Developments in psychiatric postgraduate training in the United States

Abstract

THE REDISCOVERY during the Second World War of the psychiatric lessons of the Firstnamely, that neuropsychiatric disorders were major sources of disability among the civilian population and of casualties in the armed forces-led to a major national commitment to psychiatric training in the United States, symbolized by the creation of the National Institute of Mental Health in 1946. Under its training grant support program, the number of psychiatrists in training rose steadily to a peak of 4000 by 1970; the cumulative impact of this growing training program was an increase by an order of magnitude in the number of U.S. psychiatrists, from 3000 in 1946 to more that 25,000 currently. The Office of Management and Budget in the Nixon Administration has announced a decision to phase out federal support for psychiatric training over a 3-year period; a change in the rate of manpower training appears likely. When the upsurge of national interest in psychiatry began at the end of the War, disenchantment with the limited achievements of biologic psychiatry and with the static orientation of descriptive psychiatry led University departments to turn increasingly for leadership to psychoanalysts. By 1962, half the chairmen of the departments of psychiatry in the U.S. were members of psychoanalytic institutes [I]. I have elsewhere set forth my objections to psychoanalytic theory [2,3]. There is no convincing evidence of any greater effectiveness for its therapeutic methods when compared with briefer and socially less costly interventions [4,5]. What is relevant to our present topic are the organizational consequences of the ascendence of psychoanalysis on the practice and the teaching of psychiatry. Intensive individual psychotherapy became the touchstone by which psychiatric competence was to be judged and the criterion by which the desirability of psychiatric residencies was to be determined. Attention to psychiatric nosology all but disappeared in the preoccupation with psychodynamics. Professional interest was restricted to articulate middle and upper class patients deemed suitable for intensive psychotherapy [6]. Widespread conviction of the psychogenic etiology of the psychoses created a climate hostile to the investigation of organic factors. Whatever its presumptive didactic benefits for the psychotherapeutic skills of the trainee, analytic training necessarily restricted his occupational mobility for the 4-7 years required by the Institute. Its costs, both personal and monetary, forced trainees into private practice and foreclosed research careers. The loss to general psychiatry was not inconsiderable. Although formal psychoanalytic practice attracted not more than one in ten, it was often the most promising who chose that route in the climate of those times: commitment td analytic theory led to premature closure of curiosity about other bases for the understanding of human behavior. During the first decade of expanded training, the state hospital population was continuing