Preserving the "psychosocial" in an era of biological psychiatry.

For psychodynamic thinking and understanding to feel relevant to psychiatric residents in current training programs, it must focus on the clinical problems they encounter with patients. It must be presented in everyday language and in a form applicable to their own clinical experience. Abstract theory or "deep"formulation may alienate rather than attract interest. At the start of the 215 century, there is a commonly agreed-upon recognition that the psychosocial components of Engel's (1) biopsychosocial model of illness have been significantly reduced and/or eliminated in most psychiatric training programs. The rapid expansion of genetics, neurobiology, and the application to psychiatric illness of impressive advances in psychopharmacology have focused attention of psychiatric educators away from the emotional, psychological, and social forces impinging on individuals and have stimulated a reductionistic mode of thinking about human behavior that is almost exclusively neurochemical and biological. In nonmedical training programs, the focus on the influence of psychological and social forces on the individual to create disruptive or difficult behavior and personality patterns has been retained (partly due to the fact that psychopharmacologic treatment approaches are not prescribed by this group of therapists), and a variety of different psychotherapies have been developed. The emphasis in many, if not most, psychiatric training programs has been on the psychiatrist as a medical diagnostician and medication manager. If psychosocial issues are significant, they are assigned to less arduously trained psychologists, social workers, or counselors. In other words, the relevance of the psychodynamic component of professional understanding of mental disturbances and character formations has in most psychiatric training programs been downplayed in favor of a more descriptive behavioral, nonmotivational orientation to the problems presenting in patients. Attempting to maintain a focus and interest on psychodynamic forces and factors in this current context can seem like a lonely and difficult proposition for those dynamically trained psychiatrists who continue to teach in medical school and psychiatric residency programs. For the most part, trainees in such programs are no longer interested in depth psychology, nor in infantile neuroses or deep psychodynamic formulations in regard to patients' difficulties. Formulating cases and the understanding of psychopathology in those terms (the "bread and butter" of psychoanalysts) results in glassy-eyed nonacceptance or indifference among psychiatric trainees in today's programs. The problem of maintaining the important contributions developed in the last one hundred years by psychoanalysis and psychodynamic psychiatry then becomes an issue of psychodynamically oriented teachers adapting and adopting our understanding to the needs and motivations of today's group of psychiatric residents and medical students. Psychodynamic thinking to be meaningful to today's trainees must, in one way or another, be applicable to some of the clinical problems and therapeutic stalemates that such trainees encounter in their everyday interactions with patients. This requires us to distinguish in simple terms the chief distinctions of a psychodynamic approach to understanding behavior and the therapeutic process, as compared with the other models of human behavior currently being presented in these programs. In my own experience it is possible to frame the following elements of the dynamic approach in simple and everyday terms: 1. That behavior evolves out of antecedent behavior and that the experiences, memories, traumata, relationships, and developmental processes of childhood interact with constitutional, genetic, and sociocultural factors to serve the development of a unique template for each individual. This template forms a background through which subsequent life experiences, relationships, and the subjective sense of one's self and one's functioning are developed. …