Contribution to the subtopic "The Teaching of Medical Psychology"
(a collaborative work with Dr. Horacio Etchegoyen)
We have been unable to locate where this work was originally presented.
The defining characteristic, perhaps, of modern medicine is its rediscovery of humanity. To encompass the human being in their highest and most complex unity is the great challenge today, as it is no longer possible to study humans as a mere sum of their parts but rather as a living, functional whole.
The 19th century allowed for an understanding of humans as biological beings adapted to their environment. Through the methods of natural sciences, it examined the organism deeply, rationally, and objectively, achieving a knowledge of unimpeachable solidity. However, this knowledge was partial and fragmented. It was partial in that it neglected the undeniable fact that the human environment is not only physical but also social. It was fragmented because it studied the human being in death and in isolated parts. To continue interpreting humans as biological beings adapted to their environment, it has been necessary to recognize their highest level of functioning—the psychic—and to apprehend them in their integral and indivisible biological, psychological, and social quality.
This new socio-medical anthropology has largely emerged from psychiatry, which makes it possible to resolve the antinomy between disease and patient, to assess the importance of psychological and social components in behavior, health, and illness, and to grasp the effective factors influencing the doctor-patient relationship. This explains the mission of psychiatry in the context of medical studies: to provide the foundations for a more comprehensive vision of humanity. Achieving these objectives inevitably requires a new and enhanced approach to psychiatric education.
The Teaching of Medicine and the Role of Psychiatry
It is well known that medical education suffers from excessive breadth, and there is no justification for further expanding it. Therefore, the issue is not simply to advocate for more psychiatric instruction but rather to determine how psychiatry can best serve medical training. This can only be achieved if a new balance in the curriculum grants psychiatry the place it deserves.
It is essential for new knowledge to be incorporated into education from the outset to prevent students from acquiring a partial understanding of human nature. It is also advisable for this responsibility to fall under the psychiatry department, ensuring that this fundamental aspect of medical education is overseen by a single discipline. Leaving it to the discretion of other departments would not be ideal for numerous and obvious reasons, although collaboration between disciplines should, of course, be encouraged.
Consequently, psychiatry, as a fundamental subject, should stand alongside physiology, anatomy, and histology, contributing to the student’s preparation from the early years of their education.
Incorporating these areas of knowledge is tantamount to creating a new subject, whether it be medical psychology or preclinical psychiatry. The latter designation has the advantage of establishing continuity with clinical psychiatry, which is highly significant; however, it complicates the operation of the psychiatry department, as it requires a broader scope of work for which it is often unprepared.
The dilemma between medical psychology and preclinical psychiatry can be resolved in either of the two proposed ways: by creating a separate department for medical psychology or by expanding the scope of psychiatry. Either approach would need to ensure the unity of the teaching process and align it with the general medical education curriculum.
Content of Psychiatric Education
Although there is general agreement that psychiatry should be taught throughout the entire medical program, opinions diverge regarding its curriculum, as it is challenging to define general concepts that satisfy all schools. However, perhaps it is unnecessary to aim for such universal agreement. It may be more prudent to respect the individuality of instructors, trusting in their sound judgment, which deserves legitimate confidence.
The Parallel Operation of Psychiatry Departments and Curricular Structure
The establishment of multiple parallel psychiatry departments within each medical faculty should be encouraged, as is the case, for example, in Chile. This system would allow students the freedom to enroll in the department that aligns with their preferences. In this way, each department would guide a specific group of students throughout their entire education, following a vertical rather than a horizontal structure to ensure the continuity of the teaching process.
If these departments were staffed by representatives of the major psychiatric schools—which indeed exist in the country—each school of thought would have the opportunity to develop and implement its teaching plans, allowing for a comparison of methods. Such an approach would also ensure that future psychiatrists are exposed to all major schools, an essential step in preventing sectarianism, as Whitehorn emphasized.
However, for students, such a broad and complex teaching framework risks overwhelming them with an excessive array of information, potentially detracting from its educational value.
Psychiatric Education: A Model for the Curriculum
The 1951 Ithaca Conference, "Psychiatry on Medical Education," proposed general guidelines for the psychiatric curriculum over the four years of medical education in the United States. During the first two years of preclinical psychiatry, the primary topics include psychodynamics (the structure of the psychic apparatus and personality development), psychopathology, and interpersonal relationships. In the final two years of clinical psychiatry, students study patients in outpatient and inpatient psychiatric hospital settings (preferably in the psychiatric ward of a general hospital), child psychiatry, psychosomatic conditions, and more.
On this foundation, the American Psychiatric Association has developed a psychiatric program that spans the entirety of medical education. While broad and flexible, this program has the drawback of imposing a progression from normal psychology to pathology and then to clinical psychiatry. This approach gives students the false impression of divisions that do not truly exist within the continuous flow of human life.
A Unified Approach to Psychiatric Education
The curriculum outlined here seeks to ensure the unity of the teaching process and avoid any fragmentation. The core principle is that the approach to the patient should be comprehensive and holistic from the very beginning.
The progression of knowledge should be established through an increasingly profound understanding of the patient, rather than through separate subjects or topics. This approach ensures that the teaching mirrors the interconnected nature of human health, behavior, and pathology, fostering a cohesive learning experience.
The Early Steps of Psychiatric Education
In the initial stages of their education, students engage with the patient’s situation in the context of their illness, observing how the illness affects the patient’s behavior and social group. This approach allows students to transition gradually, naturally, and often rapidly from common understanding to scientific comprehension. This type of patient-centered engagement should ideally be introduced in the first year, enabling students to connect with living patients rather than focusing solely on cadavers. Lewin, in a now-classic article, pointed out the significant distortion this creates in the future relationship between the doctor and the patient.
This preliminary study of the patient’s surface conditions and social environment is conducted both in the hospital and at the patient’s home. Through home visits, where the student acts as a social worker, they gain insight into the problems faced by the patient and their environment, assessing the impact of the illness on both.
Progression Through the Years
Second Year: Students adopt the role of observer-participant, studying the patient’s personality and psychic structure. This stage introduces students to clinical psychology.
Third Year: Continuing as observer-participants, students delve deeper into the emotional and social implications of the illness, now examining these factors within the patient rather than intermittently as in previous stages. This phase connects them with psychopathology, psychosomatic correlations, and related fields.
Fourth Year and Beyond: Students transition into operational agents in their interactions with patients, whether in individual or group settings. They develop a sense of teamwork and study patients from diverse phenomenological and diagnostic perspectives. This stage involves applying all therapeutic possibilities and requires exposure to a broad range of patients, including outpatients and inpatients, individuals with neuroses and psychoses, organic and functional conditions, children and adults, and patients from different social classes and cultural backgrounds.
Pedagogical Challenges in Psychiatric Education
Psychiatrists with a dynamic orientation agree that one of the greatest challenges in teaching psychiatry lies in the strong emotional resistance it evokes. The subject matter and concepts provoke anxiety, leading students to reject the material because it activates neurotic elements of their personalities. Thus, the primary obstacle in teaching psychiatry stems from the very nature of what must be taught.
Faced with this unique problem, two approaches have emerged:
Some authors advocate addressing these difficulties outright through psychotherapy.
Others rigidly separate psychotherapy and education, fearing that teaching could be distorted by turning students into patients.
Upon closer examination, it becomes evident that the boundaries between psychotherapy, learning, and teaching are fluid. The key challenge is to clearly define techniques and methods that enable a more straightforward and unrestricted approach to psychiatric education, integrating both elements effectively.
Although the intersection of psychotherapy and teaching has not yet been thoroughly investigated to develop a didactic approach that inherently incorporates psychotherapeutic factors, a path forward appears to be emerging.
The integration of psychotherapy and teaching suggests that while it is neither appropriate to transform education into therapy nor to treat students as patients, it is equally unreasonable to ignore the application of the principles on which teaching is based within the pedagogical process.
It would, of course, be unwise to create difficulties merely to have the opportunity to resolve them. However, when such challenges inevitably arise, the right to address them must not be relinquished. The goal is to bridge the frequent and disruptive divide between theory and practice within the realm of learning.
Sources of Resistance in Psychiatry Education
The resistance to learning psychiatry stems both from internal motivations within the student and external factors related to the instructor and their teaching methods.
The Professor's Role in Psychiatric Education
The professor must always remain aware of their own limitations, never losing sight of the fact that every difficulty in teaching is, to some degree, their responsibility, regardless of the students' involvement. The way the material is presented, the careful pacing of the course, and the selection of appropriate topics must be continually evaluated in light of the tension and reactions observed in students.
Most importantly, the professor must consider the issue of interpersonal relationships with students. The relationship between teacher and student invariably stirs strong emotional responses, which is particularly true in psychiatry due to the inherently distressing nature of its topics. This dynamic, which has been emphasized for many years and recently highlighted by Silverman and others, should be of special interest to professors, who must remain vigilant about their own conscious and unconscious emotions.
Group Psychotherapy in Psychiatry Education
Theoretical reasons, supported by practical experience, demonstrate that the group setting is the most effective method for teaching psychiatry. The scope of this method can range from educational groups fostering broad intellectual and emotional communication between the instructor and students to psychotherapy groups with a strictly therapeutic focus.
Between these extremes are learning groups (as described by Pichon-Rivière, Berman, Fey, Ganzarain, among others), where the learning process is combined with psychotherapy. The primary difference from the purely educational groups is the inclusion of a specific topic for study. However, starting with this topic, the emotional factors influencing group dynamics can also be explored.
In learning groups led by one of us (Pichon-Rivière), the focus is on the vocation and the learning process itself. Through the analysis of this task, psychiatric phenomenology and psychodynamics can be taught while simultaneously conducting a process of clarification and psychotherapy, which clears the way for effective learning.
Emotional Resistance and Anxiety in Psychiatry Students
It can be observed in these groups that the fear of madness, widely recognized as one of the most significant sources of resistance in learning psychiatry, takes on a specific form. It manifests as a strictly phobic fear, blending paranoid and depressive anxieties in relation to the object of knowledge.
Students often perceive, in vivid and dramatic ways, that learning ultimately entails identifying with the object of knowledge, essentially penetrating and merging with it. Paranoid anxieties emerge as fantasies of being trapped within the object—markedly claustrophobic in nature—accompanied by hypochondriac fears of contamination and contagion.
The early and systematic analysis of these specific anxieties shortens the path to the desired goal: clearing the operational field of learning. As one might expect, these conflicts are most intense in students aspiring to become psychiatrists. If left unresolved, these anxieties can result in a genuine fear of patients, which manifests as a constant avoidance of direct patient contact and reliance on a distanced, "delegated" approach to treatment.
A Group Psychotherapy Experience
One of us (Etchegoyen) initiated an experiment in psychoanalytic group psychotherapy with third-year medical students at the Faculty of Medical Sciences in Cuyo. The group consists of ten pre-selected students who have expressed a desire to pursue psychiatry as a specialty. In the ten sessions conducted so far, a strong dependence on the therapist has emerged among group members.
This dependence can be attributed to the students’ professional aspirations and other factors that cannot be detailed here. It is a particular aspect of the transferential relationship observed in this setting. To date, the previously described phobic fears have not surfaced, though their presence is suspected.
Conclusions
The current socio-medical anthropology necessitates a new and expanded psychiatric education.
These teachings should be integrated throughout the medical program, either by broadening the scope of the psychiatry department or by creating a new department for medical psychology, ensuring unity between the two.
Students should receive an education where informational and formative elements are harmonized, with its structure and content entrusted to the department head, avoiding rigid and uniform curricula.
The psychiatry program must ensure the continuity and sequence of the teaching process, progressing from common understanding to scientific comprehension through increasingly profound knowledge.
The approach to patients must be comprehensive from the outset, culminating in the study of patients with diverse nosographic types, ages, genders, social conditions, and more.
Alongside the official program, parallel psychiatry departments should operate, representing the main modern doctrinal currents. This will foster the expansion of psychiatry and benefit the training of future psychiatrists by providing opportunities to broaden their perspectives.
The fundamental pedagogical challenge in teaching psychiatry is the anxiety that the learning context provokes in students. Professors must prevent its emergence by carefully managing the course and their own emotional involvement in the process, but they must also address students' inevitable difficulties when they arise.
Anxiety situations that obstruct the natural course of learning are best addressed through group psychotherapy, which can be adapted to various levels (teaching groups, learning groups, training groups, and purely therapeutic groups).
In general, learning groups should be prioritized, as they combine teaching with psychotherapy.
Specific issues related to the learning process (such as the fear of madness) should be analyzed early and systematically.