Psychodynamic Trojan horses: using psychopharmacology to teach psychodynamics

Concurrences of scientific, cultural, and economic developments in the past decade have changed psychiatric practice and psychiatric training. The explosion in neurobiological sciences has left residents with an overwhelming amount of neurobiology to master at the same time that managed care has led to a de-emphasis on psychiatrists providing psychotherapy. Consequently, many residents are left questioning the relevance of psychodynamics for psychiatry, given that the majority will function primarily as prescribers. However, the illusion, increasingly common in our culture, that medications are a simple fix leaves residents unprepared to make sense of the complex and irrational processes that happen in the acts of prescribing and taking medications (or not taking medications). Consequently, residents may feel confused, angry, hopeless, and/or abandoned in their role. These residents are often hungry for a context to explain why they feel hopeless, confused, or defeated in carrying out the "simple" task of prescribing. A psychodynamic understanding can provide such a holding context, just as it can give residents tools for backing out of futile and/or destructive enactments and turning conflicts around medications to some therapeutic good. Many psychodynamic concepts that initially may have seemed to residents part of some arcane and outmoded pseudoscience suddenly become relevant when they provide both a context for understanding the resident's distress and useful clinical tools. Those psychodynamic psychiatrists wishing to promulgate a psychodynamic understanding may need to meet psychiatric trainees at their developmental level and take seriously the current emphasis on providing effective somatic treatments. By engaging trainees at the junction of psychodynamics and psychopharmacology, psychodynamic psychiatrists may find a more receptive audience and open the door for greater interest in developing psychodynamic understanding and technical skills.