Textbook of Child and Adolescent Psychiatry, Second Edition

Textbook of and Adolescent Psychiatry, Second Edition Child American “The second is even solid foundation children ment better for DSM-IV a...
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Textbook of and Adolescent Psychiatry, Second Edition

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our

Psychiatry

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who

gave

so much

for the psychiatric

to

educator.

Your consistently outstanding work as reviewers has created a superb standard for our peer-review system and the journal’s publication excellence. We would also like to extend our thanks to the journals’ staff at the American Psychiatric Press:John McDuffie, managing editor; Christopher Greene, assistant editor; and Bessie Jones, editorial assistant. Special acknowledgment also goes to our colleague Dr. Laura Roberts, who has graciously extended to us her time and expertise in manuscript review as well as in the administrative and management tasks involved in running a scholarly journal. Thank you again for your time and commitment to Academic Psychiatry. Our best wishes to you for the coming year. Samuel J. Keith, Paul C. Mohi,

Gerald

Adler, MD. Z. Altshuler,

Kenneth Jeifry Linda

Allan Tracy

M.D.

M.D.

Andresen, B. Andrews,

R. Dyer, M.D. Eells, Ph.D.

Ru S. El-Mallakh,

M.D.

Milton

Engel,

M. House, C. Jacobs,

Peter

M.D. M.D.

M.D. M.D.

S. Jensen,

James

Jensen,

Allan

Mark

M.D. M.D.

Paul Stuart Appelbaum, M.D. George W. Arana, M.D. Paul Balson, M.D., MPH. John Battaglia, M.D.

Javier Dwight

Barbara Jo Beck, M.D. Anne Becker, M.D.

Joel S. Feiner, M.D. Donald C. Fidler, M.D.

Jerald Kay, M.D. George A. Keepers,

Jules

Alison

James

R. Bemporad,

M.D.

Tami Benton, M.D. Eugene V. Beresin,

Carol

Bernstein,

David

Bienenfeld,

Susan

Block,

Joseph John Charles Amy Andrew

Murray Simon Phil

M.D.

A. Brown, H. Budman,

Sara

Steven Cynthia Arnold

M.D.

A. Cole,

M.D. M.D.,

D. Conrad, M. Cooper,

Miles

K. Crowder,

Robert

S. Daniels,

Robert

Daroff,

Richard

Friedman,

M.D.

Kathryn

A.S.

Elizabeth

M.D.

M.D. M.D.

Ph.D.

M.D.

Garfield,

M.D.,

J. Gelenberg,

M.D.

K. Gilhillan,

Carol Kuo,

Janice

M.D. M.D.

Gold,

M.D.

Marc

Judith Junius

H. Gold, Gonzalez,

M.D.

James W. Lomax Earl L. Loschen,

Tana David

A. Grady, Greenfeld,

Ezra E.H. Griffith, M.D. Frederick G. Guggenheim, M.D. John G. Gunderson, M.D. Laurence B. Guttmacher, M.D.

Litle,

Russell Teresita John

Maulitz,

S. McIntyre,

Leah Dickstein, Martin J. Drell,

Irwin N. Hassenfeld, William A. Hendrickse,

Deborah Miller, Kyra Minniger,

Steven Mina David

M.D. L. Dubovsky, M.D. K Dulcan, M.D. Louis

Dunner,

M.D.

Donald

M. Hilty,

Robert

Holcomb,

Jimmie

C.B.

Holland,

M.D.

Roger Arthur

Barry

M.D. M.D.

Tamarin

M.D.

M.D. Mega, M.D.

Meyer, M.D. T. Meyerson,

Morenz,

Nancy

Morrison,

Philip

R. Muskin,

M.D. M.D.

M.D.

McCarty,

Lesly

M.D. M.D.

H, M.D. M.D.

Francis G. Lu, M.D. Constantine Lyketsos, Kenneth L. Matthews,

James A. Halikas, M.D. Seymour L. Halleck, M.D. James C. Harris, M.D.

M.D.

M.D.

M.D. M.D.

M.D.

Albana Dassori, M.D. Paul A. Deci, M.D.

M.D.

Ph.D.

F. Lehman,

K. Goin,

M.D. M.D.

M.D.

M.D.

Ellen Leibenluft, John Lisansky,

M.D.

M.D.

M.D.

Lefley,

Anthony

M.D.

Kiieg

Lambert, Landy,

Harriett

D.O.

M.D. M.D.

Kowatch, M.D. A. M. Kramer,

Michael M.P.H.

M.D.

HI, M.D.

Jo Kotrla,

Irving

M.D.

Gaufberg,

Rosalind

M.D.

C. Charles,

Robert Thomas

Marcia

M.D.

H. Chan,

M.D.

Ira Glick,

M.D. Ph.D.

M.D.

M.D. M.D.

Kostranchuk,

Kathryn

0. Gabbard,

M.D.

Katzelnick,

Knoll

Lorian

Franchini,

Saundra M.D.

M.D.

M.D.

L. Forster,

J.

David

Gregory

Alan

M.D.

Brotman,

Candilis,

Carlyle

M.D.

M.D.

M.D.

Finestone,

Josephson,

Dorthea Juul, M.D. Nancy B. Kaltreider,

M.D.

Jay Fink,

David

Bostwick,

L. Bowden, W.

Fife,

Glen

M.D.

M.D.

M.D. Evans,

Fauman,

Janice

M.D.

F. Borus,

C. Brodkey,

Beverly

Paul

M.D.

Michael

R. Erickson, Escobar, Landis

Douglas M.D.

M.D. M.D.

D. Bloom,

Jonathan

Brenda

Robert Shelby

M.D.

M.D.

M.D. M.D.

M.D. M.D.

M.D. M.D.

Theodore James

Nadelson, Nash,

M.D.

M.D.

Scott H. Nelson, Grayson Swayze

M.D. Norquist,

M.D.,

M.S.P.H. Malkah

T. Notman,

Penn,

Linda

F. Pessar,

Linda David

G. Peterson, W. Preven, Prosen, Puryear,

M.D.

M.D. M.D.

M.D. M.D.

Ronald

M.D. M.D.

0.

Rieder,

Roberts, Roberts,

Laud

R. Robertson,

M.D.

Ph.D.,

B. Robinowitz,

M.D.

M.D.

Sally

E. Taylor,

M.D.

Bryce

Templeton,

Clark

D. Terrell,

David Schaffer, Ph.D., D.O. Stephen Scheiber, M.D.

Gail

Thaler,

Ole

J. Thienhaus,

Heather

M.D.

Troy

M.D.

Laurence

M. Schulte,

J. Schwartz, Schwartz,

M.D.

Schwartz,

M.D.

Steven

S. Sharfstein,

Shawn

C. Shea,

James Donald

H. Shore, Shumway,

M.D. M.D. M.D. M.D.

Edward

K. Silberman,

William

H. Sledge,

Marcia

M.D.

M.D.

Slomowitz,

M.D.

M.D. M.D. M.D. M.D.

M.D. M.D.

L. Thompson

Gary

Tischler,

Gary

J. Tucker,

Eberhard Luis

M.D.

H. Uhlenhuth,

M.D.

Ph.D.

M.F.

Teddye

M.D.

M.D.

Vargas,

Johan

II, M.D.

Thornton,

Verhulst,

M.D.

Warner,

M.D.

Stephen

James

Weiler,

Michael

Weissberg,

M.D.

M.D.

Sidney

H. Weissman,

Arnold

Werner,

Donald

Allan

M.D.

M.D. West,

M.D.

Deborah

Timothy

Kane

Sherwyn

M. Woods,

M.D.

Leonard

E. Sabin, M.D. H. Sack, M.D. Sajatovic,

Scannell,

Tasman,

M.D. M.D., Ph.D.

M.D.

James William Martha

Benito Santos, M.D. W. Santos, M.D.

Tardiff,

Allan

Tom Widiger, Ph.D. Thomas N. Wise, M.D.

L. Ruedrich,

Z. Sadler,

Kenneth

M.D.

Nathan Bert Smith, M.D. Zach Solomon, M.D.

Stephen

John

M.D.

M.D.

Rosenbaum, H. Rubin,

M.D.

Sally K. Severino, M.D. Pramod A. Shah, M.D. Stephen B. Shanfield, M.D.

M.D. M.D.

Paul Rodenhauser, Brenda Roman,

Milton Eugene

Alberto Cynthia

Stuart

H. Reid, M.D. Riba, M.D.

Brian Laura Carolyn

A. Sansone,

Harvey Michael

Elizabeth Rand, M.D. Alison Reeve, M.D.

William Michele

Sanders,

Randy

Stacy

Joseph

Harry Lucy

Richard

M.D. M.D.

Susan Stefan Ellen

Gordon Paul

Spitz, Jorve

M.D.

Stagno,

I. Stein, Stein, Stover,

M.D.

Philip Joel

M.D. Ph.D.

D. Strauss, Summergrad,

M.D.

Woollcott, Yager,

Kimberly

M.D.

Deborah

M.D.

Gwen

M.D.

Wolff,

M.D.,

M.D.

M.D. Yonkers, Zarin,

L. Zornberg,

M.D.

M.D. M.D.

Ph.D.

AcADIMIc PSYCHIATRY VOLUME

I 193

I 195

I

In Appreciation Samuel

I. Keith,

SPECIAL

M.D.,

The Role of the Time of Managed

Psychiatrist: Care

Verhulst,

205

Supervisor

Evaluation:From

Nathan Teaching

E. Hyler,

School

Geriatric

232

Psychiatry

Let

Hollywood Jaime

Electives

Training

and

in Adult

THE

T. Pichot,

EDUCATIONAL

Linda

Suicide

in the

Cinema

M.D. Into

Psychiatry:

Plaut,

Ph.D.,

Residency Ganzini,

A 20-Year

Eric

Weintraub,

Training

M.D.,

George

Experience M.D.

Programs A. Keepers,

M.D.

I Using

the

Internet

M.D.

by Dorthea

countermyths,

233

Testing

common

234

Feasibifity

of hospital-based

practicing

physicians

use

Psychiatry

Recruitment:

Myths,

The

in the

EDITOR

233

reasonable

Practice

I

ABSTRACTS

Abstracted

235

Help! Moore,

S. Michael

M.D.,

Residency

John

and

to Implementation

Recruitment

M.D.,

S. Levitte,

TO

Theories,

F.R.C.P.C.

M.D.,

Weintraub,

Susan

I

M.D.,

Psychiatry?

Walter

Methods,

Theory

Hemnann,

Steven Medical

Defining

I

ARTICLES

LETFER

M.D.

M.D.

REGULAR

I

C. Mohl,

I

.

226

Paul

ARTICLE

L

220

1996

APPRECIATION

Johan

212

NUMBER4.WINTER

20.

and

Juul,

Ph.D.

truths

about

use

of peer

inteffigence

sense

of cognitive or customary

taxonomies

ratings

in licensure

to evaluate

and

certification

the

performances

test

development:

of

I

VIDEO

236

Using

I

COLUMN Video

POINT

for

Psychiatric

Residency

Recruitment

I

& COUNTERPOINT

238

Point:

The

Top

241

Counterpoint:

I

EDUCATIONAL

242

Educational

10 Reasons

for Psychopharmacology

Psychopharmacology

Kramer,

I

DEPARTMENTS

244

Index

251

Statement

252

Information

Supervision

I

COMPUTING Computing:

Thomas

Supervision

Column M.D.,

Robert

Debut S. Kennedy,

M.A.

I

to Volume

20

of Ownership,

for Contributors

Management,

and

Circulation

Special The Role

Article

of the Psychiatrist

Defining Methods, Practice in the Time Johan

Theories, of Managed

Verhuist,

and Care

M.D.

This essay proposes that the division between biological and psychotherapy-oriented psychiatry originates in the discipline’s reliance on two fundamentally different methods of inquiry, that is, the medical-biological and the empathic-narrative. These terms are defined and distinguished from psychotherapy and psychodynamic psychiatry, as well as from general humanistic qualities in medicine. The division within the field may be fueled by a lack of clarity with respect to these concepts. The author argues that the essence of psychiatry is defined by a balanced combination of both methods. Psychiatry does not consist only of basic methods, but also of rules and guidelines for clinical practice, and of knowledge and theories used in the application of the methods. The role expectations for psychiatry in the managed care environment are examined and their effects upon methods, theory, and practice are analyzed. Some suggestions for dealing with the challenges of health care reform are offered.

(Academic

Psychiatry

1996;

20:195-204)

Le saint gu#{233}rit par l’amour, le magicien par le pouvoir, le m#{233}decinpar la m#{233}thode.

discipline. Practice is what the physician does, as reflected in clinical standards, protocols,

T

(The saint heals

through

through methods.)

the

power,

physician

and

of psychiatry external

inform

inter-

ods

care and

reform threaten scope of practice.

the psychiatrist’s To maintain some

atry

trol

over

a consensus

the

oped useful the

This

(1).

toward

future,

of the discipline essay

fostering in this

practice,

the discipline. The consists of the concrete peutic

activities

the

to be a first step It may be to distinguish between

consensus.

theories,

that

and

the

practice of diagnostic are characteristic

They

which

methods approach

that

what

the

two

to look clinical meth-

discipline

originally

(2), it is argued upon

other

Theories

sense of the the systematic

a distinction

based

different biological

instruct

upon

by Jaspers is

the

that

is pro-

psychi-

fundamentally

of inquiry: the medicaland the empathic-narra-

to be devel-

attempts

that

respect the

posed

on

of knowledge to possess.

to make there are

Following

role con-

about

needs

practice:

of inquiry,

founded.

body

needs

for and how data. Finally,

Internally,

Theory,

to the

psychiatrist

biological psychiatrists and psychotherapists are becoming increasingly polarized. Externally, socioeconomic changes and health

definition

guidelines.

refers

the

G. Buyse

is facing

challenges.

and

hand,

through -

he discipline nal

love, the sorcerer

methods

of

psychiatry and therafor the

Dr. Verhulst sociate professor try and Behavioral

is residency of psychiatry,

Seattle.

reprint

Address

partment

versity WA

Sciences,

of Psychiatry

of Washington

training director and asDepartment of Psychia-

University to Dr.

98195. Copyright

© 1996

of Washington,

Verhulst, Deand Behavioral Sciences, Uniat Seattle, Box 356560, Seattle, requests

Academic

Psychiatry.

tive approach. An analysis of both methods will lead to the conclusion that the essence of psychiatry as a discipline lies in the balanced combination of both methods. Confusing methods of inquiry with theoretical perspectives or clinical practice leads to misunderstandings and may be partially responsible for the polarization of the field. This proposition will be discussed. In the last section, I will review how psychiatric practice, theory, and methods may be affected by health care reform. Directions will be suggested for dealing with the challenge of a changing environment. First, a description of methods, theory, and practice is in order. METHODS: BIOLOGICAL Modem diseases

THE

MEDICALAPPROACH

medicine is based upon the idea as definable elements of reality.

disease is distinguished on the basis cific symptoms, a specific etiology

of A

of speand

pathogenesis, and a specific course of illness (3). Empirical and experimental research leads inductively to scientific descriptions of the disease and to “models” that correspond with increasing accuracy to real processes in the patient’s body. The medical-biological approach, characteristic for scientific medicine, takes an objective, observing stance and reaches a diagnosis by matching signs and symptoms with disease criteria. Such a diagnosis

relates

this

particular

case

to the

sionate attitude, empathy, and human warmth have been identified as the “humanistic qualities” that all physicians should possess (5). These qualities express personal care for the patient while the physician is objectively treating an impersonal disease. They are seen as basic traits that applicants to medical schools should be selected for and that can be influenced and reinforced during residency training (5). In psychiatry, the medical-biological approach can be defined as the formal method of objective observation, examination, and clinical scientific reasoning by which the psychiatrist identifies and treats disorders as defined by the Diagnostic and Statistical Manual (DSM). The method often involves semistructured interviews to match symptoms with DSM criteria, as well as medical and psychological tests. Because the ultimate goal of the DSM classification is to identify psychiatric diseases, the diagnosis already suggests the presence of a pathological process that all patients with the disorder would have in common. Treatment follows the diagnosis and is based upon the available empirical evidence. The medical-biological approach governs the somatic therapies. To use the medical-biological method effectively, the psychiatrist should possess the humanistic qualities of the physician. METHODS: NARRATIVE

clinical

experience and research with groups of similar patients. As the scientific method in medicine has developed increasingly objective and rational methods of observation, an inherent problem has come to the forefront: The patient feels treated as an object of examination rather than as a person. Consequently, the doctor-patient relationship tends to deteriorate, compliance to decrease, and iatrogenic complications to increase (4). To mitigate this problem, the medical-biological method requires a humanistic context. Sensitivity and respect for the patient, a caring and compas-

THE

EMPATHIC-

APPROACH

The empathic-narrative method is defined by an empathic interactional process: one tunes in to the patient and to one’s own reactions and associations to what the patient discloses; one looks for patterns and tries to make sense of all the information; and one formulates hypotheses of understanding tient

and

communicates

in a tactful

and

these helpful

way,

patient, in turn, gives feedback and associations (6). Theories of learning,

to the

pa-

and

the

further

development, cognitive processing, and interactional and social dynamics are used to extend

one’s understanding into the experiential world of the patient and to facilitate the process of translating this understanding into words. Empathic interactions lead to a meaningful story, a narrative, which can be summarized in the formulation of an explanatory hypothesis for the patient’s behavior and feelings (7). The empathic-narrative method governs the psychotherapeutic aspects of care. One will recall that one of the characteristics Yet

of the the

humanistic

empathic-narrative

be subsumed istic

physician

method

under

these

The

natural

qualities.”

is empathy.

general

cannot

“human-

empathy

of the

physician is intuitive and prescientific. The empathic-narrative approach, on the other hand, is a formal method of inquiry that requires systematic study and training. A surgeon, for instance, may be wonderfully “warm and empathic” toward her patients, yet she may have little skifi in developing narratives lyst could method,

of understanding. be a master yet

he

may

in

be rather

A psychoanathe narrative reserved

and

reticent in expressing human warmth. The empathic-narrative approach can be defined as a formal method of establishing and maintaining an empathic interactional process, by which both the psychiatrist and the patient gain a meaningful understanding of the patient’s symptoms, coping strategies, life experiences, and relationships. This method involves a degree of selfdisclosure and self-reflection on the part of the patient and a complex activity of listening, reflecting, and expressing hypotheses of understanding on the part of the psychiatrist. The narrative diagnostic formulation, which summarizes understanding, is unique for every patient, and this understanding is often in itself therapeutic. The therapeutic effect of the empathic narrative method seems related to the following: 1) being understood by another person restores one’s sense of belonging and connection to others; 2) feelings and experiences that were strange or unacceptable are

validated

and

can

now

be integrated

into

a

more realistic self-image; 3) the hypotheses of understanding provide a new perspective and suggest possibilities for change; and 4) empathic interactions strengthen the collaborative alliance between patient and psychiatrist. THEORIES

Each of these methods draws on a large pool of knowledge. To competently apply the medical-biological approach, one needs to have a thorough knowledge of biology and psychiatric

diseases,

as well

as their

epidemi-

ology, nosology, and psychopharmacology. Applying the empathic-narrative method requires sophisticated knowledge of how the mind works and theories about why people behave the way they do. It involves more than being a good listener. Even a natural good listener can easily be confused by a patient’s strange behavior, illogical ideas, or unusual feelings. What allows one to expand the range of what is generally understandable is knowledge: Theoretical constructs that offer a bridge between the inner world of the patient and one’s own. One will notice an important difference between the theories that inform the medical-biological method and those that inform the empathic-narrative method: Medicalbiological theories intend to accurately reflect an objective reality; empathic-narrative theories intend to facilitate a subjective understanding of the patient. Thus, in applying the empathic-narrative method, one can, to some extent, pragmatically choose a theoretical

perspective

that

“works”

or suits

the

subjective reality. Such flexibility is invaluable in times of transition, as will be shown next. In addition to knowledge that supports the clinical application of each method, there is also a body of knowledge about each method. One finds, in the literature, detailed descriptions of the objective, observing medical relationship (8). Major contributions

to our understanding tive

process

of the empathic-narra-

have

been

made

that

by psychoana-

research. It should be hard to reflect upon this method without key concepts, such as identification, transference, countertransference, and therapeutic alliance, to name just a few. The terms “empathic-narrative” and “medical-biological” can be abbreviated to lytic

simply

“narrative”

clinical practice the psychiatric called “narrative practice and method can be psychiatry.”

and

“medical.”

the danger

though

Also,

the

of the narrative method and knowledge related to it can be psychiatry”; and the clinical knowledge of the medical called “medical or biological

methods

can

be

is real,

inclined

trists tell us that the method is, in fact,

exclusive impossible

even

psychia-

practice of one (9,10). Both

distinguished,

and

one

can

dedicate oneself to the pursuit of one method only. For example, following the lead of medicine, biological psychiatry has made relatively successful efforts at replacing “subjective” elements of psychiatric assessment with more “objective” methods. Instead of construing a patient’s story, one attempts to reliably capture relevant information in a life-event questionnaire; instead of empathically exploring the patient’s experience of symptoms and illness, one matches a symptom checklist with diagnostic criteria. In the

PRACTICE

of reductionism

philosophically

future,

the

tic laboratory

push

tests

to use

may

shift

more the

diagnos-

emphasis

to

psychoanalytic perspective; others use learning theories. One can focus primarily on assessment or therapy, on crisis intervention, or long-term care, and so on. To define the range of what is acceptable

more objective criteria to establish psychiatric diagnoses. Clinicians are well aware of the limitations of such attempts to bring the whole of psychiatry under the medical-biological method. Despite major efforts to refine the diagnostic criteria, ambiguities keep emerging. This is especially true for the “neurotic”

practice,

disorders,

Psychiatric

practice

chiatrists may psychotherapists

the

of care practice

With

is varied.

prefer the

profession

develops

care

reform

set of values

and

priorities,

Adaptation

guidelines seems

for various conditions.

imposing

a different

standards

are being

reasonable,

a

standards

and clinical guidelines settings and clinical

practice

psy-

the medical method, narrative. Some favor

health

and

Biological

of care

adjusted.

as long

as the

the range of acceptable practice. Similarly, as there is some degree of flexibility in the use of theoretical constructs to inform the narrative method, one can choose theoretical perspectives that fit the new priorities and values. The core question, however, is: Will psychiatric practice hold the narrative and the medical methods in equilibrium, or will psychiatry be restricted to the humanistic application of the medical method only? I argue that psychiatrists cannot adequately provide service without a balanced combination of both methods. I also believe changes

stay

within

where

stantly

shifts

the with

symptomatology

ments, and where individual seem capable of generating pected syndromes. Another the fact that the patient’s tomatology used

is itself

to

evaluate

unusual

for

sciously

learn

con-

sociocultural

patients always new and unexlimitation lies in expressed symp-

shaped it. For

“borderline”

develop-

by instance, patients

to endorse

all the

the

method it is not to uncon-

symptoms

of, say, bipolar disorder in the course of repeated structured interviews in emergency room settings. The result can be the “iatrogenic” development of a pseudo-identity (11) as a manic-depressive patient and the adoption of a chronically mentally ill lifestyle.

Similarly, ented use the tivated

psychiatrists

psychotherapeutically sometimes

oriexclusively

narrative method. They may be moby a desire to always approach the

patient

as someone

man

who

condition

standable patient

in

way, as an

deals

with

the

and

under-

a unique

rather

than

“alienus,”

defining

a mind

huthe

requires

ever

more

for each

particular

NARRATIVE

complicated

case.

PSYCHIATRY,

PSYCHOTHERAPY,

AND

PSYCHODYNAMICS The

field

vided

of

psychiatry

between

the

one

or

“psychodynamic”

other.

hand It is,

is increasingly

“biological” and

di-

psychiatrists

on

“psychotherapy-oriented”

however,

psychiatrists narrative

on

the

psychiatry,

that is, the practice of the narrative method, that can be said to be the opposite as well as the complement of biological psychiatry, not psychotherapy or psychodynamics. This proposition requires Psychotherapy

further can be

examination. very broadly

the

patient.

illness “psychotherapy.”

called

theoretical constructs to expand reason into the realm of the irrational. Clinicians also know that the narrative method, by itself, can mask pathology, because both the psychiatrist and the patient tend to selectively pay attention to what fits with the evolving story. A formal, “objective” mental status examination may be needed to bring symptoms (e.g., alcohol abuse, “hearing voices,” or suicidal plans) into focus. One can say that any clinical assessment is incomplete unless an empathic narrative has been complemented by a medical-biological examination (12). Although both methods are very different, they do generate complementary information. However, this does not mean that the information gained by each method is equivalent. In some patients, the medical information is more relevant for treatment or prognosis, in others the narrative. There are few, if any, explicit criteria to help determine when to give priority to which method. Much of the art of psychiatry lies in knowing the proper balance of methods

with

a patient’s

disqualified

by a mental disease. Clinicians have learned, however, that exclusive use of the narrative method

fined. There seems to be a tendency the term to refer to any therapeutic

de-

An empathic

to use dialogue

exploration

experience

can

Even

of

then

be

the expression

of humanistic qualities during a medical evaluation, or any kind of supportive companionship, could be termed “psychotherapy.” Clearly, psychiatry a more narrow definition which pect

differentiates of

general

may

it from psychiatry:

wish to support of psychotherapy, the

narrative

as-

Psychotherapy

refers to formal treatment with a psychotherapeutic modality or with an eclectkz/integrative combination of modalities. A modality is defined by a specific theoretical framework from which specific therapeutic strategies are derived. Examples are psychoanalysis and cognitive therapy. Psychotherapy relies to a large extent on the empathic-narrative method but should be defined by its theories and practices if one wants to avoid confusion with the more encompassing narrative method of inquiry. For instance, a biological psychiatrist may very well believe that psychotherapy is no longer a viable part of the job description of the psychiatrist, yet he or she greatly values

the

derstanding experienced

narrative

method

of how and how the

in gaining

an

un-

symptoms illness fits into

are the

patient’s life story. Or a managed care company may take the “logical” steps of first assigning all “psychotherapy” to nonphysician providers and then restricting the psychiatrist to medical-biological tasks, believing that there is nothing else left. The distinction between narrative psychiatry and psychodynamic psychiatry is equally important. Psychodynamic psychiatry is the application of psychoanalytic theory and knowledge to general psychiatry (13). Described as a “way of thinking,” which complements the medical-biological approach and which endeavors to understand the patient (13), psychodynamic psychiatry can certainly be seen as a form of narrative

But not all narrative psychiatry is psychodynamic. In fact, many psychiatrists practice the narrative approach by means of nonpsychoanalytic theoretical perspectives, such as cognitive theories, systemic-interactional insights, or learning paradigms. The term “narrative psychiatry” encompasses all applications of the narrative method. Indeed, the narrative method is defined by a specific empathic interactional process, not by the explanatory theories that are used in it. The polarization between narrative and biological psychiatrists seems partially fueled by confusion between a particular psychodynamic theory and practice. Psychoanalytic thinking does not fit very well with the belief system of many biological psychiatrists. As for managed care, it is hard to imagine a perspective that appears more alien to its values and priorities than psychoanalysis. It would be most unfortunate if the narrative method as a whole would be rejected because it is associated with a treatment. psychiatsy.

and a shift in the theoretical paradigms. Drastic changes could even affect the basic methods the

of the

discipline,

very

identity.

latter’s

Conceivably, health care reform wifi lead to “capitated” or managed care systems, whose pnmaly purpose appears to be to control health care costs. Strategies to meet that goal include an emphasis on medical necessity and on time-effective, empirically validated interventions, as well as the development of a multidisciplinary approach in which the most expensive providers are assigned as narrow a segment of the care as possible. We will see that the changes that are being imposed on psychiatry by the managed care environment have profound effects upon the discipline. Consider the distinction between the methods, theories, and practice of a medical discipline. Minor changes are likely to be absorbed at the level of practice, and without much effect upon theory or methods. More profound changes may

also

require

a different

way

of thinking

altering argue

that

health care reform requires changes in psychiatry that go beyond the level of clinical practice and also involve the discipline’s theoretical perspectives. Even the basic methods of inquiry, constituting the identity of the psychiatrist, seem to be affected: The use

of the

narrative

method

as an

essential

aspect of psychiatric care may be in peril in this new environment. To argue these points, I will first briefly review the model of psychiatric practice that seems to be envisioned by managed care. I will indicate how it differs from traditional psychiatry and whether the changes that would need to be made to accommodate the new model involve the discipline’s practice, theories, or methods. Finally, I will argue that psychiatry may benefit not only from adjusting ance with

its practice managed

it is imperative THE CHALLENGE OF HEALTH CARE REFORM

thereby I wifi

method

to maintain

in patient

of all psychiatric

and theories in accordcare values, but also that care

the

narrative

as an essential

aspect

work.

CHARACTERISTICS OF MANAGED CARE: MEDICAL NECESSITY, TIME, AND COST EFFECTIVENESS In managed care, the gathering of diagnostic information is limited to what one needs to 1) develop a reasonable treatment plan, and 2) to justify the expenditure of the resources one is planning to commit. Psychiatrists may find it difficult to adapt to such a “utilitarian” philosophy.

Traditional

training

has

always

emphasized completeness and comprehensiveness: A really good evaluation consists of a multi-axial diagnosis and an in-depth psychodynamic formulation, which uncovers the underlying issues and the root causes of the problems. Furthermore, in managed care the goal of treatment is to alleviate symptoms and to improve the patient’s level of functioning.

ment cannot be reached without addressing such problems. Managed care fosters a highly practical and pragmatic approach, and demands time and cost-effective, empirically validated treatments and explicit outcome expectations. In traditional psychiatric practice, the outcome expectations tended to be vague. The goal of treatment

Many psychiatrists perceive the restriction of their role to purely medical-biological work as a threat to their professional identity: Their narrative skills, honed through years of training and practice, seem to be disqualified and may ultimately atrophy. A deep concern about the consequences of this model for patient care exists. And indeed, when the medical method is not complemented with a narrative approach, diagnostic errors and iatrogenic complications are

was

likely

One needs complaints, treating

to stay close to the patient’s overt and one should only consider “underlying”

often

problems

“personality

reconstruction”

rather than symptom managers are skeptical bitious

therapeutic

ment plans psychiatrist’s

relief. Care system about vague and amgoals,

that

if improve-

seem ideological

and

about

based

upon position

treatthe and

unique interests rather than upon scientific evidence. The managed care model differs considerably from traditional practice. Simply adopting a new style of practice will not be enough. What is also needed is a different way that

of thinking supports,

and a theoretical framework informs, and guides such clini-

cal practice. CHARACTERISTICS CARE:

OF MANAGED

A MULTIDISCIPLINARY

APPROACH In solo practice, roles: signs

the psychiatrist

He or she the treatment

conducts

the

psychotherapy, control and

managed

provides plan, somatic

fulfills

the diagnosis, negotiates the treatments

and

many defees, the

and is responsible for quality utilization management. In

these roles are decentralized among many players. All too often, the psychiatrist is left with the role of team DSM-diagnostician and psychopharmacologist. Other members of the mental health team perform the “nonmedical” clinical tasks, such as case management, psychoand

care,

divided

therapy,

counseling

establishing support take on administrative tion

review

and

quality

to

families,

and

systems. Still others tasks, such as utiliza-

control.

to occur. A managed

care

administrator

may

very

well agree with the need for both approaches, but that person may propose that the narrative assessment be conducted by a less expensive team member, such as the social worker or psychotherapist. However, if one team member exclusively uses the medical method and another exclusively the narrative, they both risk construing an incomplete and distorted image of the problem and its etiology. The patient’s disorder should not be disconnected from the patient’s story. For one person to use both methods and to integrate the information in a coherent clinical picture is a matter of medical necessity. That one person is, by virtue of training and experience, the psychiatrist. In some managed care environments, this problem is solved by giving psychiatry a more central role in the team structure: The psychiatrist offers both a descriptive and a narrative formulation; he or she oversees and coordinates the care and provides supervision as needed. This role requires the psychiatrist to constantly use both methods of inquiry. To competently play such a central role, the psychiatrist needs to also possess specific additional skills. For instance, he or she needs to be able to negotiate, among all team partners, a common understanding of 1) what the problems are; 2) how they, presumably, came about; 3) what one can do about them; and 4) what outcomes one can expect and pursue. A shared image of the problems, their etiology, the treatment options, and the

outcome expectations is essential for tive teamwork. Note that the utilization reviewer,

effec-

strategies fessionals, ministrators

who

represents the task of cost control, and the primary care gatekeeper should collaborate as members of the treatment team. As much as possible, the patient and the patient’s family should also be engaged as full team partners, who help define the problems and participate in the treatment plan. The establishment of a collaborative partnership with the patient and the family is of foremost importance in managed care (14). Traditional training may not fully prepare the psychiatrist to take on such a central role. One needs to be able to both perform a structured diagnostic

evaluation

in a limited

ration

to be able

and

a narrative

amount

to integrate

of time; the

explo-

one needs

bio-psycho-social

data and to develop a clear and jargon-free formulation that can be shared with the team; and one needs to know how, and to what extent, to negotiate the formulation and the treatment plan with the patient and other team members. Consequently, clear thinking and common sense have priority over sophisticated conceptual nuances. Many of the traditional theoretical frameworks

used

in narrative

suited to support to play a central

seem

ill

these tasks. If psychiatry is role in managed care,

changes

in “theory”

changes

in “practice.”

ADAPTING

psychiatry

should

complement

TO MANAGED

the

CARE

The analysis of the effects of health care reform on the practice, theories, and methods of psychiatry leads to some initial recommendations. The balanced combination of the medical and be

the narrative

psychiatry’s

contribution

methods

of inquiry

most

unique

and

to patient

care.

To defend

may

valuable such

a core value, the profession should consider 1) developing research programs to demonstrate the importance for patient care of combining both methods; 2) developing

for educating policymakers, about

exclusively and the

mental health proand health care adthe danger of an

medical-biological

approach;

3) encouraging psychiatrists to support medical necessity of combining both

methods role

of inquiry

and

to demand

for

the

psychiatrist

in the

As

for

adjustments

in

a central

mental

health

team. the

discipline’s

theories, some general considerations and directions for change can be offered. The narrative method uses theories to expand one’s capacity for empathic understanding. In contrast, medical-biological theories purport to describe an objective reality and laws of nature, which makes them somewhat less adaptable to socioeconomic changes. Health care reform challenges narrative psychiatry to adapt current conceptualizations and to develop and

new

priorities

ones.

cepts and theories ple, so that they

patient

and

change

and

Considering

of managed

care,

that 1) are clear can be understood

the treatment team; utilize the therapeutic

of the narrative method ment of the interview;

empathic laborative

the

connection partnership

values

we need

con-

and by

simthe

2) promote potential

from the first and 3) support

and, hence, the between patient

mo-

the coland

physician.

Conceivably, these three criteria can be made operational, and they can be used to objectively evaluate theoretical constructs and interventions. For instance, the concept of projective identification, which carries sophisticated nuances that can be helpful in psychoanalysis, may need to be translated into a clear interactional language in order to be useful in general psychiatry. (People acquire

the

cognitive

schema

of the

interaction

patterns that are prevalent in their culture. Thus, when someone in a relationship displays one “half” of a particular interaction pattern, the same schema is triggered in the partner who will feel inclined to respond with the complementary role.) Similarly, the image of a patient being “fixated in,” or “re-

gressed create

to,” early unnecessary

developmental distance

answered unambiguously. One should that a clear awareness of the challenge creases the likelihood of success.

stages may contrasting

by

the patient’s immaturity with the therapist’s superior growth. In contrast, a conceptualization in terms of patterns that were learned in the past is not only less judgmental but also offers the hope that these patterns can be unlearned. At first glance, it may seem that psychiatry should be able to adjust to managed care by changing practice guidelines and narrative

theories.

The

flexibility

of narrative

CONCLUSION In the debate about the future of psychiatry, a lot of attention seems directed at the question of whether psychiatrists will still be able to conduct psychotherapy. bate between narrative

con-

ceptualizations is limited, however. Medical-biological theories can be said to be limited by “facts and data”; narrative theories are limited by the belief systems of the psychiatrist and the patient. Indeed, it is important that the theory on which the psychiatrist’s empathic understanding rests “rings true.” Conceptualizations can only serve as a bridge between the inner world of the patient and one’s own if they resonate with one’s world view and belief system. A practitioner who has, over the years, successfully identified with a particular theoretical perspective may no longer be able to question it. As for the patient, the therapist’s perspective needs to be new to facilitate change but can-

chiatrists

not

be too

partnerships

tion

“Are

the

new

to be incorporated.

psychiatrists

new

role

The

capable

demands?”

can

of

ques-

meeting

therefore

not

hope in-

be

centers

psychotherapy. that

the

real

argues

be

issue

is whether

a “straw

the

depsy-

value that

of psy-

person”

and

psychiatry

can

practiced without a balanced of the narrative and the medimethod.

At the

same

in ways

of thinking

by managed mately

the

essay

may

be adequately combination cal-biological and

around This

chotherapy

Similarly, biological

and

time,

care.

benefit

changes

in practice

are being

demanded

These the

changes

field

as

could

the

ulti-

traditional

emphasis on defining “underlying problems,” on idealistic but vague treatment goals,

on sophisticated

alizations, placed

and by an

but

private

on ideological emphasis on and

on

change

and

that

tal, and

understandable.

conceptupurity is recollaborative

a language

that

is respectful,

fosters

nonjudgmen-

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Regular

Articles

Supervisor From

Theor,i

Nathan

Evaluation to Implementation

Herrmann,

M.D.,

F.R.C.P.C.

The evaluation of supervisors demic psychiatry programs.

and assessment of teaching effectiveness are vital for acaThe literature on teaching evaluation in classroom settings reviewed briefly, followed by a summary of the available literature on supervisor evaluation in clinical medicine and psychiatry. While student evaluation forms of supervisor’s teaching ability may be reliable and valid, this popular form of assessment is insufficient fulfill

all the purposes

required

of such

evaluations.

The development

and

of a new process for supervisor evaluation is described for the University partment of Psychiatry. (Academic Psychiatry 1996; 20:205-211)

T

he evaluation of teaching effectiveness in clinical medicine is essential if instructors are to improve their skills, educational directors are to strengthen programs, and deans are to promote faculty members (1). Despite these crucial functions, surprisingly little has been written about the evaluation of teaching effectiveness in medicine as a whole, and almost nothing pertaining to psychiatry in particular, While several studies have attempted to examine the process of evaluating supervisors in clinical medicine, these attempts have paled in comparison to the systematic implementation and thorough research of teacher evaluations in the dassroom setting (1). Furthermore, a recent review concludes that what literature exists deals almost exdusively with studies that have focused on the use of student evaluations (2). While an exhaustive review of the education literature is beyond the scope of this article, it is worthwhile to examine some of the themes of these studies before considering the work in clinical medicine.

Education there are

OF THE

researchers essentially

LITERATURE have two

recognized that ways to judge

to

implementation

of Toronto’s

De-

teaching effectiveness: 1) use of an “objective criterion” based upon what students have learned from their teachers, and 2) use of a “subjective criterion” based upon students’ evaluations (3). While ratings in education and clinical medicine have often focused on student evaluations, faculty resistance to this aspect is well documented. The following concerns predominate: 1) evaluation forms are often prepared by persons who are unqualified to construct such instruments, 2) student ratings are unreliable, 3) student ratings might favor an “entertainer”-style teacher, 4) student ratings are highly correlated with expected grades, and 5) students are not competent judges of educators since the long-term benefits of a particular course may not be clear at the time it is rated (4). While most research has shown a weak positive

correlation

between

student

is postgraduate

ratings

and

education coordinaCentre, and assistant professor of psychiatry, Department of Psychiatry, University of Toronto, Ontario, Canada. Address reprint requests to Dr. Herrmann, Sunnybrook Health Science Centre, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5. Dr. Herrmann

tor,

REVIEW

is

Sunnybrook

Health

Copyright

© 1996

Science

Academic

Psychiatry.

other indices of teaching effectiveness, such as class performance (5,6), some have questioned whether good teaching can be measured at all by using the typical criteria in student

rating

by Rodin

forms.

A controversial

and Rodin

study

(3), for example,

a negative correlation between ings of teaching performance

showed

student ratand objective

of student learning, prompting the authors to report, “Students rate most highly instructors from whom they learn least.” Hyratings

pothesizing

about

their

results,

the

authors

suggest that students may resent instructors who force them to work too hard and learn more

than

they

wish.

Rodin

and

Rodin

also

postulate that the more students learn, better they are able to detect weaknesses teaching

ability,

important teachers

to consider when of senior residents and

search

such

phor

a suggestion

as this

of student

that

suggests

might

be

evaluating fellows. Re-

that

as consumer

the in

the

is not

metaalways

not always know what is best. Despite these concerns, a comprehensive review of the education literature suggests that student ratings are reliable, with good stability (test-retest appropriate-that

is, the

reliability) and rater reliability)

customer

internal

does

consistency

(inter-

seven

dimensions

guished

that

the best

were

from

enthusiasm,

significantly worst

distin-

clinical

teachers

organization/clarity,

clini-

cal competence, modeling, group instructional skills, clinical supervision, and knowledge. With some modifications, Irby and colleagues used these dimensions to design a rating form later tested in a follow-up study (I). They found that the form was highly reliable, as assessed by interrater reliability

and

internal

consistency.

Irby

et al.

also used factor analysis to determine construct validity based on the literature and concluded that the ratings were specific enough to identify individual strengths and weaknesses in a sample of obstetrics-gynecology

staff

recently,

rated

Irby

acteristics

by

clinical

et al. have

shown

of clinical

teachers

clerks. that

More the

char-

in ambulatory

care settings were similar to those found in prior studies of ward teaching (8). These results may be important because they suggest that

different

rating

forms

may

needed

for evaluating clinicians in different services or milieus. Other

studies

on the

cal (9) and internal sicians (10) further

evaluation

medicine confirm

not

who

be

teach

of surgi-

attending the reliability

phyand

(4). These authors also conclude that while student ratings “fall far short of a complete assessment of an instructor’s teaching contribution,” they do provide valid data based upon their review of studies examining content, criterion, and construct

validity of student evaluations. al. (9), however, have suggested need to be grouped according

Tortolani et that ratings to postgradu-

ate

and

validity.

evaluating

David ment

Irby,

of Medical

of Washington,

a professor

in

Education

at the

Seattle,

much to the literature teaching effectiveness

the

has

Depart-

cine,

University

contributed

on the evaluation in clinical medicine.

Over the past two decades, Irby leagues have attempted to study

and the

year

of

his colcharac-

(PGY)

to reduce

bias

error

re-

lated to rater education. In an interesting description of the measurement process for clinical

asks supervisors formance, Irby’s items brief ual

form

teachers

in internal

medi-

et al. (10) describe a form that students and residents to rate

Guyatt medical

according to 14 domains of permany of which incorporated (11). While concluding that this effectively

supervisors’

differentiated

strengths

and

individweaknesses,

teristics of clinician educators and how to assess their teaching validly and reliably. In an early study (7), the medical students and

they

directors residents’

did not always review individual evaluation forms. Instead, the

residents

and

training

directors

of di-

feedback

to supervisors

worst mensions.

were

clinical The

asked

to rate

their

teachers

on

a number

results

suggested

best that

the

also

noted

of the trainees.

that,

in practice,

based

Guyatt

their

the

training

ratings

on group

et al. suggest

and

interviews that

the

reluctance

to use

evaluation

forms

is based

Psychiatry.

Each

hospital

or teaching

site has

upon the following factors: 1) the difficulty of getting house staff to complete forms consistently and carefully, 2) the reluctance of house staff to give low ratings even when confidentiality is assured, and 3) the possibility that house staff may make idiosyncratic ratings. While the validity of these assumptions was not addressed, it is difficult to argue in favor of evaluation forms if they were

a local postgraduate education coordinator (i.e., the hospital coordinator), who is a member of the medical school faculty and reports to the director. In 1991, the director of postgraduate education formally convened the Supervisor Evaluation Committee (SEC), with a chairperson (the author) and repre-

not

SEC

being

used

by the

training

directors.

Although several studies have addressed the evaluation of teaching effectiveness in psychiatry, they have dealt only with psychotherapy supervision (12-17). Ratings of videotaped supervision have been used to determine which factors distinguish outstanding psychotherapy supervisors from good or average ones (12,13). The reliability of a standardized rating scale for psychotherapy supervision has been demonstrated by Shanfield and his colleagues (14), who found that supervisors judged to be excellent were empathic and focused on the concerns of trainees (15). In a survey study by Pate and Wolff (17) that examined supervision in psychotherapy, the residents’ ranking of the supervisor’s

ability

to

teach,

the

rapport

between supervisor and trainee, and the supervisor’s fund of knowledge were by far the most important features that distinguished satisfactory from unsatisfactory supervision. These studies seem to suggest that it is possible to design generic forms for evaluation of all psychiatry supervisors without the need for modification to account for what might be considered special circumstances in psychotherapy

THE

supervision.

UNWERSITY

OF TORONTO

sentation

from

grams

as well

was

asked

evaluation the

sisted

of a 6-page

of submitting graduate

Department

of

At

evaluation

the

with

of that

form

con-

major

sec-

forms

directly

Office

to the

without

Posthaving

to show it to their supervisor. While the director of postgraduate education reviewed all the forms, there was no formal process for identifying poor supervisors, notifying their hospital postgraduate education coordinator, or dealing with the negative evaluations.

forms

university’s

system.

document

Education

ation

to the

The

process

supervisory relationship (12 aspects of supervision (7 in specific areas (13 items), and psychotherapy supervision (17 items). These 49 items were rated on a 5-point Likert-type scale, ranging from unsatisfactory to excellent, without criterion references. The last page of the form included sections for narrative comments on the strengths and weaknesses of the supervisor, as well as another 5-point Likert-scale rating for “overall evaluation.” While there was no written policy for the process, the expectation was for residents to complete this form every 6 months, discuss it with their supervisor (who was to sign it), and submit the form to the Postgraduate Education Office. Because of resident concerns, this unwritten policy was changed in 1991 to allow residents the option

described

sponsible

pro-

tions, including items), practical items), teaching

ture

re-

the

the

supervisor

single

education

and

representation.

revise

time,

For

of postgraduate

divisions

to review

and

The psychiatry residency program at the University of Toronto has over 130 residents (PGY-1-PGY-5) and about 30 fellows. The residency program occurs at 16 training sites. The program is highly centralized, with a director

major as resident

tee’s

the

yearly

academic

meeting,

scores

of the

narrative The

the

promotion

director

evaluations

would and

commitpool

summarize

the the

comments. SEC began before

used

by reviewing and

by other

examining

departments

the literaevalu-

in the

faculty of medicine cine) and by other

internal mediof psychiatry. A new form was developed, with the goals of making it shorter and easier to complete. To ensure that the form could evaluate characteristics that determine the quality of supervision, the committee borrowed heavily from the literature, especially the work of Irby and colleagues (1,7,8,11). The new form had three brief sections. Section One used a critical-incident approach to evaluation, asking the following three questions: 1) On the average, how many hours of regularly scheduled supervision did you have per week with this supervisor? 2) How many observed (live or taped) interviews did you have with this supervisor per 6 months? and 3) How many times during the rotation did your supervisor provide detailed feedback about your progress? Section Two asked residents to rate their supervisors in six categories: enthusiasm, organization/clarity, knowledge, clinical supervision, availability, and modeling. Each category contained a detailed description of the factors residents should use when rating a supervisor. For example, under the category of modeling, the

resident

supervisor professional

(surgery, departments

is asked

to consider

1) is an appropriate role

model;

whether

the

clinical

and

2) is an appropriate

role model as a teacher; 3) is responsible, self-confident, flexible, respectful, and nondogmatic; 4) relates to the resident as a colleague; and 5) is sensitive to gender, ethical, cultural, and socioeconomic issues. A seventh

question

assign an overall All 7 elements

asks

rating of the use a 5-point

scale, ranging from poor tion Three is a full page, tions requesting narrative the supervisor’s major weaknesses, ing

supervision

and

the

(A

to

supervisor. Likert-type

to excellent. with three comments strengths,

suggestions quality.

resident

Secqueson major

for

improv-

copy

of

the

complete “Supervisor Evaluation Policy and Procedure Manual,” including the rating form, is available from the author upon request.)

more

Having useful

designed what and efficient

was felt instrument,

to be a the

SEC turned to the task of formalizing a process of evaluation. This task was far more difficult than the committee members could have imagined, largely as a result of a number of diametrically opposed opinions on both the process and philosophy of evaluation. The residents were extremely concerned about the possible repercussions of giving negative evaluations to supervisors. The residents felt that because of the power imbalance

in

the

resident-supervisor

rela-

tionship, anonymity had to be safeguarded to collect meaningful, honest, and impartial assessments. Residents’ concerns extended not only to the consequences of negative evaluations on their training, but also to implications for their future careers. Residents did not feel that the current system that allowed them the option of submitting the forms directly to the postgraduate director was

suitable

sors

might

“protection,” assume

because

(often

correctly)

supervithat

they

had chosen that route because of a negative evaluation. Many supervisors were concerned about a process of evaluation that was not face-to-face in nature. Concerns were expressed about the availabffity of evaluations for promotion purposes, as well as their right to view information collected on them immediately, with the opportunity to respond quickly to negative evaluations. Members of the Postgraduate Education Committee argued that the principles of education theory, including

dealing

negotiation, ment with inconsistent

communication, and reassessstudent and teacher (18), seemed with a process that did not en-

courage

face-to-face

believed

that

with

a situation

problems

evaluation. in which

through

This

group

a resident

would provide personal feedback about supervision was valuable, if not essential, to an educational experience that has the goal of preparing residents for their future careers. In the end, however, the most persuasive argument came from the associate dean of

postgraduate medical education of the university. He noted that it was university policy to maintain confidentiality of evaluations by trainees. According to this perspective, the process was unacceptable if there was even a perception on the part of the trainee that a poor supervisor evaluation could lead to later poor evaluations of the trainee. In light of these concerns, the SEC proposed a formal process documented in the “Supervisor Evaluation Policy and Procedures Manual.” All residents are expected to provide verbal feedback to all their supervisors at least every 3 months; however, this type of evaluation is recognized as separate from the formal written evaluation done before the end of a rotation that is included in the supervisor’s teaching record. Residents evaluate their primary clinical supervisor (the

service’s

attending

physician)

and

their

psychotherapy supervisor. A resident’s rotation is not considered completed until such time as the Postgraduate Education Office has received the feedback forms. All residents are responsible for submitting these forms directly to the Postgraduate Education Office at least 2 weeks prior to the end of their rotation and prior to receiving their individual evaluation from their supervisor. The supervisor evaluation form has a face sheet with the resident’s name and a statement indicating the resident has evaluated the supervisor prior to receiving his/her own evaluation. This is the only location on the evaluation form that contains the resident’s name or signature. After documenting receipt of the supervisor evaluation forms from each resident, the director’s administrative assistant removes and destroys the face sheets. Hospital dinators and pooled

postgraduate individual

evaluations

from

education supervisors the

previous

coorreceive 4 6-

month blocks. The SEC reviews all forms after each 6-month period for “negative” evaluations, defined by specific criteria. When a supervisor receives 2 negative evaluations in any 2-year period, the individual

supervisor,

hospital

coordinator,

and

hospi-

tal chief are notified. It is the responsibility of the hospital postgraduate education coordinator

to submit

a written

report

to the

SEC

detailing the circumstances of the evaluations, the supervisor’s responses, and the actions

(remedial

taken

or

if necessary.

otherwise)

that

were

maintain the any evalu-

Supervisors

right to file a grievance regarding ation or the process, according to the university’s grievance procedure. The supervisor evaluation

forms

are

the

purpose

request

for

teaching

dossier

made

available of

for promotion

upon

inclusion

in

a

procedures.

OUTCOME One

of the most

ing July

introduction of 1993 was

number

dramatic

outcomes

follow-

of the new procedure in a significant increase in the

of evaluation

forms

submitted

by

the residents. Before 1991, 56% of the residents submitted evaluation forms. Between July 1991 and June 1993 this figure increased to 76%, coincident with the policy that allowed residents the option of sending in forms without showing them to their supervisors. From July 1993 to June 1994, when all forms

were

sent

directly

to the

postgraduate

education coordinator, 89% (189/212) of the residents submitted these forms (most residents in this program change rotations every 6 months). Of the 11% who did not submit their forms, the vast majority were senior residents

graduating

or leaving

the program.

Over the course of 7 evaluation periods between 1991 and 1994, 44 negative evaluations from a total of 619 (7%) were identified. Only four represented multiple negative evaluations, necessitating formal review by the SEC. While all the reviews were painful and difficult for both the supervisors and the committee, the outcome was positive in three cases. In these instances, the hospital coordinators carefully reviewed the causes

of the

poor

evaluations

with the supervisors, initiated changes, such as ensuring that

and,

together

important the residents

received clarification scheduling of more stance,

better orientation to the service, of expectations and roles, better of supervision, and the provision observed interviews. In one in-

the

negative

evaluations

were

based

almost exclusively on lack of supervisor availability caused by the supervisor’s heavy clinical load. These evaluations were then helpful in encouraging the hospital chief to reduce the clinical load and provide more supported teaching time for this supervisor. In the one review that the SEC did not feel resulted in a positive outcome, the hospital coordinator, siding with the supervisor, attributed the negative evaluations (in this instance

more

conflicts”

and

dents.” satisfied

than

two)

“the

prejudices

to

Because the hospital that the supervisor

emplary

job,

the

SEC

“personality of

the

coordinator was doing

requested

resi-

was an ex-

CONCLUSIONS process

programmatic process can

useful?

For

improvement, be quite helpful

the

purpose

of

it appears this for both training

directors and individual supervisors. With respect to faculty development, it is unlikely that feedback provided by these forms is used by individual supervisors to improve specific more,

the

aspects 2-year

of their pooled

teaching. evaluations

Furtherare re-

ceived too infrequently to reinforce teaching improvement. A study by Skeff (19) of internal medicine supervisors demonstrated that teaching improvement occurred only when the supervisors received intensive feedback (trainee evaluations, videotapes, self-assessment) and not student evaluation-form feedback alone. Skeff’s study is supported by research of college teaching, which also demonstrated back

by

that

student

questionnaire

itself

seldom

improved

effectiveness (20). With respect these ratings have

ing effectiveness all levels, there elements

sions

feedteaching

promotion, as one piece

teaching on

inform

deci-

(21). He suggests

teaching

should

be de-

upon scholarly evidence (papers, attractive evidence (recruitment

and subsequent evidence (invited

honorific cludes,

should

promotion

based

pendent chapters);

success lectures,

evidence (prizes, “Such evidence

of

trainees); symposia);

peer

and He cona more

awards). provides

compelling argument for a teacher’s promotion than a local reputation or an accumulation of testimonials from students” (p. 879).

The be

University tremely

generalizability of limited. As described of large

Toronto and highly

this process before, the

program centralized.

is

exThis

helps ensure anonymity of the residents and provides for multiple evaluations over short periods of time. Programs with fewer residents and supervisors may need to consider modifications, such as longer periods to

pool

evaluations,

or

the

use

of

group

evaluations. The

student

evaluation

form,

the

most

popular method of assessing supervisor teaching effectiveness, is not only simple and economical, but also appears to demonstrate acceptable reliability and validity. Exclusive use of this form, however, cannot effectively address all the previously described needs of academic departments. This conclusion is echoed by a recent study of the Association of American Medical Colleges’ Group on Educational Affairs (22). In this survey of 110 medical schools, the faculty and administration listed inadequate methods to evaluate teaching evaluations evaluation.

be to academic been helpful

of

effectiveof faculty McHugh of teach-

is essential for promotion at is still debate about which

regarding

promotion

may

a face-to-face

meeting with both the supervisor and the hospital coordinator to discuss the evaluations.

Is this

of objective evidence of teaching ness. However, in a recent review promotions in medical schools, notes that while the documentation

directed

and

specific as the Future

problems

with

major problems research must,

at developing

more

methods for evaluating teaching demic medical departments.

student in faculty therefore,

effective for all aca-

References 1.Irby

D, Rakestraw

medicine. 56:181-186

MB,

instructors

Woolliscroft

by

1989;

3. Rodin

ings

teaching

Education

JO:

third-year

in

1981;

Evaluation

medical

of clinical

students.

B: Student

evaluations

1972; 177:1164-1166 F, Greenough WT, of college

fulness.

teaching:

Review

of teachers. RJ: Student validity,

Educational

rat-

and

Research

use-

PK:

Evaluation

of instruction.

Science

1973;

180:566-570 Student

ratings

of Medical DM,

of

Education

Ramsey

istics of effective medicine.

PG,

teaching:

Med

1978;

Gillmore

clinical

Acad

validity

of

nal

process medicine.

DM:

classroom

GM,

teachers

1991;

et al: Character-

of ambulatory

tory. Am

J Psychiatry,

PC, Mathews

be a

Education

PC,

EL,

Mathews

LE, Kapoor

Krul

residents’

et al: Quanti-

of psychotherapy 1992;

in Canadian

grams:

KL,

of behavior

J Psychiatry

Am

inven-

supervisory

1989; 146:1447-1450

assessment

pervisors.

K, et al: A reliability

psychotherapy

SB, MohI

tative

66:54-55

for evaluating Can Med Self-assessment teaching

MK,

Kline

FM:

teachers

Assoc 11993; inventory

Supervision

LA,

su-

149:352-357

R: The

teaching

psychiatric

perceptions.

Wolff

of psy-

residency

CanJ

pro-

Psychiatry

1984;

in inter-

149:1097-1102 for clinical

KM:

in Clinical

Teaching

observed.

J

Nerv

the

residents’

1990;

per-

14:122-128

45:67-86

Evaluation

of a method

performance

of attending

for improving physicians.

Am

1983; 75:465-470

20. Kulik

A, McKeachie

in higher cation, 1975,

and

Supervision: Psychiatry

RG, Biilson JM: The social context of teachlearning. New Directions for Teaching and 1991;

19. Skeff Med

TK:

Academic

teaching

clinical

in medicine,

17. Pate

Learning

care

for Medical Residents: Roles, Techniques, and Programs, edited by Edwards JC, Marier RL. New York, Spnnger, 1988, pp.255-260 12. Goin

of the

18. Tibenus ing and

53:808-815

DA, Rosati RJ: Resident evaluation of surgical faculty. J Surg Res 1991; 51:186-191 10. Guyatt GH, Nishikawa J, Wifian A, et al: A measure-

11. Irby

SB, MohI

assessment

spective.

AJ, Risucci

9. Tortolani

ment

You can

W:

of Psychiatric

29:658-663

PW:

several rating factors. Science 1973; 182:83-85 7. Irby DM: Clinical teacher effectiveness in medicine. 8. Irby

Journal

1:174-179

chotherapy

5. Gessner

Journal

supervisor.

16. Perez

1971;

158:208-213 MK, Zimmerman

FM, Goin

15. Shanfield Menges

reliability,

of

1974;

Dis

1977;

41:511-525

6. Frey

Ment 13. Kline

14. Shanfield

Acad

64:159-164

M, Rodin

Science 4. Costin

clinical

of Medical

better

2. Donnelly Med

P: Evaluating

Journal

WJ:

education, edited

pp.

21. McHugh

by

The

evaluation

in Review Kerlinger

of teachers

of Research

FN.

in Edu-

Chicago,

IL, Itasca,

210-240

PR: A “letter

promotion

in

medical

of experience” schools.

about Acad

faculty

Med

1994;

69:877-881 22. Jones views 1994;

RF,

Froom

of problems 69:476-483

ID:

Faculty

in faculty

and evaluation.

administration Acad

Med

Teaching

Psychiatry?

Let Hollywood

Suicide

Help!

in the Cinema

Steven

E. Hyler,

Jaime

Moore,

M.D. M.D.

Commercial films on videotape may be helpful in teaching medical students and residents about psychiatry. Recommendations are made on the use of specific films to illustrate various aspects of suicide, including depression, posttraumatic stress disorder, adolescent pressures and suicide, suicide gesture vs. suicide attempt, and the spiritual and philosophical aspects of suicide. In the Appendix, the authors list several dozen films depicting suicide that might be used for teaching purposes. (Academic Psychiatry 1996; 20:212-219)

ecently, Fidler has reported on “the diemma of unavailable videotapes for psychiatric education” (1). We describe the usefulness of videotaped commercial movies in teaching medical students and about psychiatry. Such videotapes

residents

are readily available and have been used successfully by the senior author in teaching such topics as psychopathology, psychiatric diagnosis (2), personality disorders, and transference and countertransference (3). For the past several years, the senior author has been the director of the “Teaching Psychiatry? Let Hollywood Help!” course at the annual meetings of the American Psychiatric Association. Along with the course faculty, the senior author has demonstrated how commercial film depictions can be used as adjunct aids to enhance teaching. It should be emphasized that the majority of commer-

available film depictions of psychiatry and related topics are often dreadful. Many are unrealistic and misleading at best, and serve to stigmatize our profession and our patients (4) at worst. We report on the use of selected commercial films to teach about suicially

cide,

and

we

recommend

specific

SUICIDE, DEPRESSION, POSTFRAUMATIC STRESS Dr.

Hyler

is associate

professor

of clinical

the

in

AND DISORDER

psychia-

of Psychiatry, Columbia University, and on the staff of the New York State Psychiatric Institute, New York. Dr. Moore is a graduate of the Columbia University College of Physicians and Surgeons, New York. Address reprint requests to Dr. Hyler, Unit #112, WHCS, New York State Psychiatric Institute, 722 West 168th Street, New York, NY 10032. try,

scenes

films that we believe are useful in educating students about the topic. The number of films that portray suicidal ideation and behavior is considerable. Aside from sex and violence, there are few topics as powerful in their impact that can be portrayed on the screen. A search of movies on the Cinemania ‘94 CD-ROM computer ifimography (5) revealed over 100 films that depict suicide. Appendix 1 presents a selection of films that include suicide and/or references to suicide. selected

Department

Copyright

C 1996

Academic

Psychiatry.

Ordinary People is the 1980 Oscar-winning film adapted from the Judith Guest novel. It stars Timothy Hutton as Conrad Jarret, the survivor of a boating accident that killed his older brother. The film depicts the effects of the tragedy on Conrad and his parents

(played by Donald Tyler Moore). The itial suicide attempt, atric hospitalization, particularly

moving.

attempts

to

trasted by and deny Conrad’s of the tant

Sutherland

effects and

his any

the

father’s

and

and

stress disorder) illustrates vivor guilt. A particularly involves Conrad’s attempt that

he

knew

covering templates he

from

that she cutting

chooses

Berger

the

trauma (resul-

of surscene a girl

Upon

dis-

psychiatrist,

Hirsch),

to see him immediately. come to a breakthrough

and

of their

films

Together, of insight

patients

depict

negatively.

tion

in patients

ifim

provides

a

accurate portrayal traumatic stress that lends itself

how

the

lack

of

to suicidal ideawith other risk factors. The highly detailed and relatively of major depression, postdisorder, and teen suicide well to teaching purposes. contribute

ADOLESCENT

Heathers

psychiatrists In

illustrates can

they in a

addition,

film provides an excellent illustration of a number of typical suicide risk factors, as outlined recently by Buzan and Weissberg (6). The foremost of these factors is the intimate correlation between affective disorders and suicidal tendency, with depressed patients having a 25-fold greater suicide risk. In the film, Conrad exhibits most of the classic symptoms of a major depression, including decreased sleep and appetite, lack of interest in school and extracurricular activities, latent guilt about his brother’s death, and suicidal ideation. Conrad’s relationship problems with his girlfriend Jeanine (played by Elizabeth McGovern), his dispute with a former best friend, and his previous suicide attempt are all high-risk factors often seen in teenage suicide. the

support

is able

session.

that

attempt,

social

Dr.

who

Even though this film may be criticized for its overly simplistic view of the psychotherapy process, the positive portrayal of the dedicated psychiatrist, as well as the sympathetic portrayal of the troubled patient, serves as an effective counterbalance to the majority

Particularly pertinent to the feelings of hopelessness experienced by many who are driven to suicide is Conrad’s description of what drove him to his first attempt: “It’s like faffing into a hole, and the hole keeps getting bigger and bigger and suddenly you’re inside and you’re trapped and you’re the hole.” Finally, Conrad’s sense of isolation from his mother, because of her inability to talk about his brother’s death or his initial suicide

posttraumatic

the topic graphic to phone

hospital.

his

by Judd

cathartic

con-

to avoid Similarly,

has killed herself, he conhis wrists. Fortunately,

to contact

(played

powerful

are

to minimize the its aftereffects

depression

Mary

halting

incident

mother’s attempts such discussion.

attempt accident

major

His

discuss

and

of Conrad’s inresultant psychion the family is

the

is the

careers

PRESSURES

AND

SUICIDE

1989

film

of

that

Winona

helped

Ryder,

launch Christian

Slater, and Shannen Doherty. The film is a black comedy of adolescent suicide that manages, often in spite of itself, to portray the

effects

of suicide

able high school Early in the film,

on

a cohort

students Veronica

of vulner-

and their parents. (Ryder) is induced

and seduced by her boyfriend J.D. (Slater) into murdering the tyrannical leader of the school’s most powerful social clique while making it look like a suicide. This “suicide” initially generates a lot of confusion within the

school

as

to

how

the

issue

should

be

addressed. However, when J.D. subsequently tricks Veronica into murdering two of the school’s football players and making it seem like a double suicide, the school and surrounding community rally under the banner of teen angst to acknowledge the inherent stresses of teenage life. Unfortunately, the overzealous faculty organizer of this movement goes so far as to promote the notion that suicide is sometimes an unavoidable sequelae of teen problems: At one point, he states, “whether to kill yourself or not is one of the most important decisions a teen-

ager

can

make.”

The

promotion

of this

atti-

real suicide attempts, one by a popular cheerleader, the other by one of the school’s social outcasts. It is then that Veronica recognizes the hysteria of the “suicide frenzy” occurring around her and takes action to diffuse it. While this film promotes the dangerous misconception that talking about suicide can influence an individual’s overall suicide risk, it does retain some educational value. First, the film spothghts the notion of “copycat tude

later

suicides.” nomenon timated

to two

leads

While the is somewhat that

from

evidence for controversial, 1%

to

2%

this

of

pheit is es-

all

teen

suicides do occur in clusters (7); therefore, this factor merits consideration in the proper context. A second strength of the ifim is its portrayal of many of the ship stressors experienced

social by

and relationteens. While

the ramifications of peer confficts and dating problems are often downplayed by parents as minor concerns, they can play a significant role as risk factors in teen suicide. The portrayal of these confficts and problems, along with the reactions of the film’s characters, lends important insight into the severe stresses teens experience. SUICIDE SUICIDE

GESTURE

disorder. Forest

Glenn

ATFEMPT

demonstrates

Close’s the

portrayal DSM-IV

wrists.

that

help

Here

we

have

distinguish

attempt:

the

pulsive

nature

all the

the

dramatic

to ifiustrate

personality of

Alex

diagnostic

criteria of impulsivity, self-destructiveness, affective instability, and frantic attempts to avoid being abandoned, as well as idealizatiorildevaluation. The film can also be used to highlight the distinction between “suicidal gestures” and suicide attempts. Following a weekend of passionate lovemaking with Dan Gallagher (Michael Douglas’s character), a married man looking for sexual excitement (and himself an example of a narcissistic personality), Alex, in a desperate attempt to prevent him from leaving, slashes

ingredients

gesture

from

presentation;

of

the

act;

the

the

the

im-

choice

of

method (superficial wrist cuts, being less lethal than firearms, jumping, or hanging); readily available assistance; and clear-cut secondary gain (Dan stays to help tend to her wounds). Alex even goes so far as to ensure discovery by engaging him in a goodbye embrace during which she smears the blood from her cut wrists over his face. A somewhat older movie with a parallel plot and a similarly staged suicide attempt is the 1971 film Play Misty For Me. In the ifim, Clint Eastwood plays a disc jockey in a small Pacific-coast town who is pursued by a obsessed fan (Jessica Walter). After a brief physical relationship he tries to break things off and discovers she is willing to do anything to keep him, including slashing her wrists. As with Fatal Attraction, this effort is aimed more at gaining his attention and forcing her way into his life than representing a serious

wish

to die.

An Officeranda the

other

suicide.

end David

Gentleman of the

Keith

(1982) presents

spectrum, plays

Blount) presents he can

completed

Sid Worley,

commissioned officer going through ors of naval flight school training new girlfriend Lynette (played

VS.

Fatal Att raction (1987) can be used a “textbook case” of borderline

her

a nonthe

when by

rig-

his Lisa

tells him she is pregnant. The news him with two very difficult options: forget about her, remain loyal to the

code of his military family, complete his training, and marry the woman they have chosen for him, or he can forsake his family, quit naval training, and many Lynette. He acts on the second of these choices, but is scorned by Lynette who has lied about the pregnancy because of her dream to be the wife of a navy aviator. The abrupt loss of support from his family, the loss of his future goal of becoming a pilot, and the rejection he experiences by Lynette are all strong risk factors for suicide in someone of his age rigid

group. His ultimate suicide illustrates characteristics of a serious attempt: a method

with high lethality potential (hanging), a solitary location (a motel room), a swiftly executed plan with little chance for second thoughts, and a failure to tell anyone of his

serious

whereabouts

tranged room);

or intentions.

A similarly fatal involving a character sented

in the ifimA

character (played self

in the

Lt. Colonel

when

faced

with

is pre-

(1992). The Markinson

Matthew the

again

military, Men

chooses

his military

commanding

attempt,

Few Good

by J.T. Walsh)

dishonoring his

suicide

to shoot

dilemma

service

him-

of either

or betraying

officer.

Another film that highlights many of the risk factors of a completed suicide is ‘Night Mother (1986), from the Pulitzer Prize-winning play by Marsha Norman. Sissy Spacek portrays a young woman who is bent on self-destruction

following

a series

of

per-

sonal disappointments. Her mother, played by Anne Bancroft, is shown to be powerless to prevent the ultimate outcome. The entire film is a study of the careful preparations for the

deed.

sions

Particularly

between

futility

the

of trying

now

that

the

mother

she

has threatens

moving

are the

protagonists

discus-

involving

the

to stop Spacek’s character made up her mind. When to call

her

daughter’s

psychiatrist, a family member, or the police, the mother is told, “Go ahead and while you make the call, I will shoot myself now rather than later.” Similar careful preparations leading ultimately to suicide are seen in Ironweed (1987). Jack Nicholson plays Francis Phelan, an alcoholic vagabond, who is a grief-stricken father who blames himself for the accidental death of his infant son. Many in the audience will be moved following the final days of his life, where he is shown paying one last visit to the wife that he abandoned, before committing suicide by jumping out of a moving train. In the recent ifim Scent of a Woman (1992), we witness the elaborate preparations of the blind Lt. Col. Frank Slade (played by Al Pacino), who decides on a last fling in New York City prior to taking his life. Here again, we see

a number

of factors

associated

with

planned

suicide

attempt:

gunshot

a lethal

to

the

method

head);

thought-out plan; the placing order (including a final visit brother); an isolated a last fling (complete

(a

a well-

of affairs to see his

in es-

location (a hotel with limousine

and an expensive hotel, dinner, and call girl); and a lack of future plans (buying a one-way ticket to New York). The deed is prevented only by the timely intervention of his compassionate travel companion (played by Chris O’Donnell), who gives him the strength to live on in the face of his vision loss. SPIRITUAL AND PHILOSOPHICAL ASPECTS OF SUICIDE Any discussion plete without

of suicide would be incomsome efforts to portray the spiritual aspect. In It’s a Wonderful Life (1947), George Bailey (played by James Stewart) decides to end his life because of desperation over forces that he cannot control. He is shown by Clarence (his guardian angel) that his life, indeed, has value and that his existence has enhanced the lives of all those with whom he has had contact Though it is unlikely that any potential suicide victim will respond

to the

cheer

and

goodwifi

espoused

in the film, it makes a wonderful case for remaining optimistic in the face of overwhelming odds. Many a therapist, or potential therapist, should find much to relate to in this classic film. The film Thelma and Louise (1991) also illustrates more of a philosophical perspective on the issue of suicide. In the final scene, the two protagonists (played by Geena Davis and Susan Sarandon) are faced with the choice of either continuing to live in a maledominated world and being judged for a murder committed in an act of self-defense against

women selves. valuable a

illustrating

rape,

with

or

dying

as

no one to answer this film is not

While teaching

common

aid from suicide

two

liberated

to but

them-

a particularly the perspective risk

factors,

of it

provide

does

an

example

excellent

strength

of human us that in certain sons would sooner

conviction circumstances sacrifice

than

their

compromise

and

of the reminds some perown lives

their

video

is not

“pirated,”

tional

rather

than

the

clip

is relatively

and if the nounced.

beliefs.

DISCUSSION

not

choose just

them

to use

videotape

commercial

a series

teaching

to illustrate

and

psychopathology,

use

psycho-

or any related topic, like suicide? response is that videotapes of actual are quite useful and, if available,

therapy, The best patients

should indeed ing purposes, various

be used. commercial

topics

can

often

be

superior

to the

tapes of actual patients. First, a good deal of thought (and money) has gone into the often high

production

values

ing

in graphic,

typic

ifiustrations

“real

life.”

patient

of these

films,

Second,

when is played

students, or trainees, tient relating a story

a videotape

are

allowed

their lives ing to the

of

what is seen is the pa(or history) after the fact.

up

attempt,

themselves,

emotions sider the

Scent

as well

and share difference

terview

of,

say,

the

events

fateful reasons tapes

we

can

view

leading

the

as experience

Al Pacino

several as compared

attempt,

of the

experience

the desperation. between viewing

of a Woman

tive

and

as they unfold. Rather than listenteffing of a story of events leading

to a suicide

events

the Conan in-

character

in

days after his aborwith watching all

up to and

including

the

day. Third, it might be difficult for of confidentiality to present videoof

students. ethical The cial

to observe

films

beyond the “fair

actual

patients

Using issue.

commercial

legality

of using

is controversial, the use

to an

audience

films clips and

from

article

or several

supply

of material

is available

knows

which can

tape

to rent a film

of

for example, pages

of

to advertise the Finally, a large to anyone

who

a video

store

from

wealth

of

movies aired each week by the dozens commercial and cable television stations.

from

the

of All

the films mentioned the Appendix, should

in on

earlier, or included be readily available

videotape.

Suggestions Depictions

for Use of Commercial Film for Teaching Psychiatry

of a

to an audience

By contrast, in the film portrayals we are able to view the protagonists in context: that is, we

include,

materials payment

result-

dramatic, and often protothat are not easily found in

interview

the

be ifiegal admission.

films

if

5 minutes),

film is clearly andoctrine” allows

a book.) It would movie or to charge

or who

However, for teachfilm depictions of

(under

copyrighted

would of an

for educapurposes,

without

This

photocopies

Why

film?

of patients

certain

to use

in

their

short

identity of the (The “fair use

teachers

royalties. Why

if it is used commercial

avoids

of this

commer-

a discussion

is

scope of this article. However, doctrine” is likely to apply if the

The senior author has used clips of commercial ifim depictions to teach psychiatry to medical students, psychiatric residents, and faculty, as well as to other mental health professionals, including psychiatric nurses and occupational therapy students. For instance, film clips demonstrating the stigmatization of the mentally ill in the movies have been used by the author at professional meetings and at meetings hosted by allied groups of families of the mentally ifi. The courses

that

annual

meetings

the

author

has

of the American

taught

at

the

Psychiatric

Association have been extremely well received, as judged from the course evaluations and personal contacts with the participants.

To follow

are

some

suggestions

for using the film clips discussed earlier. Beginning a lecture with a brief film clip is a good way to capture the attention of the audience. The scene from Ordinary People where Conrad cuts his wrists after discovering that his friend from the hospital has committed suicide is effective in this regard. Alternatively, the lecturer can conclude alec-

ture by presenting a film clip that summarizes key points of the lecture, such as ‘Night Mother, or a clip that leaves the audience with a topic to discuss in small groups following the lecture, such as the final scene from Thelma and Louise. Films clips are also useful in small

group

cussion.

Choosing

what

discussions

to stimulate

clip

a film

ambiguous

that

in its content,

dis-

is some-

or message,

is a good way to the audience to has always been ating discussion.

excite interest and provoke participate. Fatal Attraction a potent stimulus in generAnother particularly effec-

tive

is

technique

assignment

to illustrate sion

to

to bring (e.g.,

the

group

an

videocips of a potential discus-

an aspect

topic

give

in their

suicide).

own

The

author

has

been

continually students

impressed by how creative the can be in finding film clips to illustrate a variety of topics in psychiatry. It was through an exercise of this type that the coauthor of this paper was rate on this article. Though this paper cide,

psychiatric

dance

of

has

focused

clips

selected

ifim

to collaboon

sui-

will find an abun-

educators

illustrative

commercial films that juncts in teaching about psychiatry. The teacher present

recruited

available

from

may be used as adalmost any aspect of may find it useful to clips

to ifiustrate

the

various aspects of psychopathology as would be reported in a mental status examination: the Joker, from Batman (1989), to focus on appearance; the Kevin Costner character from Field of Dreams (1989) to dis-

cuss auditory hallucinations (“If you build it, he will come”); and the psychiatric examination scene from The Terminator (1984) to ifiustrate the definition of delusion. Scenes including Kevin Kline’s character in Sophie’s Choice (1982) or Peter Finch’s character from Network (1976) can be used to illustrate various aspects of mania. The hospital scene from Vertigo (1958) showing James Stewart in a state of catatonic stupor can be used to illustrate marked psychomotor retardation found in serious depression. In either large lectures or small groups, the teacher can present a film clip and ask how the students would arrive at a certain diagnosis or formulate a treatment plan for the character. An excellent case study is to be found in the character of Travis Bickle, the Robert DeNiro character in Taxi Driver (1976). Indeed, a series of scenes from that film have been incorporated

in an interactive

to teach

a systematic

computer approach

program to evaluating

a patient’s mental status (8). To take advantage of this vast, nearly untapped teaching resource, educators need only learn to shift their perspective when viewing films toward keeping an eye open for scenes

or characters

that

may

be useful

to

their teaching. The author has accumulated a personal collection of some 1,200-plus ifims that are regularly used for teaching. Of course, a system for cataloging and indexing such film clips is highly recommended. The list of potential ifims that can be useful in teaching about psychiatry is almost endless.

References 1. Fidler

DC: The

for psychiatric

dilemma

of unavailable

education.

Academic

videotapes

Psychiatty

1993;

17:171-173 2. Hyler

SE:

DSM-III

movies.

Compr

3. Gabbard

GO,

at

the

cinema:

Psychiatry Gabbard

1988; K:

madness

parasites:

mentally

movies.

atry

1991;

ill in the

42:1044-1048

therapeutic

29:195-201

Countertransference

the movies. Psychoanal Rev 1985; 72:171-184 4. Hyler SE, Gabbard G, Schneider I: Homicidal acs to narcissistic

in the

the Hosp

stigmatization Community

5. Microsoft Corporation: Cinemania ‘94 (CD-ROM) Interactive Movie Guide. Seattle, WA, Microsoft Corporation, 1994 6. Buzan RD, Weissberg MP: Suicide: risk factors and

in

considerations

emergency

Med 1992; 10:335-343 MS. Wallenstein S, Kleinman

7. Gould mani-

ride

clusters:

of the

Am

J Public

Psychi-

in the

depart-

J Emerg

ment.

8. Hyler cation.

an

examination

MH,

of age-specific

Health 1990; 80:211-212 SE, Bujold AE: Computers in psychiatric Psychiatric

Annals

1994;

24:13-19

et al: Sineffects.

edu-

APPENDIX #{149} Absence Melinda whose paper

1.

Selected

movie

depictions

of Malice (1981) Dillon as a helpful, frightened life is ruined by a thoughtless story

of suicide

news-

#{149}After Hours (1985) Roseanne Arquette’s character overdoses unclear reasons in lower Manhattan #{149}And Justice Jack Warden judge bent

for All (1979) portrays a mentally on self-destruction

#{149}The Bell Jar (1979) The Sylvia Plath autobiographical picts the mental breakdown

paign

to find

that

his

#{149}Hamlet (1948 and Both Sir Laurence

for

spectively,

drama of a young

dewoman

beloved

has

cam-

war killed

herself

#{149}Captain Newman, M.D. (1963) Eddie Albert plays a psychotic, manic Army officer who jumps off a water tower when confronted #{149}The Jaye

with

his illness

Crying Game (1992) Davidson’s portrayal

volved

in a

IRA terrorist leads native to unrequited

relationship

to suicide love

with

attempt

#{149}Dead Poets Society (1989) A student kills himself rather than the will of his domineering father,

him to become

a doctor

rather

#{149}The Deer Hunter (1978) Russian roulette turns deadly Walken’s character following

would

an actor

War

experiences #{149}Down and Out in Beverly Nick Nolte, as a bum, tries the swimming pool of the a Beverly Hills mansion #{149}The End (1978) Burt Reynolds attempts kill himself, after being

Hills

(1986)

to drown unhappy

himself owners

in of

capable

Nikita punk

to change his life, or given a fatal diagnosis

prison

(1990) chooses

#{149}The Godfather, Part Imprisoned Mafioso well-being

over

an ines-

term

#{149}A Few Good Men (1992) J.T. Walsh’s character chooses honor

the

death

2 (1974) chooses

of his family

death

suicide

before

to ensure

(1971) Harold

Mel

Gibson,

ceases

the even

re-

of existence

more

simulating eccentric

suicide and attempts community to cope

jump from save him?

the ledge?

Will

have

been

like if George

had

never

#{149}Last Tango in Paris (1973) After his wife commits suicide, Marlon gets to play an “American in Paris” #{149}Lethal Weapon (1987) Mel Gibson plays a suicidal a nervous breakdown after

Brando

cop on the verge of the death of his wife

#{149}Meet John Doe (1941) Gary Cooper plays an unemployed man duped by a fascist newspaper magnate #{149}Network (1976) A third-rate TV network ings after its anchorman self on-screen

dis-

a

been

who

is

gets a boost in the ratthreatens to kill him-

#{149}‘Night Mother (1986) A young woman is determined to kill herself ter a series of personal disappointments

#{149}Fatal Attraction (1987) Glenn Close’s character, Alex, responds poorly to rejection and makes a desperate suicide attempt to maintain her relationship with Michael Douglas’s character #{149}La Femme Ultra-violent

meaning

#{149}It’s a Wonderful Life (1947) Savings & Loan President George Bailey is saved by his guardian angel from despair and suicide attempt by showing him what life born

as an alter-

for Christopher his Vietnam

the

the suicide by the Hol-

#{149}I Never Promised You a Rose Garden (1977) A disturbed 16-year-old experiences command hallucinations to kill herself

in-

succumb to who wants

than

examine

#{149}Hero (1992) Will Andy Garcia Dustin Hoffman

an

of a transvestite

complicated

versions) and

#{149}Heathers (1989) Film illustrates adolescent of the school officials and

housemates folof the group

(1992) his successful

Olivier

1991

#{149}Harold and Maude Eccentric 20-year-old suicide after meeting 79-year-old Maude

unbalanced

#{149}The Big ChilI (1983) The reunion of former college lowing the suicide of a member #{149}Bram Stoker’s Dracula The count returns from

#{149}Guilty by Suspicion (1991) Robert DeNiro’s character witnesses of an actress whose life is destroyed lywood blacklist

woman

#{149}An Officer and a Gentleman A young Navy cadet chooses honor following abandonment

af-

(1982) death over disby his girlfriend

#{149}Ordinary People (1980) Timothy Hutton’s character attempts suicide following the death of his older brother in a boating accident. His psychiatrist, portrayed by Judd Hirsch, interprets his survivor guilt and heals him #{149}The Prince of Tides (1991) A suicide attempt by Nick Nolte’s troubled twin sister Savannah brings him to New York to work with his sister’s psychiatrist, Barbra Streisand

APPENDIX

1.

Selected

movie

depictions

of suicide

#{149}Saturday Night Fever (1977) An unplanned pregnancy and an inferiority complex lead John Travolta’s disco buddy to “fall” to his death from the Verrazano Bridge #{149}The Shrike Jose Ferrer tor whose overdose

(1955) plays a depressed Broadway tyrannical wife drives him

#{149}The Slender Thread Sidney Poitier plays line who attempts to a suicidal woman at line

directo a drug

(1965) a volunteer at a suicide hottrack down the location of the other end of the phone

(continued) #{149}Sophie’s Choice (1982) Meryl Streep is the concentration camp survivor who is led back to life, and then to death, by her “manic-depressive” boyfriend Kevin Kline #{149}Splendor Natalie

in the Grass (1961) Wood’s conflict between her Warren Beatty and her moral values to attempt suicide

love leads

#{149}What’s New Pussycat? (1965) Peter Seller’s hilarious attempt to commit cide is thwarted by Woody Allen

for her

sui-

Medical

Electives and Into Psychiatry

School

Recruitment A 20-Year Walter

Experience

Weintraub,

S. Michael Eric

Plaut,

Weintraub,

M.D. Ph.D. M.D.

Part of psychiatry’s recruitment problem is a result of defections among students who were planning careers in psychiatry when they entered medical school. The authors present data from a 20-year (1974-1993) experience at the University of Maryland that shows that students who expressed a preference for psychiatry as a career in the freshman year were four times more likely to enter psychiatric residency training after graduation if they participated in the Combined Accelerated Program in Psychiatry (CAPP), a 4-year psychiatric elective program, than if they pursued the regular undergraduate psychiatric program. More than 20% of the CAPP students who preferred non psychiatric careers as freshmen were “converted” to psychiatry and later entered psychiatric residency programs. Recent changes in the ideology and economics of our profession have neither lessened the popularity of the CAPP nor diminished its apparent ability to shelter students preferring psychiatry from the stigmatizing experiences of medical school. (Academic Psychiatry 1996; 20:220-225)

D

uring the past few years, recruitment of American medical graduates into psychiatry has taken a downward turn. While

taking fewer candidates interested in psychiatry (2). These explanations of the recruitment

problem

the

since

the

reasons

for

psychiatry’s

losses

are

not

known, educators have offered a number of speculations. We have been told that psychiatry has a gloomy future under managed care (1), that our profession has been unfairly portrayed in the press and movies, and that medical

Dr.

school

admissions

W. Weintraub

associate

professor;

professor; versity

of

committees

is clinical and

Dr.

Baltimore, Department Street, Baltimore, MD Copyright

© 1996

Dr.

E. Weintraub

all are in the Department Maryland School of

Maryland. Address reprint traub, School of Medicine,

professor,

Academic

Plaut

is

is assistant

of Psychiatry, UniMedicine, Baltimore,

requests University

of Psychiatry, 21201-1549.

are

to

Dr. W. Weinof Maryland at

645W.

Psychiatry.

Redwood

outside

may

causes our

and

be

termed

proposed

professional

activities.

“alloplastic,” solutions

are

“Alloplas-

tic” theorists, for example, suggest influencing admissions committees’ decisions, improving psychiatry’s image in the community, and trying to ameliorate our economic future. There is, unfortunately, no evidence that such praiseworthy efforts have any influence on recruitment into psychiatry. The “autoplastic” approach to psychiatric recruitment focuses on changes within the medical school, specffically in the medical school environment. This approach assumes that many more students enter medical school with the ing careers in psychiatry

intention

than

of pursu-

actually

do so

after lieve

graduation. “Autoplastic” that large-scale defections

educators befrom psychi-

are attributable to an unfriendly medical school environment (3,4). Of the various specialties, only psychiatry is viewed in a consistently negative way by nonpsychiatric faculty and house staff. The “autoplastic” approach to recruitment is to use the re-

atry

of medical

schools’

departments

of

psychiatry to create a friendlier environment for students interested in psychiatry as well as for potential “converts”-that is, students with an aptitude for psychiatry who are open-minded about their future careers. Educators do not agree among themselves with respect to which experiences may influence a student’s choice of psychiatry. It is apparently possible to offer medical students a well-integrated series of lectures and clinical experiences of high quality without

ing

increasing the likelihood of their psychiatry as a career (5). We describe an undergraduate

chooselective

program, the Combined Accelerated Program in Psychiatry (CAPP), which has had remarkable success in recruiting medical students into psychiatric residency programs over a 20-year span (1974-1993). After briefly describing the CAPP, we report recruitment data for the first 20 graduating

factors

dasses

that caused THE

COMBINED

PROGRAM The idea Department

and the

try to account

program’s

for the

success.

ACCELERATED

IN PSYCHIATRY

for the CAPP was initiated by the of Psychiatry of the University of Maryland in 1970. In a sense, the program was a response to the student revolt of the 1960s, a movement that was sharply critical of the content and manner of medical school teaching. A behavioral science and psychiatry track, the CAPP enables selected medical students to enroll in a specialty program while continuing in the usual curriculum. Traditionally, 12 students are selected from approximately twice that number of applicants. No pledge of a career interest in psychi-

and

students all applicants

spring

no preference

planning

CAPP

atry

sources

is required,

to applicants

is given in psychiatry.

careers are chosen accepted

as follows. to the next

Each fresh-

school dass are sent letters deCAPP and inviting interested students to apply. During the first freshman psychiatry dass in the autumn, the director of CAPP speaks about the program and extends a second invitation to interested students. Applicants are evaluated in two stages.

man medical scribing the

First, the program director all candidates and screens seem

unsuited

who

have

plicants they

to

the

may

and

those

its goals. Some apat this point when

withdraw that

interviews those who

program

misunderstood

realize

briefly out

participation

requires

more

time than they are willing to give. The second stage of the selection process consists of two lengthy interviews, one with a faculty member and one with an upperciass CAPP student. The interviewers report their impressions of the applicants to a committee that makes the final selections. A student’s chances

for acceptance

are enhanced

if he or

she has an unusually brilliant college record; has a special accomplishment or aptitude (Ph.D., published research, high MCAT socres etc.); belongs to a minority group; and comes from rural Western Maryland or the Eastern Shore. Although there have been some minor changes in the CAPP curriculum, it has remained fundamentally unaltered throughout the 20-year period. Students are expected to be familiar with the general culture of the psychiatric profession by the middle of the junior year of medical school. Reading seminars are scheduled during the first 2 years to guide students in their mastery of basic psychiatric concepts. The clinical part of the CAPP is highly structured and consists of a sequentially arranged series all participants semester

are

taught

interviewees,

of experiences must pass.

of the

how

freshman

through year,

to establish

using

first

which the first

During

each

the

students

a rapport

with

other

then

and

ward patients as subjects. During the second semester, the students learn to elicit and describe the signs and symptoms of psychiatric

ration

illness. In addition to the interviewing seminar, CAPP students spend a block of 4 hours a week on 1 of the psychiatric inpatient units. They become familiar with a ward commu-

uted to the program. Summer stipends for CAPP students remaining in the Baltimore

nity

and

mental

submit

status

reports

to be

evaluated by a faculty member. CAPP students who desire personal treatment are offered psychotherapy at a fee they can afford by members of the local psychoanalytic society.

During man

the

year,

spend

at least

atric

The

into

the junior

London,

the

students faculty.

is done

CAPP

students

attention preference

in

is supervised

get in other by the

senior

a great

faculty.

deal

ways, too. Department

the

20-year

of Psychiatry atry had sciences

combined

of perThey are of Psy-

discussion

A 6-week

outpatient

and

Data

complete a specialty 1970, the year the groups of students

effects of the program significant for students

found

in prior

publications

(6,7).

Program funding plished in several ways. is done faculty

by fullfree

tor possessing tion. Early

and

of charge.

has Most

part-time

been of the

accomteaching instruc-

a rare skill receives remunerain the program’s development, costs and defrayed

tute

Health

summer fellowship by a National Instigrant.

After

the

expi-

inpatient

assign-

requirements.

to

and entered We have

residency included

in

trainour

who completed at the possible positive are not likely who spend

to be only a

few months in the program. Of the 244 students admitted into the program during the 20-year span, 224 completed at least 1 year and

departmental

An occasional

administrative stipends were of Mental

about the can be

and

preference form. Since program was started, 20 have graduated from

those students in the CAPP;

1 year

lectures

after their acceptance students are asked

faculty. Additional goals and strategies

least

Psychibehavioral during the

Collection

Within 2 weeks the CAPP, the

study only

the

groups were used junior derkship, which

the formal

completed

Department

students.

Large group

years.

postlecture for instruction.

medical school ing programs.

CAPP

local, contrib-

undergradu-

hours to teach psychopathology

small

into

the

a strong

for non-CAPP 150 and

preclinical

ments,

period,

offered

chiatry when applying for fellowships and jobs, are invited into professors’ homes for dinners and parties, and often develop close relationships with many of the psychiatric information of the

hospitals

TRAINING IN PSYCHIATRY FOR NON-CAPP UNIVERSITY OF MARYLAND MEDICAL STUDENTS

supervision from and mentoring

by full-time

Affairs

office;

and

to go elsewhere.

adults and children. do psychotherapy, the

receive individual Much of the teaching

in CAPP sonal given

with they

time

beginning

year,

choosing

ate program

and Turkey.

program,

sophomore

psychotherapy During the

rotations

they train. They stipends and are

Switzerland,

Veterans

the dean’s

Psychiatry;

area are provided by those institutions to which the students are assigned. Departmental funds provide stipends for students

During in-

in the world. Since 1970, gone as far as San Fran-

of the

student’s

psychiatry

and

of

to

psychi-

are generally

in which modest

Italy,

heart

with

grant,

Department

state,

fresh-

required

working

free to go anywhere CAPP students have The

the

are

students

of the institutions are provided with

cisco,

following

students

8 weeks

patients.

tegrated

summer

CAPP

of the federal

the

graduated

224 students, psychiatry preferred In freshman complete

from

medical

school.

Of these

98 indicated a preference early in the freshman year;

another specialty. 1972, 1973, and 1974, medical the same

students specialty

all

for

126

entering

were asked to preference form

given

to

CAPP

completed

students.

within

academic

the

year.

Of

the

dents who entered land

School

years,

405

of

indicated

forms

few

446

of the

non-CAPP

stu-

an initial

former

the specialty 405 students, 20

entered graduation.

for psychiatry. records

kept

and Office of Student school, we were able to

ascertain

the

specialty

choices

students expressed the early

and 20 non-CAPP students a preference for psychiatry part of the freshman year.

of the

of the

veals (15%)

that 68 (69.4%) of of the latter entered

the

and 3 resi-

18.29;

=

recent

de-

cline in interest in psychiatric affected the CAPP’s effect

specialization on recruitment,

we compared first 10 years

figures (1974-1983)

those

results

the recruitment of the program 10 years identical.

of the second are almost

10 years,

69.1%

psychiatry chiatric vs. 70%

in the freshman

year

training second

the

“Converts” Of the specialties

During

students

residency during

of the with

(1984-1993).

of CAPP

The the

other

than

entered

classes

P

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