĳŤ Ř Ť ñ 8Ť ;Æ 7Ť òiŤ - ó 7Ť Py VjŤ T Ť ô z %Ť Œ ĝ Ť © Ť Ť Ť Ť FŖĞ ğŤ Ä KĔ3Ť č¹Ť º Ĵ Ö Ť ¿Ť þŤ YH Ť Ġġ ĽŤ Q ®õ1 Ť Ď Ť U 2 ) Ť ] œö Ť Ť - Ť Š Ť ľ! Ť Ě Ť ÀŤ Ê ĵŤ · <Ť ª Ť× Ō 'Ŀ Ť ĢŤ Ť E & Ť Ť Ť Ć ģŤ EŤ H "+»Ť Ť Ť Ť 6A ´ kŤ ĤêØ 8Ť #Ť ¦ & lŤ = Ť , 'ŔŤ #Ť ëmŤ ? Ť , ĥ nŤ Ť ÿ oŤ =@ Ť , pŤ ÷Ť@ Ť ¢ ř Ť #Ť Ķ/ 9Ť > Ť §R :Ť ø Ť #Ť £ Āā Ħ:Ť ?> e<Ť Ť (Ù Ť qŤ Ť ħ I ŀŤ Ť Ť ) Ť ù $Ť Ť ±S" BĨÚŁ Ť Ť "3 Ť µ Ť ]L !Ť + Ť 0 ţ $ Ť Ť M ķ { N ł Ť ĩ $ ŃM Ť ď ĸ Ť « Ť CŤ Ť ' Ť Û'Ť Şě /Ť 4 Ť P Ī Ť . [ Ť ŕ Ü5 Ť ń ī Ý rŤ ¯R ¶Ť Ë B J sŤ ! Ť 2 ÞÅ )ß ĐŤ )! à tŤ ć áŅ OŤ đ Ť -Ĉ ú Ť( Ĭ uŤ %Ť Y %1 vŤ Ť ¬ Ť Ťè Ť Ť !Ť Z Ť ņ Ť X[â Ť X ( Ť ãĹ Ť ş ä Ť å Ť ĂăŤ û Ť Ť Ęĭ Ň Ť ¤ 5 &9Ť ¸ ÇŤ 4 æ Ť Ē Ť 4 0 1W\ Ť Ť ň Ť Ť ēŉ¼ Ť Ś" Ť ĄçZō Ť ° CS ŊŤ ŋĕŤ

Teaching Psychotherapy in Contemporary Psychiatric Residency Training

borderline, and related disorders. The most prominent clin ical features have been described as problems related to aggression; impoverishment of affect and avoidance of commitment; permaneni ad olescence with fading of adulthood as an aim; omni potent and narcissistic expectations; superego defects and conflict; impaired ego-ideal function; regressive phenomena; defective sense of identity; feelings of alienation and unrelatedness, . . . and a compelling need for change, action, movement, immediacy, and fluidity (Lazar, 1973). (pp. 585-586) Although Lazar's findings are taken from a predominantly white upper-middle-class population, other phenomena point to similar changes affecting all socioeconomic strata. The explosion of the "drug culture" in the past two decades has resulted in dramatic increases in numbers of pathological patterns related to addiction and drug abuse, with their related episodes of drug overdose. Moreover, epidemio logical surveys reveal that the incidence of suicide in ado lescents and young adults more than doubled in the decade of the sixties, alone (O'Brien, 1977). Whatever the underlying explanations for these changes in perceived clinical picture, a significant portion of the resident's current case load is subsumed under diagnostic categories (e.g., borderline and narcissistic personality dis orders) that were hardly delineated 30 years ago. Further more, the popular psychodynamic formulations of those times, centering around Oedipal-level conflicts and more mature defensive processes, are not the dominant framework for understanding these patients. New dynamic concepts, involving early object relations, primitive defenses, such as splitting, and early self-object representations, must be in cluded in the resident's theoretical vocabulary, within a developmental framework that encompasses patterns of de velopmental arrest and consequent structural deficits so prominent in such cases.

Changes In What Is to Be Taught

In practice, the first case assigned to a resident for in tensive outpatient psychotherapy is often a severe narcissistic or borderline personality disorder. The primitive emotion ality, arrogance or clinging demandingness, and related clinical characteristics of such patients, coupled with their ability to evoke intense countertransference responses, fre quently make therapeutic encounters with them a trying experience even for skilled and experienced therapists. For a beginning resident, even with competent supervision, such an experience can be painful and discouraging, coloring future attitudes toward psychotherapy. In addition to these changes in the prevalence of path ological entities (or changes in diagnostic fashion), the pub lic's conception of what constitutes mental illness and its expectations of what psychotherapy has to offer have also changed. This, in turn, has influenced who seeks psychiatric help and therefore whom residents are trained to treat. Psychiatry's own view of mental illness is, of course, an important factor in this process, and definitions of mental illness have progressively broadened in recent years. For example, a generation or so ago it would have been much more unlikely for anyone to consult a psychiatrist for marital difficulties, unsatisfying interpersonal relationships, or prob lems in making commitments. Not only are such patients common today, but psychiatrists may encounter patients who look upon any reduction of personal potential as an indication for psychotherapy, who think of health as the fullest realization of self (mind, body, and spirit), and who regard psychotherapy (not necessarily conducted by psy chiatrists alone) as appropriate for everyone as an aid in coping with the psychic stresses of human existence.

Patient Population and Treatment Settings In addition to changes in psychopathology and in types of treatment, there have been changes in the populations served by psychiatrists and in the clinical settings in which they

4 +0 #. ' &14 4 $ / &%' (34 ,2 /) 4 - ! 34 * " 4

c ǂ ǂ ǂ n ĳ ǂ 6 å !&ǂ V ƓǂË@ Ũǂ ǂ Ī ǂ Æǂņ ƧæAç ǂ 46 Ûè 'ǂ Ż ŃƔǂ X ǂg C 4ǂ ǂ żH ¹V ) ƿ :ƴǂ $B Ĵ éÑ ǂ + ǂ # ǂ Ň E ǂ "ǂ Ƶ Ü &>ǂ ƙ #ǂ ǂ ¾ ĵ ƶǂ d Kǂ ğ ň2Ž 9ǂ Ư7 yǂ ƚĶê 0ǂ į s ž Ġǂ ǂ Ŏ zǂ ǂ īë $° {ǂ ì ǂ Õ ±í |ǂ ǂ ũPT Mǂ ǂ ưb ºǂ iǂ î ǂ ¿Ū ǂ ǂ h ïķ hǂ ðÏ ŏǂ Íŧ ǂ ǂ Ő B+ D Zǂ ġ ǂ "ǂ ǂ & ſ ! ƀ ǂ Ʊ ő Z ñ² Ģǂ ĸ ūǂ 3 0ǂ WĹƨ [J ǂ F ŒN³ ǂ 1 ǂ ǂ (Ö ǂ = G}ǂ Ŭ ò ǂ Ʃ2´ ǂ ¥ _ $ ŭ~ǂ ] ǂ Ů # ů ǂ ¦ ǂ S@ ǂ ńÐQ i ǂ ¡ Àǂ œ(Űó» ǂ G Ʒǂ Ý q ǂ ǂ Ŕ ėaŌ5ô ǂ 7 ǂ "Á , ģǂ IƦ ǂ ǂ Îo õ_ ǂ ö ǂ ŉ 6' ÷ H)¸ǂ ) ×ű?ǂ ¤ >ǂ ǂ ǂ (ǂ ø ǂ ù ǂ ǂ ǂ !ęǂ 1 ǂ ƁÞ ǂ ú ǂ ^ 0ǂ 8 ǂ GE ƛ ! Ƃ ǂ eǂ < 5 ǂ *Ƹǂ ƃ ǂ 3 ǂ k. % % Ĥǂ 5 .Jû ! Lǂ ß ǂ UƜ ǂ / % 1 0ǂ ĺl 1*Ɲ ǂ ǂ N\ &ǂ İ*$ ; n ǂ ǂ Ò+ ǂ r % Ųǂ u .ťüų ǂ ǂ ĬM ǂ w?ǂ £ Ěǂ % ǂ # ǂ ǂ rƄ ǂ ǂ ) ǂ ǂ ý ƕǂ ƹǂ¬ ǂ þ ƞ:ƅ ƟŴĥ&ǂ ƆÿĻØǂ ǂ - ǂ Ā ǂ R< '7 >ǂ ǂ Ù ļ)ƽ ā ǂ µ Ľ /: ǂ ǂ# jǂ * Ơ ǂ ǂ ōơ 2 ŵǂ * Ƣ ǂ ǂ O o ŕĂ ǂ "ǂ à ǂ - Ç ǂ ǂ á ǂ Ó ! ; Aǂ "ǂ Cľ ǂ ǂƇ ǂb &' ă I Ŷ t ǂ ǂ ǂ O ǂ Ę 2ƈ ǂ ǂ ǂ X ǂ 4Cƪ ǂ ' - ĄƫÂǂ ` ǂ "ǂ ě$ ǂ ą ǂ 4ǂ ǂ -d âǂ Ć3ǂ ÔŖǂQ aŷ; Ɖć Ŀǂ Bǂ c 3 ǂ ŗǂ Ĉ ǂ ǂ 0 % Ř2 Ɗǂ ǂ Ʋ ǂ D ǂ Ŧ Ħ ǂ ĉ ǂ fı ǂ "ǂ 5 ř Kǂ § Ś < ħ0ǂ f 7 ǂ / , ǂ k ǂ Ċ ǂ p + ǂ ¶ċÃ ǂ śǂ Ŋ!,< ǂ · . + ǂ ǂ Čŀǂ T Ŝǂ ƺ ǂ 9 (ŝč ǂ # ǂ Ƌ D ǂ Ł ǂ Èǂ ǂ Ÿ= ƌ 'ǂ ãƻs ǂ ¢ ǂ 3 6ǂ ǂ ǂ % ǂ ) ǂ ǂ Ş % ǂ Ĝ ǂ ł ǂ ǂ m6- ǂ Éǂ , ǂ ǂ ǂ ǂ ǂ gǂ H ǂ Ê ǂ 5 S@^Ď ď¨!ǂ ǂ ǂ ƍ ş ǂ ǂ &ǂ 8 ǂ \ ǂ Š š ǂ ǂ :-ǂ ǂ Ä ǂ ǂ EƎ#ǂ Ə ǂ ǂ 4' Đƾ ŋ ǂ) ǂ ǂ " =ǂ ƣ ǂ ǂ ǂ 8 Ţ( ( ; ǂ , ǂ $ ǂ ǂ đ ® ǀ ǂ Uǂ ], Ē ǂ . Źpǂ Ɛǂ [?ǂ v xǂ ä Ƭ ǂP .e ĨƼǂ/ţ ¼ǂ m ǂ / q + ǂ j ŅƤ ǂ 8 ǂ $ ` ǂ ǂ l# ǂ ƥ ĩǂ Y ǂ I ǂ ēR ǂ W ĭǂ ¯ ǂ ĝ ǂ ǂ / Å Ğ ǂ J ǂ ½ ƳĔǁ © &Lǂ ǂ ! *9 ǂ ǂ ǂ ĕA ǂ Ì« ǂ $ ǂ Ƒ ǂ Ť Ė Úǂ Ɩ 1 ǂ Ĳ =ǂ ƭ ǂ Ɨ ǂ ( Ʈ ǂ Ƙ ǂ ƒ ź ǂ ĮF F ª9ǂ Y ǂ ǂ

š Uš ¥ &úbš ĝ š õ V 4cš š Q&? ?ê š öĄĞĪš ¼ U š ī š #š G š + R š H š š û š #š 3X! Ç È tš Éğš C N $1śš ĠÊġĬĢš ±š À,1<Čš 2@ ĭË Cģš @Ş 5 š ĮŎ0 š š Ì čdš , š Ř š š 3į 4š Ď 'š š š N ) š İ ÷ Ōš ü šı š š Y š Í xš š š : š \ ý H š $ ď š š Î š FÏ eš ĈQ S ë š š » š š š š #š Ĥ ì +fš š % š #š ĥ ĲÂ ĉ š š ŕ š ²š0 Ð š Ñ [Òþ 8š `( gš ¿ š \ ø í hš î iš z/ } š æ Ó š -š : % Đ Ôÿjš ./~{ š I š -š çkš . 99 š ; š ( ŏ ĳ *6š ( lš -š mš ./ |8aš Ċ ZÕ M š š ¹P "š š š ĴJ ] š D š đš ş ą Ŝ 2K nš š š Ē ,ĵÖ š ē 7š š š š Š !)Ħ ^3š ř! š O š ºŔĀ Ķ × Áuš ċķØ2 $1ŝoš ĸš T Ù³ĹTš < èš š BP š Dš ' 7š !¬ Úā š š ĺ š XĔ š #š Ļ š ¦òÛ Ü =ïš = §š ¨ ¡ ļ ðš ĕ& "6š ĽÃ š Ý ľ Ė 'Ŀš ©š éÞóôš ´š š + ! ėŖL ®š > š ŀ š "Ő Ę "&ępš > š Ł š F " š µš š ¯š ł ! š š 4 š Y A ŗß M Ăvš A š š ¶ š à š 5 š š J š ) SŃ; š š š +ő Zá" *š Ś % š [š š Ě V_ š & E ¢ š Ć ¾I£ ħš ě· Ĝ š 5Gń š ÄL š *š Å Rš Bć ¤ š Ĩš š Ņ â yš š ù š š š ņ š ½ qš Ňš š' % š °š ã0 O %š ō š 'š , ňK ă ñš ŉ wš (Œ * ä š Æ œ$ š š š rš $W E š š š š Ŋ sš ªš Wš ĩš åŋš š «š š ) š ¸š š

_ O8ǚ {6 L ǚ ý ǚ =5 ŀ 1 ǚ ǚ & ǚ x ǚ Ûǚ ǚ %ǅ Ħǚ ² ,ŚƸ ǚ 3 ǚ ƪ ǚ jǈǚ %J ǚ ǚ 3 6ǚ - ǚ $ŏ,Mƹ= ǚ é ) ǚ b ǚ Ïǚ 'V O ǚ A fǚþ Ƨ | ÿ .ǚ ǚ ś Zm ǚ Eǚ í ǚ Ƌ N Ő,$ ǚ ǚ = ǚ + ǚ ǚ ǚ ŜÜ ŝ ǚ Āƌ ǚ ǚ ƍ> ħǚ åv (ǚ Xǚ 9ƫ Şy4 H ǚ £\ ǚ H Ƭ ǚ è !ǚ ǚ ! %ǚ n ƺ ş ǉǚ ā5ǚ @ | G ¦ ǚ ¢ ǚ³ ĨĂ + ǚ*- ǚ ] ǚ Ż 0 ă !ǚ ĄŁǚ ] ǚ ? ǚ 1 ǚ Xǚ î ǚ Š ǚ ƭĩ ǚ ;ǚ ) ǚ < A ą ǚ ǚ ǆ f A,ǚ Ǝ Ðǚ ǁ0šĪÉǚ ÊĆŢ »ƨĶǊ ǚ §żǚ Tǋǚ Ļ >(êǚ t&Ñǚ ćļ7lţƏ¨( ǚ 7 Ō7gÒǚ `łǚ # ǚ #a .# "ǚ īĈÝ ǚ RB' ŤŽǚ ©ž" ťBǚ Ɛ' )ǚ "Ʈ 'ǚ ĉſ ŦB ƀǚ ^ 1 ǚ ´ ǚ ǚ ǚ ǚ o Ĭǚ ç ķ ǚ Þǚ Ċ Ř$ ŧ ǚ b ǚ ǚ ¼ Ƒ ő ǚ L ǚ ǚ # 8ǚ Ũ ƒ [ǌǚ Zmũǚ Ń"#Źu B ń[ǚ ċ"ǚ " ª ǚ z ĭ ǚ ǚ 2 ǚ µ ǚ Ư ǚ & jǚ * ǚ 6c! ǚ + ǚ Ǎǚ È ŅC dk *_ ǚ ǚ i ǚ h ǚ ǚ ǚ . *ź$ ǚ ǚ ĮC Ǖ ǚ Ëǚ ßǚ ï ǚ ' o ?" ǚ Ū ð Mǚ /ǚ ư ;Č5Fǚ < ǚ @ =, Pǚ ¡ qǚ u Nč c į ǚ Œ ǚ ^ ǚ + U ǚ ǚ ūǚ Ɠ ǚ & ǚ« 7 K ½-ǚƔ (ÌǚƩ0ǚTÓD0J ǚƁƱœÔ ƻĎ! ŬƂǚǂ&lǚ¬ x ¾ ǚ C ǚ . i Ʋ ǚ ǚ Q ƃ ďC%ǚ ñ ǚ 6 g ŭǚ + ƕ 8ǚ 3 ǚ Ɩò?Ƅǚ ņ p y% ǚ ¶ 1 ǚ } 2e Ɨ Ƽ ~ǚ ƽ%r v ǚ :2Ĥ I+ ǚ 81 ƾIƅ L ǚ Ŕ ǚ ' ǚ N,ǚ $ # ǚ ǃ ǚ 2 ĸ + ǚ ƘóVǚ # ǚ Ů ǚ #ǚ Đ ¿ Ľ ) ·İW ǚ ¥ @ ǚ àǚ 8 . ǚ p ǚ 6 A4 đ Ĺ ǎǚ " $ a ǚ ǄĒ) ǚ ǚ q ƆI; k ǚ ēŇǚ ō(ǚ ǚ ǚ r :ı ůǚ : ǚ áǚ Ű À ǚ / * Ƈ ǚ ® ǚ ǚ 1 æw ǚ J ǚ âǚ 2M ; 3/Fǚ ǚ ű ` ǚ ( ǚ Yǚ &Ĕƈǚ KŲǚ Õ ǚ ų0Ĳ ǚ ¸ŎtGǚ K¹ĥ ÁƙĕƿÖǚ ¯ňÍǚ Ǉŕ ŴĖ×(ƚėSĳ ǚ Ę/ǚ ƛ- ǚ ƜôØ °7 Ƴ ęÂǚ ŵ D Ɖ ǚ

QĚ Ɲ?Ãǚ < Fǚ ±Ĵ ǚ ǚ ǚ s ǚ ǚ ! ŉ 4 ǚ Ǐǖ õ ö $ ǚ n ě d Pǚ s hĺ ǚ ƞ÷Ĝ ǚ ǚ Yǚ z ǚľ > ǚ ǚ R. ǚ Ɗǚ ) ǚ ƟÙ Uøĝ ǚ ãǚ ǚ 'wĿ Ŋǚ ǐ ù ĵ ëǑ ǚ :Ä ǚ ǚ Ǘ ú 4 ǚ ǒ ǚ ǚ Ğ ǚ {@ *% ǚ ǚ $ Wǚ *- ǚ : Î ǘ 5 ğ ǚ ŋ ǚ ǚ > ǀ / ǚ EǚƠG ǚ !ǓD 0ơ& Ŗ49 ǚ ¤ ǚ \ ǚ Ġ ǚ Ƣû ǚ ƣ 3/ìǚ Eǚ < ǚ ) Ú Ŷǔǚ ǚ ÅƤġ ǚ äǚ ŷ Ǚ ƴ HÆǚ -5ĢřƵ ǚ ƥǚ ģ 9 ǚ Ʀü ǚ ǚ ƶºe Ç !ǚ SŸ ǚ 9Ʒ ŗ 9

ªŁǥ &m ǥş = ǥ ô2 ( :ǥ ǈ À ,ǥ ǥ 7 ǥ k ǥ sǥ PƔl w ǥ bƄ uǥ 1 Íǥ Ā %; ǥ ¦¥ǥ 5Ƈǥ´ ǥ ¯ ā 2Ƽ ǥ uµ ǥ ǥ eǥ ¶ǥ Š , šǥ 5ǥ & 5ǥ Ǔŕ m 2 ǥ ǥ =ħN)ĲÎ ǥ $õ B 3ǥ Y ·);Ǚǥ Ţ V ǥ ǥ ƕk x ǥ ?ö deǥ ł ǡ ǥ ĂE ǥ <ǥ . ǥ E ţ ăŃ @ǥ ±' ǥ ǥ \Ïǥ "VŤƖĄ9Q C ǚǥ Kƅƽ. c ǥ ǥ ǥ ť (, ǥ ą ǥ ī %: ǥ Ɨ ǥ 7 | ǥ Ć ǥ ǥ ' zǥ 4## Ŧǥ ǔ" ŧn ǥ &ǥ 1 ǥ ć Ƙ= ǥ Q"ŖC 2 !D ǥ ÷ ǥ Ũǉ¸ D ǥ Ûǥ ƙf ǥ ƚf ũ "Hǥ Fǥ Ǌ ǥ ìƆ ǥ ƾ LI ǥ ƛ aǥƜøÐŪ ŗ ƈ @ǥ °Œ/aǥÑÊƿ` Ɲ Ɖǥ] :Ĉ ǥ ǥ Ɗ*ĉ3 ǥ ǥ W ñ ūǥ Üǥ ĳs Ǒ ǥ ǀ ƞ Ċ Ĩċńdǥ Č/ Ɵ Sǥ ǥ >ǥ G> K ǥ êŔŬǥ % òo ǥ E " =-Ƌǥ Ơ ǥ , ǥ ǥ v )ǥ č ǥ X ǥ $ǥ -' ǥ ǥ n ơ ǥ ¹ ǥ Ĭ ǥ ;Hǥ Ņ ǥ «3ǥ ! ǥ " ǥ 3g ǥ ^hǥ Ď M ǥ Ĵ ǥ W ǥ Ƣ ǥ p ǥ ď 0ƸBíÁ ƣ ņǥ º ǥ »Q$ G ǥ cǆ $ w 2 @ǥ ® ǥ ǥ & ǥh Tǥ Đ ǥ ǥ ǥ ŭ ǥ ǥ ǥ đx D ǥ F őƹ ǥ Ů ǥ v ǥ # ǥ ǥ ǥ ; )ǥ I }!î Ē ǥ N$jǥ 2ǥ # ů ǥ ĵǁ !0 ǥ ùē ǥ * ŰAY" ǥ Ĕ 4 ƤNÂǥ % ' ǋ4 ǥ ǥÃ ǥ ĕ-1ǥ & űǥ Ǖ4 q Uǥ ǂ ǥǌ! ( ǥ Ýǥ 2 0 ǥ~ " ǥ >ú ) ǥ ǥ Ų , + ǥ bOųǥ ĭ ? ǥ l ǥ ?z . ǥ §$ǥ 1 ǥ Ė ǥ ė~ǥ / ǥ % ǥ ĮŘKǇįǥ ëO ǥ 6 ƌ. ? ǥ? ǥ ] Ŵ ǥ û -ǥ ǥ ǥ Ŀ ǥ +ÒǍ ŵ ǥ œÞǥ / Ŷ ǥ _ Ň ǥ ¾ ǥ ŷJÙ` ǥ ƥ + Ʀ> ǥ ³ Ƨg ǥ % ǥ 7 ǥ ß Ä ǥ ( ǥ # ǥ ƨA Tǥ ǥ { 8 ǥ R* Ÿ Ę ( ňSǥ ǃ ǥ ^& ǥ Å #ǥ 9 ǥ $ ǥ )4 Ź ǥ ǖ ǥ ĩ ǥ !0ǥ ƩA ǥ ƪ ŉ ǥ B ź ǥ ę üǥ ǥ R* <ǎ £ǥ ¬ ǥ ( . İǥ " { M ǥ ƫ& ǥ L# 4 ǥ . $ǥ 87 ǥ+ Ë ǥÆ #ð 0 ǥ . ǥ 6ǥA 6ǥ Ż6 5 ǥ ǥĚàǥ,GP" ǥ Ǜǥ ǥ I C ǥ ř 1ě ǥ * ǏL, 5¤ǥ ² ƍ ǥ Ĝ0Ħ 5 ,ǥ Ƭ ǥ 7 rá ƭ ŀǥ Ŋ0 3ǥ ǜ ǥ ǥ ÓŜ Z Ķǝǥ Zķ$ǥ ǒ!- ǥ ! ' 83ǥ Ʈ ǥ R Ì Ǝĝ+ % ǥ $ Əï+ ǥ âǥ Ưý ǥ GP | ( ǥ ( ǥ ż ư@ǥ ǥ ǥ + 8 ǥ ƺĞ ǥ #ǥ ǥ / :tǥ ǥ ǥ Ç ǥ 7. Ʊǥ / ǥ ǥ %) ǥ - ǥ È / E ǥ * ǥ Ǘ" < ǥ ǥ ã ; ŋ Ɛǥ ǥ & Ƒ ǥ äǥ + ǥX ǥ Ʋþ Ž % ǥ å ǥ : > ǥ ğŌ ÔŝǄ ¡ǥ ©+ 8Śǥ _ ǥ ǥ ǥ 6/!-ǥ & ǥ *¼ž 9( ǥ Ƴ ǥ 9 t ǥ ǥ * #ıǞǥ i ǥ o 68 ƴ ſ ,ǥ 3i Ġ )ǥ M Uǥ - ƀǥ !Ƶǥ \ ǥ * ǟǢ 1 ō C FpFǥ <ǥ Õ' B <ġ ǥ ' ǥ ĸ qŎ ǥ JO ǥ ǥ 1 Ĺƻ'Ǡǥ ǣ rĺ 9} ǥ ǘÉ' ó ǥ ½ ǥ ÖĻļǥ [ƒǥ [ǥ Ɓ ĽĢ æǥ çǥ ƶÿ×ǥ ƷØŏƓģyŐǥ śƂyǤ ǐ Ī ǥ ¿ ǥ j Ĥƃǥ JÚ )ĥ0 ǥ èǥ !D Şǅ H¢ǥ ¨ ľ H ǥ - ǥ = ǥ éǥ

Teaching Psychotherapy in Contemporary Psychiatric Residency Training

group teaching permits residents to be exposed to a wider range of clinical phenomena and issues than is available through their individual experiences.

CHANGES IN THE RESIDENTS

Decline in Popularity of Psychiatry Even while psychiatry has been expanding its theoretical foundation, clinical application, and populations served, it has declined in popularity among medical students as a career choice (Gurel, 1973, 1976; Nielsen, 1979, 1980; Reinhold, 1980). The number of medical school graduates who select psychiatric training has decreased both in absolute number and in percentage of total graduates. The projec tions of national requirements for physicians made by the Graduate Medical Education National Advisory Committee indicate that adult and child psychiatry will continue to be medical specialties whose practitioners are in short supply, in sharp contrast to others, such as internal medicine, general surgery, and obstetrics and gynecology, which are expected to be oversupplied with physicians within the next IO years (Reinhold, l 980). Nielsen (1979) attributed the decline in the popularity of psychiatry among medical students to shifts in the charac teristics of applicants admitted to medical schools, the impact of the medical school experience, changes in medical cur ricula, the attitudes of medical students about psychiatry and its role in medicine, and the competing appeal presented by primary-care specialties. In addition, it is possible that many psychiatrists selected their specialty because of its psychotherapeutic orientation, and that as that theme has 25

¤ ŀ Ɠ # Ɠ " 5[ Ɠ Þ Ɠ & ß ĕƓ Ĩ Ɠ Í Ɠ : Ɠ Ɠ " Ɠ% Ɠ # à¥FĖƓ Ɠ ¹Ɠ Ŗ ƓŢ Ɠ Ç f Ɠ RhƓ Åa &Ɠ Q Ɠ Ł Ɠ 'Ɠ # #Ɠ á Ɠ Ɠ 3Ɠ ( %* Ɠ â ŗ Ɠ ã Ɠ ţ Ɠ , ä Ɠ ĭ ėƓ ! Ž*! Ɠ Ɠ 0®Ɠ l, œ . Ɠ Y 9 #ĩ Ɠ Ɠ Ɠ¦ 4 Ɠ å Ɠ" Èł Ɠ Ə Ɠ J {Ɠ Ɠ Ń ^Ɠ ( - e Ɠ æ Ɠ Î Ɠ - #Ɠ & ç ĘƓ ! žXl&|Ɠ Ɠ Ɠ )ƍ ¯Ɠ Ɠ >è Ɠ Ɠ q _ *Ɠ +9 Ɛ é ( ńrƓ Ņ g Ɠ y ƎƓ wƓ İ @Ɠ ƓzCƓ E Ɠ _ Ɠ ŤO Ɠ h.4 j Ɠ Ï Ɠ 1 Ɠ ê ņ ť 4Ɠ ë Ɠ ì Ɠ Âĺ Ɠ i ³Ɠ s Ð / Ɠ % <tƓ Ɠ Ɠ Ɠ > Ɠ P º Ɠ j í Ɠ ęg Ɠ î Ɠ 5a Ɠ 5H )XƊƓ Ŧï§ Ɠ < Ɠ CƓ E Ɠ 6)Ň Ɠ Ř!I Ŕ$ſ }Ɠ &ƀ Ɠ F#* ~Ɠ ".ŧƓ » Ɠ R Ě Ɠ Ƅ2ěm Ɠ ¢ Ɠ S Ɠ ň ð Ɠ Ê & Ɠ Ɠ Ũ Ã[` Ɠ ñ = Ɠ )ıƓ Ɠ ř V Ĝ Ɠ 'Ɠ ? ¨ 2 ò Ɠ Ɓ 7 Ɠ ó Ɠ 7 !/ Ɠ " Ɠ Ɠ Ɠ 0 ! Ƒ " * T ĝƓ ô Ɠ ¼Ɠ Ɠ ŉ Ɠ Ɠ b © Ɠ õũƓ Ɠ GƓ NW Ğ Ɠ Ñ2ŪƓ cƓ I$ƂūƓ %$Ɠ ! Ŋ Ɠ Ɠ p\ öƅ Ɠ k Ɠ ½Ɠ Ɠ Ɠ Ɠ Ē # Ɠ ŬƓ Ɠ -ē Ɠ ÷ % Ɠ ƒ đ Ɠ Ɠ ŭ ´Ɠ 8 Ɠ ¾ Ɠ Ɠ Ĳ ËƓŮ ø;Ɠ (Ɔ -;U% Ɠ Ɠ Śļ Ɠ Ò Ɠ ù ú ;Ó Ɠ + û Ɠ Ɠ ś 6M Ɠ Ɠ Ɠ n ^ Ɠ] 6ü ů Ɠ ý þ !@Ɠ & ŰƓ ŋ Z% Ɠ (° Ɠ Ɠ ŕ Ɠ 'Ɠ % 8 Ɠ Ɠ Ô ÿ Ɠ ű Āĳ7Z Ɠ Æƃ ! Ɠ Ɠ Ɠ : ğƓ * Ƈ Ɠ Ɠ " Ɠ ¿Ɠ ª1āŲĂ ĠƓ Ĵ Ɠ i T<. Ɠ Ɠ Ɠ n mŜƓ ųG ĔƓ $'Ɠ ġ ă Ɠ Ɠ u vƓ Õ ƋƓ Ō Ɠ ŝ Ɠ , Ɠ Ɠ ƈ = Ɠ ÀƓ ÁH ŴĶ AƓ o Ɠ + ĢƓ Ŀ! ģ BƓ p AƓ Ɠ> oµŞƓ Ī Ɠ £ Ɠ ŵ Ɠ ō Ą ą Ɠ Ć şkć . $ Ɠ Ɠ ī/Ɠ bƓ Ö¶Ɠ Ĥ L Ɠ dķ«Ĉ$ K$?

( $ ( "# % ( & ( ' ! '( × Ɠ Ŏ ĉ Y xŠƓ Ľ Ĺ ¬OƓ Ŷ Ɠ / Ɠ \ Ø Ù·1 ƌƓ Ċ Ɠ ' Ɠ ĥ 3Ɠ, Ɠ ċ -Ɠ Ɠ ƓČ Ɠ ŷ šƓ ! :S Ɠ " ÄĻ9 Ɠ Ż 0ÌƓ ¸ č± ĵK DƓ $Į Ɠ ŏLc)² Ɠ Ú Ɖ Ɠ Q 3Ɠ Ő 0 Ɠ ľd ? =Û 1 Ɠ , É Ɠ Ɠ Ɠ P Ɠ Ɠ Ɠ + ) Ĭż DƓ Ɠ Ÿ M Ɠ Ɠ e Ħ Ɠ 'Ɠ ] J U f Ɠ į Ɠ Ɠ + ő Ɠ Œ Ɠ Ɠ Ď VNW ĸ Ɠ ďŹ Ɠ `Ɠ + ħƓ Ü 8Đ ź BƓ ¡ Ɠ Ý Ɠ ( Ɠ

;

# ; 27 (4 - +8; %; )$5 ",*. /9; 27 60 ; 3 % :; 1 &!' ;

# Ť ż 2ż ż ż ¼ ż ż ¦ż ż ŷ µ* ż ż ż ż õ # ż ŝ ż ġż &Ÿ Wż ůB $ ż ż ż ( ż , ż ż !čĢ ŋÐ;ż # ú! ŌÑ ż §ż $ ż Ò - ż R º 8 ż ż ż = % û ż Y 4Ź J ż ż ż ż . ,ż ż ż ü ' ż ż ż ³ Ó ż % ż ż ľż J ż ōģ ż SD ż ė C xż ( żT żŎ Ô kż D ż () ż F ż8 ż B Ĥ ? ż ĕż f Õ ż ÖD ż ŏ , lgż % Ŀ ż ¨ ż Ď Ő ż × ż . ż Ė7ż ũ żK 7 , ż Ø ĥ yżH Ã ! Äż % żő U6 ż F ż & ż E 31 ŒÙ ż 3_ 4ż Ú ż Ű Ħ mż ħ nż B ť) ^Ć ż œ ż ]V "ż ż Şv 4ż Û şż - Gż ŀ # ż Ŕż % Ü ż ż ğ! ö ż 6 ż 5 Ĩ ż EÝ ż ¶ ŕ zż IÅ ż Ł # Þ ż ż b ż ż ßM łż =_ Yż `7 Âż 9 ż 0 6ż Æ /ż @ ż ©żŖ ż ż ż # ż ż * ż ż %à 5 ż ż ' ż # {ż ¡ż Ū ¢ ż ªż8 ż á ż ) ż · K ż ĩ hż â Ī ŗż ż Ę P |ż ż ī a ż ã ż 9 @ "ż ?ďż Ç ż È R ż Ċ ż ²ô ż ýF ż ä ż ż Š >ż ' ż Éż å W (ż ż Ń.<Ê < þż ę + Ě < æū£ ż + ż ě ÿ + Ŷ }ż ç¸ Ĭ ż 31 ź ż 05 ż Ë ż 31 ć ż ż ¾*ż * Z oż Đ pż ż + ńè ŘŅiż ĭŬé ż ř qż [ ż X >S$ Āż - Įš:ż ê ż « ż 2 Xż & ż ż ż Ś' "ż į \ ë ż ż ċ ż ¬ āż L Č Mż ż Q ż ż [ Aż c /ż ÌŦ ż ¿ Ĉ U >ż ż ż ; ż ż ! )ż ű ì ~ż V Ĝ9? í ż - ż ż ¹ ż ®ż ĝņ ,Í ż Ŵż Ż ] " ż Ň đ9 ż Á 4ż aÎ ż P ż Ů 7÷ż İ ż ` ż LĠ!îı ż

H - ż ż .ż E& ż Ũ& żĲ ï ¤ ż ż @\ Ų ĳ ż ) Aø ż ś ż ż A j ż ż 2ż ż ż Cż O !Ĵ ż $ &ż :ż Ï ż ( ż rż ð ż sż T ½de ż ż ż 5! $ ż ¯ż ų Z ż Ğ bĵ ż ňż ŧ ż Ăñ2 w tż ĉc "ż ´ /ż » Ē /ż " Ķ ż ă e uż 0 Nż N Ą Gż ż ż ŭ ļĽ ò ż ±1 + ż ż ¥ē ŉż ùż d ż ķż O ż ż I ż ĸ ' ĔŢż ż ż ż Ĺż ż 8 ţó ż ż ĺ ż ŜQ C ż Ŋż 0 6 ż ż ^ ż $ Ļ ż " ą ż ż ż À*ż ;.ż ż = ŵż ° :ż ż

5 -2 %0 ) '25 5 &!0 (%* )35 .4 1+ 5 / " 25 , # $ 5

ŕ ź Ū .É ! Gź &ź & Q Ê dź -Ń ź ź / WX ź H/ź 5 ź ź 6 ź ź ģ ź ń ŅË +ź rć 3 csź ź ţ ź Ì Í Ĥ ÎŤ ź ø %c ź .ź ņ: ź ź (; \ĥź e 0 ; ¸ Ė Ŗ ź 8 B |ź Ĉ ź 7 ( ź ăŗ ź ź * > Ï ċ ź * lOź ź $ ź Ð ź U ź Ħ ŇY" ź ¥źė'/ U ħ1 /ź Č ź ¹1ňź , ź t 4ùuź œ ź Ñ ź º ź ? ź ¦ź » ź < 6ź Ò ÓĘü@ }ź MP ź ź I Ô #ź ę o ¼ ; Õ ź ź f / = $F ź ź Pūe ŵ ĨÖ ! ź ý ź NZ L )g 2 - ź Ļź ½ Ŭź ³ ź $l ź ġk¡ļŉ× čØ Sź h¾ Ù ź 5 ÷ ź kĩĚēĽ ź Ú ź D ĪÛĎSź D¿¢ź öOþN~ź [ ź ě\ #ź ź 3 ź ź ź V (ź i ź Ř I ź §ź : ÿp ľź ź o * = g ĜÜ ( ź [ ź ř ź Ŷ ĿÝ Z ď ź À ź ] ^ ŀÁ ź ī Ł Þ C% ź ź Đ ź 0 ź ŚĀ ź & $ ź % ź ź , 7 ź ¨ ź % Ĭ 60ź @ ź ĭź % 3 $ź _ & Į vźm<Ĕź pź hź ť ź Ŧ ź ź iź>-ź Ąß b" Cź F Âà į0wź + ź + ź ŭL W İ q ź ,á!ź " & 'xź * M)4 ź 5 yź ź ĉ@ ź ĝ ś. ź Ċ ú ź âŊź ã ŷ A T4Ůź ä± )B ź ź 8> ź ź Ğ 0 Ŝŋå ź ı "Ō ź n` ź źĲ 7" ź . £ źæ ź ź " ? ź ç-#Gź źj ź Ã A ź 8 (m ź ź Ũ ź ź Rō ź źJ ´ ź EÄ ź ź ©ź _ ů ź èŎ ź ą%ź(* ź®ĕĳ ź a ŝ # µźH ź V é ź đź4 16 ê #ź Ű : Fź )Ĵa 2ź. A ź ë ì ¶zź , qźĵ ŏ ź ź C ź° źKűź ź K Ķ ź3 ź = ź 7 ź ªź1 Ģ)í Tź < ź ² )d ź û]ā+ ź n ŧ {ź j ź 2ĺ Ş ź «ź Y ź î ź ? Ÿ ï 2ĂŲź ų #ź ŐÅ ź ķ` ź Rź ź & Q ð $ź B¬Ź ź Ē ź ğ ^5b ź J ş ź ¯ŢEš ź fĸ őX· ź ź , E ñ +ź 'Š!!¤ł'ź ũòŒÆó-ź DÇ9ôĹź !È '9 ź 'Ġ9 õ ĆŔŴ ź

$ < 17 *4 , +8< %< *&5 #+*- .9< 2: 6/ < 3! ' ;< 0 "( ) <

ģ. ƫ ƫ ƫ e ƫ 9 ƫ ŀ ƫ "ƫ Ŝ ½ &$ I ƫ 1 %D5 ƫ ƫ 7 ƫ ( ƫ # nƫ ƫ - ƫ ƈ ƫ 7 ƫ ƫ Łƫ ƫ ( ƫ A łƫ ŃŞƫ ¾ƫ ƫ OL .- ƫ şƫ !oƫ ƫ Ò ƫ ƫ 3 ƫ ä ƫ ? ƫ !/Ê ƫ Í ƫ ƫ "ƫ 4 ƫ = Šƫ "ƫ ) ƫ ń #%® ƫ b Ï 9~ƫ å ƫ , ƫ šƫ Ĥ ƫ ; Ņæ8+ƫ ; ƫ ƫ Ë% Fƫ űƫ çAƫ ƫ ƫ ƫ !ƫ ƫ Ţ c ƫ ƫ 3 ƫ ´ƫ Ɖ ē ƫ ƝĔƊ * ƫ ƫ Ų ƫ 8 ¯ƫ % @ƫ ų ƫ ņ #ƫ ƫ 4 ƫ `èE ƫ Ć ƫ ]"ƫ ĺ !+ 9é,ƫ +1Ó h Ô ƫ ĶŇƫ Ŵ ƫ Õ ƫ Mfĕ z êĞµƫ ĻƋňţƌëBƫ ¿ƫ ì^ ķSí I ĖƠƫ ŉî ƫ 9/¡ƫ ¢)% Ŋ ƫ ƫ WKY ƫ Àƫ 3 ƫ ƫ g ƫ 6 ƫ ï ĥ ƫ ƣ a X Gƫ 3 ƫ / . ƫ 6 ƫ R. ŋƫ £ ļċ% ƫ ƍ ƫ ƫ ' Ƥ ƫ Áƫ Ō ð?$ ƫ ƫ ƫ ė - ƫ Qć ƫ ñŵ)ƫ Ö ƫ ƥ , >ò { +¤( $ ƫ $ ƫ ƫ ƫğ ƫ ƫ ƫ "ƫ ) ƫ ÈƗ =| ƫ OL ƫ H 6 ƫ ƫ 8 ƫ ƫ T #ƫ Ŷ ƫ ŷƫ = ƫ ō ƫ ƫÎ ƫ Ŏ% Čƫ P Ę pƫ Ǝ ƫ 8 ƫ * ƫ × ƫ ŏ ƫ É 0ƫ ó "0ƫ Ħ ƫ ƫ ƞ ƫ ƫ ( ƫ b %Ʀ ƫ Ə ƫ ƫ & ƫ qƫ ƫ Ÿƫ "ƫ B ƫ @ 7 &rƫ Ɛ# ę- ƫ Ø ƫ č ƫ sƫ <' QĈ ƫ ô ƫ 4 ƫ / ƫ tƫ ƪ ) ƫ Ƒ * Fƫ ħ ƫ <* Ź ƫ õ¥ uƫ Ùö ƫ ƫ Ú ƫ l M Ĩ Ő ƫ $Ð)Ď ƫ ! 'mƫ . ƫ E Ťƫ c ƫ ƫ ƫ ĉ Tź NƫA) ƫ ƫRfĚ } ÷ ƫ Æ vƫ , Ŀƒ ě ƫ P¼ 5ZSƫ ƫ1^ ÌV1Ż g ƫ ĩ U,ƫ , ƫ Nƫ i ƫ ƫ Âƫ ( ƫ ƚ ő ƫ h # Ĝ* #ƫ a øĪ ƫ ƫ īƫ Œ ƫ Yƫ ť ¦ ƫ ƫ ƫ Ƨ 5Ĭ ĭżƫ ŽÛ¶Ġ;ƫ _"ƫ ĽŦơ§Ü5 Bœ+ƫ Z°ƫ Ý·Įƫ @¸ŧù ¹įžŨƫ ƛÞ_ƫ ±ú²ƫ İĸ ľďJıƫ ¨ Ŕ ºŕũƫ ſßJƀƫ © ĲƁ Ŗ 'ƫ Ɠ: ƫ UCƫ ƫ *û !ƫ Ūƫ Eü [ ƇCý .! #ƫ ( ƫ ƫ :: : Gƫ ŗƫ Cƫ d ƫ ª ġ 0ƫ þĳƫ $& ƫ ƫ K ƫ? ƫ ƫ ÿ ƫ ƫ H &jƫ /ƂƔ ū > ƫ ƫ ƫ Ř !ƫ ƫ ƫ ƫ $ ƫ \ƫ ƕ Ƙ + ƫ Ãƫ Đ ƫ à * ƫ &ƃ ƫ 4 ƫ X ƫ ŝ Ɩ 'ƫ Ƣƫ Ĵ ƫ Ɵ Ā ā Ñƫ »ƫ ' > 'ƫ ÇĹřƫ Ƅá2 ƫŬ2ŚƙĂ«2ŭ ƅƫ â ƫ ã ƫ ¬V 0ƫ ƫ ƫ ś - D ƫ ! ƫ ƫ 7ĵƨ W ƫ Äƫ ă `Ą ƫ Ģ ƫ ƫ ( ƫ ƫ Ů 6 đ$ & ą#ƫ -ĝƫ Ċ[ ƫ \ƫ <2Åwƫ ƫ ³ k ƫ dƫ "ƫ ů ]Ʃ ƫ Ɯ ƫ & e xƫ +ƫ ƫ Ɔ Ű ĒD yƫ ƫ ƫ

PROPOSALS FOR THE FUTURE

Functions of Psychotherapy Training In view of the changes that have been discussed here, what is the future role of training in psychotherapy for residents? There are those who advocate abandoning all such training (Detre & Weinberger, 1985; Kroll, 1986). Psychotherapy, they say, should be left to the nonmedical disciplines, such as psychology and social work, while psychiatry should be restricted to its "biological" compass. At the other extreme, some advocate extensive training in psychotherapy as the keystone of psychiatry for all residents. To delineate more clearly just where psychotherapy training should fit into future residency training, we must examine what functions are performed by this training. Psychotherapy training here refers primarily to supervi sion in the conduct of psychotherapy, along with seminars that are designed to explore the theoretical bases of the clinical activities. Such supervision and instruction can be separated from the teaching of psychodynamics and psy chopathology as basic sciences, these being analogous to physiology and pathology in medical training. They are obviously both prerequisites for training in psychotherapy, but they may be taught to a limited extent without teaching psychotherapy. (To what extent this is feasible without clin ical exposure is a matter to which we will return.) With this in mind, we can identify at least three functions

5 ,2 #/ ( &35 5 $!0 '%) (25 -4 1* 5 . 25 + " 5

Ƨ Ƨ +T ÁƧ $ Ƨ ŭ, Įį)Ƨ Ƨ O Ů Ƨ g vƧ Ƨ ůƧ Ƨ Ě şƧ $ Ƨ Ƨ Ƨ Ƨ Ƨ D ! ) Ƨ å Ƨ -×W wƧ Ƨ ŰÞ Ƨ æŠƧ Â Ň ®] Ƨ ľƧ ¯ ³ĿİçcØƧ Ƨ N èNé )Ƨ š ´ (ß FƢ fê KƧ . xƧ Ƨ " Ƨ 7 ë ő Ƨ Ţì cű Ƨ :&" Ƨ 3 %ŀ Ƨ ƣ Œ íţ KƧ 8Ƨ Ƨ D Ĩ#Ƨ Ƨ - R œ Ų Ƨ 5 Ƨ Ƨ :C Ƨ îŤ Ŕ Ƨ ňğ Ƨ + Ƨ = pƧT Ƨ Ƨ ŉ ï ĠƧ µ \O Ƨ Ƨ Ƨ ı R ųð Ƨ ËƧ /+ yƧ . Ƨ Ƨ Eà¡i ( ŕ ƞƧ Ƨ $ Ɣ ŖƧ Ĳ 0Ö 4 Ƨ Ƨ ƛ Ŋ" Ƨ ! - Ƨ 3 Ƨ Ŵ Ƨ ° ġƤ 1 Ƨ ŵ Ƨ ŗ¶ ñƕ?Ƨ Ŷá¢ Ƨ £Ƨ ·Uòơ Uh?Ķó¸Ƨ ŋ¤ ôÆ' Ƨ ĳ¥ƟƧ ť 2Ƨ ¦ěõ'ÙƧ _ ö¹M ÷ 'Ƨ ø'Ƨ @ 7 Ƨ ŁƧ Ì #Ƨ Ƨ 6 -Ģ ` Ƨ GƧ *ķƧ Ƨ Ƈ ` Ƨ ( Ƨ 3 Ƨ G J Ƨ Ƨ Ƨ A #2 "Ƨ !* Ƨ & Ƨ 5ƌ+ I §dlƧ zƧ d Ƨ â Ƨ Ĝ !" Ú Ƨ Ƨ , 4 ŷƧ A Ƨ ¨Ƨ Ÿ ŹƧ Ĵ Ƨ F Ƨb Ř Ƨ Ƨ Ƨ Ƨ )ř Ƨ Ƨq B 1 rƧ± ù ŚƧ Ƨ Ƨ 8 F{Ƨ $ P 9 Ƨ úźƧ Õ , Ƨ + Ƨ E I Ƨ ( Ƨ û Y Ƨ ƙüŻ Ƨ ż Ƨ Žã ś ý ;Ƨ º 'Ã|Ƨ lV Ƨ Ŝ Ƨ ł Ƨ » A H Ƨ & # Ƨ < Ƨ M Ƨ Ƨ oþ Ƨ ] ² , ipƧ ÓŅŝƧ Ƨ ŎIZ žÿ Ƨ ÍƧ ## Ƨ ĝ :ģ Ƨ Ƨ Ƨ Ƨ ſ <WƧ Ō & Ƨ !* - Ƨ2 ¼ - 0½Ƨ ?Ɯ GĀ ' Ƨ Ƨ ŏJ ĤÇ Ƨ Ƨ eƧ ƈ 2 Ƨ m Ƨ ( % Ƨ ƍ Ƨ Ƨ :ā V Ǝ Ƨ % Ă Ƨ Ƨ Ƨ 3/Ƨ fä 5 ĵ@ Ƨ Ƨ Ƨ 7 Ə }Ƨ $. Ƨ Ƨ ¾ Ƨ Ƨ e Ƨ ƝE găÈ Q Ƨ ( Ƨ ÔņjƧ &a Ƨ X ĥƧ Û = ĦƧ Ő9[ b 8 Ƨ Ą+ ~Ƨ m 1ĸY Ƨ X Ƨ # %B / Ƨ S« ą 8 Ƨ Ƨ Ƨ ÎƧ ƀZƥ Ɛ Ƨ Ŧ Ƨ ƁĆ 9 Ƨ C ĩƑ Ƨ Ƨ >ćĹÉ Ƨ Ƃ Ƨ ' Ƨ Ƨ " Ƨ ŧō ¿ ŨƧ ŃÏƧ Ĉĺ>ĉƖĊÄJ a . 1 ċ Ƨ $ B 4 Ƨ [Ļ%^ƒÅ4 ÜƧÀ Ƨ Ƨ !ÊĪīƧ ńƗ kn Ƨ 2 k ėļ)ƓČ nč Ƨ Ƨ Ğ* 1=Ƨ Ƨ ! ĬƧ Ƨ .Ď ƃĘ Ƨ & ũ& Ƨ ,Ƨ Ş ƉƧ j " o 5%ď Ƨ ©ŪƧ ! ĭ^Ƨ H Ƙ ƊƧ P Ƌ LƧ / Ƨ Ƨ Ƨ Ƨ Ľę9 Ƨ \ . Ƨ Ƅ * Ƨ sª% Đ tƧ _ ( 0 Ƨ ħ0 Ƨ 6 Ƨ $7@ Ʀ * 6Ƨ đ Ƨ Ƨ S¬< Ƨ ÐƧ Ƨ ƚĒ Ƨ h ) Ƨ ÑƧÒ C ÝūƧ ē Ƨ Ĕ ; LƧ , Ƨ Ƨ ƠƧ uŬƧ !6Ƨ D >Ƨ " H/ Ƨ Ƨ #ĕƅ0 Ƨ ĖQƧ Ɔ ;

kc -ū ½ ū ! ū ¾ ū P ū ū C ū Ĺ ť Ŗ ¿ ū ū s , ū BKĔū } ŗÀ Od le -ū ū ū Á ĕū ū + ĺ ū ū þ W Ļ ¢ . ū ŏ !, ū =" ū $ ī# "% ū ÿ ū tū ! ħ (ļ ū u Yū Ė ė Ĭū ū ū Ľ® Ę ŐľÂ4ū Ŧ î6Ŀ ū f mg -ū + Ã ū ū ū ū ū ū ū ū $ Ä D ū ū ~ % E? ū ŝŀZū ĭ ū 2¨ + «ū Ł ū ū ÷ ŘÅ P ū Æ&¯ 2 ū ," ő ū Ĩ ÇĮ ū £ū (ŧ Ā hū -8ł ū A| Èï ū ū ū 0ċ ū ( IF ū ū & ū ū G 4 ū U ū ū # 0 ū > ū ū ; G ū ęį [ū ā ū ð ū (& ū . 6 ū ū ! ū ř ñ ū ū / ū # ! I'X ū ŒR ū ū Ş òÉ ū )Ă ū Ń°ū İ ū Ê 3 nË 8 \ū BK ū ū M 1 <ū / ū ş# Ì ū ū " ū % Ũ ± Ě ū D ū ū F 'ū Ś 'ū Íăū ń C ū ı Î Ą ū Ĳ ũ . ó ţ &Ï ū v ū # Ð ěÑ ]ū ū , ū Ņ ū ū ū ² 'ū 1 Ū ņ ū ū ś $ū Ò ū ū Ó Ē " ū ôÔŤÕ ū Š Ö . ū ¦ĐĜū û × ū œ ū Ø ! ū E 3ū

" " "

!" "

o9ū Ù%ū H Nū :³= ū ČŇ ) šū ū ū ū ĳ ūV ū ´Ú :+ <ū *Ŕňū N $ū Û ū ū Üw 9Ţū Ý ū ū *ĩ ĝū © H iū p&ū ū Ĵ ū ø )Ğ^ū 9 "_ū µ):ū xū ğ ĵ 5ąŉū ū J Ķ@ķū Ŋčū Ďü@ū

'( ( " ( ' # !$( & ( % ( (

'O 7 7 ¬ū Þ ū ū é7 ù ū ū ¶ ū · ū Ć ū ;¸ ū ū ćďQū %Jū % jū q¹ ū y ū ū º `ū V S Ġaū S ū T + ū ß ū ' ū >ū AĪ ; ġêū àR ū /14 ū ū Ģū ū Ĉū &ū ĉ ū L ūT?8ŕ ūë ū ū ì bū *2!ū ū0 ģ ū zū ¡ ū ū ŋ , ū )$ ū §đ ū ū ª 1 ū ū ý Ċ ū $5 ū ¤ū »á 3ū r ū í U ū L2 Ĥ ū * ū ū ēĸ / M 5( â ú ū Qĥ ū ã ä { ū # ¼å 6 ū * ū ū 0 Ŝ õ ö ū è( ū Ō ū ō ū æŎ ū ¥ū ç Ħ ū

7 -3 $0 , '47 7 %!1 (&) *57 .6 2+ 7 / " 57 + ! # 7

Ķ Ʈ K Ʈ * ýƮ % !Ë ] Ʈ .ĚG 7> Â ť HƮ Ʈ ķ . iƮ Ì3Ʈ Ƅƅ Ʈ ) Ʈ ? Ʈ ĸƮ# Ʈ ) yƮ Ʈ ! ] jƮ 5©Ʈ #3 :! , +ƋŦ ĈY Ʈ Ʈ ( 'Ʈ , Ʈ Ʈ ƙ ƪ ? Ʈ Ʈ Ʈ ( ĹÍ Ʈ $ Ʈ 8 Ʈ ĺ kƮ Ʈ ŧƮ 6 Ʈ ĻƮ Ř Ʈ - Ʈ Ʈ Ĳ$ ÷ Î 9Ʈ "» 0 Ʈ 9Ʈ Ʈ 1 1Ʈ Ʈ Ʈ A Ʈ Ʈ Ã Ʈ Ï ƝƮ °Ʈ Ũ Ʈ ^ £zƮ U Ʈ Ð&Ʈ ũŕƕ Ʈ S Ä ļƮ Ʈ ĽƮ ř Ʈ Ʈ Ʈ ĉ Ñ;TL/JƮ ľ ; lƮ Ś Ŀ ŀIƮ ŁƮ b; ł{Ʈ ƞ Ʈ ºŗ Ʈ '!Ò Ʈ # Ū mƮ Ʈ ĳ8 Ó Ʈ QƮ', Ʈ À $0 Ʈ Ń ªƮ ±Ʈ Ô " Ʈ Õ Ʈ ĬśƤ 1ĩ`1«Ŗ ĭƥƮ ½ńƮ Ņ¬_Ö¤+ěūŜƮ ×_Ʈ ĜĪŬƮ /Ʈ < + * ø )Ʈ ĝ+Ʈ ²Ʈ Ɵ! ŭ! Ʈ ņƮ Ʈ ƌ 5Ʈ Ů LØ/Ù\ Ʈ .ŝƮ #% ƫ # nƮ ƍ Ʈ Ʈ % = Ú Ʈ Ʈ ³Ʈ Ʈ Z4 -Ʈ # ( > Ň Ʈ ň ÛĞ Ʈ Ü Ʈ Ĵ8< Ʈ ' Ʈ " -Ʈ +Ʈ 3Ý Ʈ ¥b )Ʈ C Ʈ ¹ī Ʈ Ʈ "O Ʈ Ʈ B Ʈ Ʈ < Ʈ Ʈ Ʈ Ē Ʈ Ʈ Þ Ʈ f( ů " |Ʈ Ʈ ŉƮ Ʈ ' A Ʈ ĵƎ 'A Ʈ Ʈ ) Ʈ Z Ʈ Å Ə 6Ʈ ơ2 ß }Ʈ à Ʈ N$( Ű 0 oƮ 6 G DpƮ 8 Ʈ 'á 4" Ʈ Ʈ Ʈ Ʈ Ʈ Ʈ Ɔ 4O" XƮ Ʈ RƮ 2 űS # Ʈ >0 â\ Ʈ Ʈ 5 Ʈ ğ ŊƮ g WùĊċx D ã hƮ ) Ʈ , Ʈ , DVƩ Ʈ $ 4* Ʈ Ʈ' Ʈ> ĠƮRƘƇƖ ƮĮ - ! qƮ Ʈ , Ʈ %2 %ŋ Ʈ ; Ō Ʈ ƦƮ Ʈ þ Ʈ Ʈ ƚ 4 Ų Ʈ ƛ 0ä Ʈ Ʈ #^ Ƭ [3~Ʈ K Ʈ ¡ ē *< Ʈ '!Ʈ Ʈ ´Ʈ ÿ rƮ ųƮ Ʈ [ Ʈ Ʈ 6 Ʈ ƮF Ʈ NƮ&8 å& Ʈ &f - ō Ʈ Ʈ Ƣ æ Ʈ # ?! Ŏ # Ʈ 1 Ʈ Ʈ Ʈ Ʈ Ā Ʈ ƮU Ɨ(ŴƮ Ʈ& ( ¸û Ʈ üúC sƮ $ŵƮ Ŷ Ʈ ŷ Ʈ Ʈ Ÿ ġƮ QƮW ā Ʈ Ʈ Ź Ʈ ƈaçac¦+7Ʈ §èŞ Ɛ77@ Ʈ M d Ʈ ƉƮ é7Ʈ Æ¯)įÁĂtƮ ƠÇ/+d@ Ʈ İ şŠ *@uƮ ¾ Ʈ Ƒ P &Ʈ Ʈ š Ʈ Ţ ( ź 2 Ʈ = X Ʈ 1 ŻƮ Ʈ / Ʈ e ČƒE Ɯ * Ʈ %ţ :- =.:IƮ vƮ È . 0 ăHƮ ƣê ` Ģ T *JƮ Ʈ Ʈ 0 Ʈ ŏ 9Ʈ ë Ʈ Ʈ Ʈ Ʈ µƮ ż, Ʈ Ĕĕ Žì® Ʈ & ƊƮ í Ʈ čƮ ¿ Ė Ʈ ¶Ʈ ı&Ƨ ÉP Ʈ Ʈ Ą ħ Ʈ ž Ʈ ģ Ʈ 9 6 9 " Ʈ 4 " Ʈ ſ Ʈ Ʈ Ʈ FÊ Ʈ Ő ƀî Ʈ Ʈ ¨ Ʈ Ʈ $ Ʈ Ĥ ėï Ď Ʈ Ɠ ¢ ĥ& ð Ɣ Ʈ 3Ʈ B Ʈ ñ Ʈ ò Ʈ B ď* wƮ Ʈ % Ę" Đ Ʈ Ĩ? Ʈ Ʈ $ Ʈ e%ąó V đ Ʈ $ ő Ɓ Ʈ / Ʈ Ʈ Ć Ʈ Ʈ $ . F Ʈ Ʈ ¼ Œ ŤƮ Ʈ )CƮ Ʈ Ƃ Ʈ Y . EƮ M= Ħ Ʈ ƃ5 Ʈ G œô c3Ʈ ćõ ö Ʈ ·Ʈ 2 ! / ę :Ʈ 2E 5 ƭ - Ŕ %ƨ Ʈ

! 7 .4 &1 * (47 "7 '#2 )&+ +57 /6 3, 7 0 $ 47 - % $ 7

8 5 Ə ń w Ə Ə 5Ə dd Ə Ə 9 Ə ºƉ $ Ə ß/Ə )L4 Ə Úv ř Ə &Ə ) :^ q-4 TƏ 2 Ś Ə : Ə 8 Ə Ə ś Ə )- »>ċ Ə ŉ ¼ M, Ĵ Ə Ə Ə ®č ĵƏ N, Ĝ"Ə ÑƏ M, _ĶƏ ¯/ $ŊƏ Ə ã ŋ Ə ?, Ə ķ ×Ð è Ə . ŌƏ 8é55Ə z Ə > $Ə Ŝ Ə ÒƏ ō 3] ĸ Ə ¡Ə n Ə Ņ Ű Ə Ə Ə B 4 Ə 3 Ə &Ə { ^ Ə ' Ə Ə % Ə ! ĳPê t@Ə §% < Ə Q Ə ű rë Ə Ŏ R Ə+ ìĠƏíġƏ e Èî½°ďƏŏ Ə $Ə ż Ə+ àk" Ə 8ïsäƏ vH Ə Ə Ĺ Ə (Ə 9 Đ 3 đƏ . 6 Ə±( ƏÛźĢ¾ #= Ə ¦ ? Ž ĺ Ə ð Ə 0 Ə Ď# Ə &Ə Ɓ Ő ! Ə Ə ¿: D Ə -ñ ' Ē Ə ' Ə 2 Ə ģ Ə E Ə p R> Ə ò Ə f ' ;Ə h Ə Ə H 3ƅƏ À ! ó 6 Ə ŝƏ * Ļ Ə [ň Ə / Á Ə ¢ ļ Ų Ə ƂƊ h 04 Ə ų , %Ə ' Ə < ( Ə t $F Ə Ə Ù$ Ə á Ə F L { ô cƏ 7 Ə # Ə ő L Ə V Ə N_ Ə Ş Ə ĤƏ H z %Ə %Ə Œ Ə - ş Ə ÓƏ XēƏ . 6 ĝ qƏ X %Ə ÜŻ # 747 UƏ 7Ə Ëâ! Ə ƃG Ə &Ə # Ə Ƌ Š Ə R sƏ ¸ Ə P C Ə £ ž Ə &Ə Ľõ . Ə Ə ( UƏ Ə S c#Þ Ə+ Ə¤«ª WVWƏ šö Ə * !D Ə Ə Ý ÷ =*Ə Ə 3jŴ # 0Ə * Ə ø Ə 8 Ə : Ə K Âå Ɔĥ Ə Ô OŹ! œƏ N, Ə ] ľ 0 ùƈ Ə Ə . / ŵ Ə =| l Ə ¥ rú Ə Ħ - Ə Q %Ə 2 Ə ī Ə B Ə ė ` 5 S Ə į/ Õ + Ə ûĘ Ŷ *Ŀ 0Y Ə + Ə 9YŀƏ Ĕ . Ə ü( x# ? Ə $Ə x ŢA ƏŁ I D @Ə Ə Ə - Ə) ę6 Ə | Ǝ"JJ²łyƏţiƏa ŷ 1Ť"Ə} ĬŃE1;~Ə¹"æ1ſa mƏ É"ƀ";iİE" ť1 ƏJŦ1\"ŔT % ' ' ' ³ŕƏ # ' ' ! ' $' " & Ə ¬ Ì # <Ə Ə 9 ĕ Ə B Ə ) ' Ə Ə O Ə ) Ə & Ə ç - Ə ŧ ƏŨ Ə ( $ ýħ Ə ÖƏ ( þ f Ėÿ Ə &Ə Ŗ Ā ā Ə ! A> 0 Ə 2 ũ,Ə 2 ; ' Ə Ə + ƌ . Ə ŗƏ ? Ě Ə Ə * Ə k Ə ın ŘƏ ´ %Ə Ă OI Ūă @Ə ¨* b Ə j < Ə ūƏ Ə S)6 !ÍƏ Ğ ÃƏ[· ! Ə / u b Ə Ƈ µFĄ Ə *! ŬğÎ=uƏ ČŭąÏKƏ Z Ə ņgĆg Ə ZĭI Ə l Ə G $ ć Ə ©ĨƏ ¶Ə Ä o Ə ÅPpmĈÆQ e Ə Ƅ o` Ə CƏ MŇ ĉĩ Ī\Ə Ə Êyƍ 7A ĊÇ ě Ə ' ØĮ Ə KŸ)G !Ů w Ə ů Ĳ Ə (CƏ + &

Teaching Psychotherapy in Contemporary Psychiatric Residency Training

grounds. For example, in order to evaluate the suicidal risk, residents need to experience and learn the dynamic differ ences between the depressed obsessional character with su icidal rumination, the depressed hysterical personality dis order with threats of self-destructive behavior, and the depressed borderline patient with a pattern of impulsive self-mutilation. Supervision should be ongoing over a suf ficient period to permit experiences of therapeutic move ment in the various phases of the therapy. 6. Seminar instructors-and supervisors-should include experienced and psychodynamically oriented clinicians com fortable with various modalities of psychodynamic therapy, rather than narrowly based. In addition, practitioners of nondynamic modalities might participate in "interdiscipli nary workshops," exploring cross-applications of principles. As an example of fruitful collaboration, in one department with equally strong biologic and psychotherapeutic orien tations, the director of psychopharmacology and his assisting staff are also each practicing psychotherapists. In weekly psychopharmacology seminars with residents, the history and dynamics of a case are first reviewed, prior to consideration of drug management. The appropriate psychotherapy su pervisor is invited to attend the psychopharmacology sem inar to provide clinical input and to participate in decisions about the use of psychoactive medication. This informal context for interaction provides an excellent model of the complementarity of psychotherapeutic and biological ap proaches to patient treatment and indicates to residents the relevance of psychotherapy to clinical practice, even from the biological perspective. 7. Planning meetings of participating faculty are ex tremely desirable, to enable integration of teaching and minimize unnecessary repetition or parochial focus. For instance, in one biologically oriented department with a strong clinical psychotherapeutic faculty, many of the full time faculty may harbor an antipsychotherapeutic bias or

Proposals for the Future

skepticism that gets transmitted to residents in didactic or research meetings. Regularly scheduled meetings of both full- and part-time teaching faculty (including the clinical psychotherapy supervisors) allow these biases to be discussed in face-to-face dialogue in the presence of the training director, with guidelines for psychotherapy teaching clearly spelled out. Such direct encounters may limit the deleterious effect of such biases and allow a more truly integrated teaching program. The faculty must maintain a clear sense of the goals of such a core curriculum in order to prepare the resident to be a better psychiatrist, whatever his or her career direction might be, rather than to train him or her to be a skilled psychotherapist. Alternate career choices, e.g., psychophar macology, research, or administration, must be fully re spected and the program geared to enhancing these sub specialty skills through the content and attitudinal education discussed above, as well as through appropriate elective tracks. Only by respecting the complexity and pluralism of modern psychiatry and neither exalting nor depreciating psychodynamics and psychotherapy will the increasing po larization within our field be reversed and the values of psychodynamic sensitivity, as well as psychotherapy, enrich all of psychiatry.

Teaching Psychotherapy in Contemporary Psychiatric Residency Training

Rothman, D. (1979). Conscience and Convenienre. Boston: Little, Brown. Sachs, D., & Shapiro, S. (1976). On parallel processes in therapy and teaching. PsJchoanal. Q., XLV, 394-415. Schuster, D., Sandt, J., & Thaler, 0. (1972). Clinical Supm!ision of the Psychiatric Resident. New York: Brunner/Maze!. Smith, M., Glass, G., & Miller, T. (1980). The Benefits of PsyclwtherapJ. Baltimore and London: Johns Hopkins University Press. Somers, A. R. (1977). Accountability, public policy, and psychiatry. Am. j. Psychiatry, 134, 959-965. Strupp, H. H., & Binder, J. L. (1984). Psychotherap)' i,� a New Key: A Guide lo Time-Limited Dynamic PsychothernfJJ. New York: Basic Books. Thompson, M. (1979). A Resident's Guide to Psychiatric Edurntion. New York: Plenum. Yager, J. (1974). A survival guide for psychiatric residents. Arch. Gen. Psychiatry, 30, 494-499. Zaro, J., Barach, R., Nedelman, D. J., & Dreiblatt, I. (I 977). A Guide for Beginning P;ychotherapists. New York: Cambridge University Press.

GAP COMMITTEES AND MEMBERSHIP

COMMITTEF ON ADOLESCENCE

Silvio J. Onesti, Jr., Belmont, Mass., Chairperson Ian A. Canino, New York, N.Y. Warren J. Gadpaille, Denver, Colo. Michael G. Kalogerakis, New York, N.Y. Clarice J. Kestenbaum, New York, N.Y. COMM!Tri::F. ON AGING

Gene D. Cohen, Rockville, Md., Chairperson Eric D. Caine, Rochester, N.Y. Charles M. Gaitz, Houston , Tex. Gabe J. Maletta, Minneapolis, Minn. Robert J. Nathan, Philadelphia, Pa. George H. Pollock, Chicago, Ill. Kenneth M. Sakauye, Chicago, Ill. Charles A. Shamoian, White Plains, N.Y. F. Conyers Thompson, Jr., Atlanta, Ga.

Paul L. Adams, Galveston, Tex. James M. Bell, Canaan, N.Y. Harlow Donald Dunton , New York, N.Y. Joseph Fischhoff, Detroit, Mich. J oseph M. Green, Madison, Wis. John F. McDermott, Jr., Honolulu, Hawaii John Schowalter, New Haven, Conn. Peter E. Tanguay, Los Angeles, Calif. Lenore F.C. Terr, San Francisco, Calif. Co:1-1MJTTF.E 0:--1 COLLF.GF.

STUDENTS

Kent E. Robinson, Towson, Md., Chairperson Robert L. Arnstein , Hamden, Conn. Varda Backus, La Jolla, Calif. Harrison P. Eddv . , New York, N.Y. Myron B. Liptzin, Chapel Hill, N.C. Malkah Tolpin Notman, Brook.line, Mass. Gloria C. Onque, Pittsburgh, Pa. Elizabeth Aub Reid, Cambridge, Mass. Earle Silber, Chevy Chase, Md. Tom G. Stauffer, White Plains, N.Y.

COM:1-llTTEEON CHILO PSYCHIATRY

Theodore Shapiro, New York, N.Y. Chairperson

# 9 16 )4 , *79 $9 )%4 "+)- .69 26 5/ 9 3 & 89 0 '!( 9

> ˑˢ Į K˝·ˢ ł ²ˢ Ħ ¯ Ȕ ˢ ȴ ˢ > Ȏ §ˢ ! ˢ į(Ǖ ʝ ˢ ŃDˋˢ @ɔ 8¸ˢ ĳ ðˢ ?ʞ34Ǽ Ÿˢ |:ˢ İ)ˀƿ¹ˢ ǖ Ɠ% Źʟ_lˢ @Ǉ ˢ ˢ y ˢ Ĵ ° 'ɽȵ ºˢ şʱ#+ ȕ ˢ !ɕ%˞Mˢ ʲ Gˢ A ˢ ĵ%[˟»ˢ . ȶ1ƌ¡ǗƞǀƦ¼ˢ =ȷȖ ˢ Ŋɖ $ ˢ u ˢ {% 3ʠƼɈ ʡ½ˢ Ē ɾ ȗ¾ˢ źɿʀñˢ ` 1ˢ òˢ Ķ ʳ)a ¿ˢ Ėǈ ˁkˢ * Àˢ Oˢ ń ɗ5 (ˢ Ļtˢ TȸʴˎÁˢ W e ʁ± & mˢ " ˢ zȹ] ˢ ˢ | ƔķƧ 9ˢ ƕ « ˢ @^cȺˢ ĸ ˢ ľ ȻjÂˢ ō3 1ƨIɊE ŻÃˢ V sˢ 3 h& ʂˢ ˢ ǽȼ Äˢ Ǿ ° I ȘƟnˢ @] Ƚˢ ŎƩJ ɘˢ !óˢ X Kb Åˢ U ǲ ˢ ?¢c Æˢ Z3ôˢ !ǳ ˢ ż88 (Çˢ Ž C ¦k Èˢ j D ˢ RH ˢ !õˢ ŷċ T Y oˢ . *Kg JÉˢ 6ș ˢ ˂a ˢ Ț ,ˢ ħ ®8KȾțoˢ Š ˏ ˢ ˒ˢ ˃ūöˢ Ŀ )Êˢ š ɋ rˢ ı Ȝʃ ˢ )˓ˢ Ĝ ˢ əƖ )Ëˢ Ņ˔ ƗǴ-ˢ ņMŰsˢ Ě £ƪǵˢ ǘe 27Ìˢ ė #/ -ˢ ī ȋćˢ Ĭ i ɌEˢ ˢ ~ȿiGɍ ʢˠÍˢ . ¨ Ǚ ȝÎˢ x Ęǉžɚǿƫʄˢ ÷ˢ ŋ¶ēɛ ƬfÏˢ ŏǊ ȀſƠƭȁɎǋǚƀÐˢ ˢ < ɜȞ0ɝ1ˢ Ĺ;ˢ Ő ƘƮI Ñˢ ŇƯ³ˢ ű Ƕpˢ øŲ ˢ Ĩ ɞƍ ɻ ˢ £[ ʅÒˢ }ư²ˢ ųɀɟǷÓˢ ňNŴùˢ ŉ h5 ˢ ļ ˢ ő ʵȂ ˢ U ´_ LɁȟÔˢ Yʆʇ ˢ ɠ¯Ǜ ˢ ĝQˢ ŒƱ ǸǜȠ+ ˢ ȃ 59ˢ ˢ Ĕ LL˕ˢ " ƽD7 Ɓʶ5Õˢ ĩ ʷ*ʯ '9ˢ Ţ ː ˢ ęǌ0ɼ 8ˢ čNˢ œǝ 1 ɡǍʸǁǎ ʈÖˢ < C ɉɢC×ˢ 0ʉʊ ˢ

ěY˄4 ˢ ~:ˢ /ʣ ± ƲØˢ < ʤ^ +ơ/-ˢ Cúˢ ů ɂȡƂȄ ˢ Ƀ©©Ùˢ =% Z Ȣ B 4 ? Ǟ U §L ɣˢ ĪOˢ ®Ƣ˖Úˢ wǏ_Zƃ ˢ yȌHĈˢ Ĥ ɤǂ ˢ Ğ ˢ ʹƾÛˢ "Gǟ ɏ Ǡ qˢ ˢ ˅ǡ ˢ ˢ ŘƄ'$ ª ˢ {6ªˢ !ȣ Ƹ&\¨ ˢ IǱƻQˢ ȅ$ˢ ƙF ɥµ-ˢ v7 Ʉǹ&˗ -ˢ }Oŵ ˢ Ĳʺɦʥˢ Ċûˢ #Fd ʋǢ ǃ ¤Üˢ řƅȤˢ Ġ¡0'ƚǣ+ Ýˢ wB b ;ˢ ^ ɧH ʌˢ ǐ ʍʎÞˢ ŔǑ4H &g]4 ,ˢ ŕ üˢ bȆ ʏˢ ġ ˢ Śǒ ɨ2 ˢ S ʐ¬ ȥ ˢ 0ʑʒýˢ RȇƎ ɩJˢ śǤ ˆ 7ȏƆ ßˢ Ȧȧˢ ɪ 6ɫ ˢ ` E ˢ < ʓ Ȩˢ Pˢ W ˘$ àˢ XȐƏ¥ǥ Dáˢ ʔ+Pˢ ˇaƣˢ ĎMˢ W ʕǺǦ* ˢ u Bˢ ˙ȩˌk ,ˢ " ˢ zƳ (Ȫ ˢ gʻɬȈ # qˢ . ʖ ǧ ʦ ( ˢ Q=ĉ vɭ $ʧˢ Ģþˢ Ŝʨ2 mˢ ˈ ɮâˢ Ʌe ÿˢ ȉ/ ˢ ďĀˢ ŝʩɆ lˢ /ȑƐɯǨ$ ƴ ˢ iʗāˢ Ƒ 7 ˢ ğ ˢ ³`ʪˡ ɰãˢ ʼffˢ T ǩ ,ˢ Ŭ ;ˢ Ŗ2 ˚ˢ = ˢ ţB ǻǪȫ äˢ x +åˢ Ť2´ ˢ Sɱ˛# ˢ ť\Ȓɐ ʫ æˢ "Fǫ [ ȊɑFǬ nˢ " Nˢ ŗɲ ʘƛ «ʰˢ A;ˢ Ŧ ȓɒ* Ȭçˢ S Ƈˉ ɳ¬ɇ rˢ ŌɴƵǄĂˢ > ˢ V ˢ ŧʽɓ (èˢ )Ƌ5 ʬ éˢ &ǭ ˢ >6Gȭˢ Đ ˢ Ũʾ¤ ɵêˢ ŞƈȮˢ ģɶ ƜǮʙƝ Čˢ d ƹ:ˢ ĥ ˢ Ľtˢ Ū* c ëˢ jˢ ?¥ȍ\ 'ʚìˢ ĺƉ:ˢ Ŷŭ ¢¦ ˢ ũPˢ Xʿ E pˢĭɷă,ˢ V ɸJ ˢ Ů d ˜íˢ %ƺ ˢ đ'Ƥh ˍˢ Ąˢ . ʛ ˢ RȯȰˢ ɹƒ6ɺ9ˢ ŀǯ#Ǔąˢ ĕ ˊƊȱʭˢ ŁĆˢ AƶƥǅƷîˢ A ʜǔǰȲǆʮ ȳïˢ

¢ĸ¥ £¡¦Qĸ Ă ĸ ĸ

Îĸ ĸ i ĸ f ĸ:ÂĸJ " ^ ĸ ØU .½ ĸJK Ï õ {ĸq (ĸ ( Ĵ ĸĨ V ĸ # Ë# ĘĸT ĸÙIĸM ĸ , ĸ Yĸ& ăė =2& ĸ ; ĸ6 ĸU ' |ĸ /Wĸ` ĸ;Úx% cĸ;% - Û%/ĸÜGĸ; ĲB Ý ÞBĸ 'ĩB _%Gĸ

3 %< 6 = C /4 "> 5 # C *&.4C 6 C öf8 ĸ gĸ¬ Ĉ < ĸ Ãĸ1E ĸ K u<ĸX Kĸ1E ĸ Wy ÷( 1ĸ Xĸ¤m ĵ 7-AC' 8 @ BC 0 ?00 0C9 C0( (+'! : C $ 1C) C ÓÀĸ, 2;C ĉmĸN +ęĸ y ĸ¶675 *53ĸ& Nj8 ĸ k+F ,. ĸ 'ĸą F }ĸ ĸ ĸ đ "A ĸA / ` GĸĚ ĸ&n 1 0° @ĸ Q] ĸ § & ĸ Ì ĸ $ [ ĸ ĸ ? :> ĸ ø ~ĸ òb ß R$ ĸ n !, d #! ĸ 3ĸ o!à *#Ä !ĸ ! oĸ ě ,Hĸ +g3ĸ ur áV ĸ ĸ 'â ë $ ĸ ĸĜÔ)ĸ >S )ćv) ĸ ) ĝ# ĸ (ĸ-ùĆ ĸ 7ĸĒĪ! ĸ .Ð ēĸ ĸ ı ú# 4ĸ6 ûĸM ĸ 4 ãý ĸ 7ĸ ·ĸ ĸ ĸS ĸ v[ Oĸ ĸäĞĸ9 ĸ īÑ Oĸ ĸd lIĔĸ"* ĸ+ Cĸ ĸğ ± ĸ#Ħ ĸ ĸe ĸ ¼ħ" ĸ". Đ '> ĸ- / ? Ġ8? ĸ< 2í ĸÅ =ĸ* ĸZwġw ĸ %Æĸ<p ¹ a 09 ĸ0 p ' /º ĸ sĊ - _ Òĸ Õ ĸ ecĸY: ĸ ĸi x ċ $ĸ:Çĸ Ö ĸåþĶ A " \ĸJ ² 9ĳ 1 ĸ ^s a ĸ ÁĸÍì5îCĸ³HCĸ+ ĸ, Ģ5\Č Næ ĸ Zĸ& ! ķ ( ĸ 4ĸM )ĸ )>0 ( ĸ E ĸ b$óĸ I0ç ĸR $ĸ 7ĸ&ĕ ] l ĸ® Ėĸ ¨ %kqĸ - ĸ ¸ ĸ ÈĸĬ.ĭ Į $ĸF r č *ĸ*%ĸ 2 ĸ = ĸ ĸ ô ĸ ´LĸLtį4DÿtL@ĸ

+ Ab, bF b0 AFb b ` 5Ab 5 b5 V Y b Z G b % 6 G\b * b +B H b + bI b7 BS' b JBb-+bBJS +KC bL 8D b -*M +Ib

G W #_b b -+ $T + b1<2-B %Bb -9bN b S( *P b ;]b + b/ SIU:b5 35 A +Jb +b *E 6 * b + b & + * b ,T+ J ,*b ,9bJ b *Q 7 R-*b- bG b3A^ - ^+ ) b1 >4 J X b + bJ b* T=a A + Ab[!J *b .*J (3-9 ?b1A^ " O@ b ©" j3ĸ ĸª9ü ĸ ĸ @ĸ P 6 =ĸ ÉĸP z 82 zĸ ¯Hè? Ď éģ ĸ Êĸ ï ¾ ĸ ðĤ×ĸ«»ê T ĸ Āĥ ĸ DāİDď ĸ hñh µ¿Ąĸ

* & % $)* * ! * "' # * (* # * * *