LETTERS
are perceptibly different in quality from psychotic and netirotic symptoms” (emphasis added). For example, the actingout but voluntary patient with a ‘ ‘character neurosis’ ‘ seen in a university outpatient clinic or in psychoanalysis should not be confused with the individual with an antisocial personality disorder seen in a military hospital or prison.
We
have
shown
that
those
with
well-defined
personality
disorders are unable to develop and sustain psychologically soothing experiences and modes ofrelating (2, 5). They treat their inner life as concretely and impersonally as they do that of others. Attempts to establish emotional closeness characteristically make them edgy, even panicky. The psychiatrist is hard pressed to find anything such patients regard as sacred and to which he can appeal in forming a working alliance. Some of these patients have a limited capacity for expenience in this mode and can be helped to develop the ability. As they become more able to relate transitionally they begin to apprehend the nature and magnitude of their illness (5). Therefore, the likelihood that the unawareness of illness (anosognosia) shown by these patients is related to a primary cerebral disorder does not necessarily preclude experiential modification or compensation (1, 5).
To those edness severe
who
understand
the concept
oftransitional
relat-
and have personality
worked extensively with well-defined and disorder, our hypotheses offer many opportunities for development and testing. For example, one could (if resources were available) compare cortical biopsies of tertiary zones of the minor parietal lobe from personality disordered patients with controls. A cortical aberration in these areas would be consistent with my hypothesis.
TO
THE
EDITOR
has delineated many of the criticisms and challenges to it, has pointed out one specific criticism-the Board does not supply either adequate or useful feedback with regard to a candidate’s performance in either the written or oral examinations regardless of the candidate’s grade. The Board and their examinations are virtually a givenfait accompli, since
it is doubtful that to hand: therefore, spond
to Dr.
viable alternatives I believe that
Small’s
the
to certification Board should
are close now re-
criticism.
It is a well-established
fact
that feedback
is an effective
fa-
cilitator in learning, and it is unconscionable that the Board, which prides itself in establishing criteria for professional competence, does not point out the weaknesses and strengths of each of its candidates. It would seem a simple procedure, especially with the assistance of computer technology, for the Board to tell all candidates how they rank among their peers in the tested areas and to offer suggested readings in areas where deficiencies are noted in order to help the candidates improve their skills. This could be done in a way similar to that used in the Psychiatric Knowledge and Skills Assessment Program. It may even be desirable to set a goal of, for example, 80% of all practicing psychiatrists to be certified, instead of the approximately 60% who took and passed the Boards in 1975. Useful feedback on both written and oral examinations could possibly improve psychiatry’s standing in the certification numbers game as long as certification is still a sine qua non for recognized professional competence.
REFERENCES I
REFERENCES I . Horton PC, Coppolillo HP: Unconscious causality and the pyramid of science. Arch Gen Psychiatry 26:512-517, 1972 2. Horton PC, Louy JW, Coppolillo HP: Personality disorder and transitional relatedness. Arch Gen Psychiatry 12:193-214, 1973 3. Coppolillo HP: The transitional phenomenon revisited. J Am Acad Child Psychiatry 15:36-47, 1976 4. Freedman AM, Kaplan HI, Sadock BJ (eds): Comprehensive
Textbook Co. 1975 5.
Horton order.
ofPsychiatry,
2nd ed. Baltimore,
Williams
& Wilkins
.
2. 3.
Patterson DY: How to avoid taking J Psychiatry 132:79-80, 1975
the Boards
Fligsten KE: The Boards: candidate anxiety havior(ltrtoed). AmJ Psychiatry 132:976-977, Nigro SA: Back on the Boards (ltr to ed). 132:671, 1975
but save face.
Am
and examiner
be-
1975 Am J Psychiatry
4. Small SM: Recertification for psychiatrists: the time to act now. AmJ. Psychiatry 132:291-292, 1975 5. Chase RA: Proliferation of certification in medical specialties: productive or counter-productive. N EngI J Med 294:497-499,
is
1976
PC: The psychological treatment Am J Psychiatry 133:262-265, 1976
of
personality
dis-
6. Small I, Guide.
Carter
New
L(eds): The Psychiatric York, Medical Examination
Boards: A Preparation Publication Company,
1972, pp 45-48 PAUL
C.
HORTON
Meriden,
M.D.
F.
MICHAEL
Conn.
Feedback
on the Boards
SIR: There is a hint ofturbulence stirring in the psychiatric horizon, as is witnessed by recent letters and articles appearing in thefournal that address themselves to the issue of certification and recertification (1-4). Whether specialty certification is even productive in regard to improving the quality of health care-a raison d’#{234}treof the specialty Board-is questioned by Dr. Chase (5), who feels the consequences ofthis certification may distort an objective view of ‘ ‘the conflict between what protects the public from incompetence and what serves the self-interest of dedared certified specialists through exclusivity. “ Dr. Chase wonders if research could be directed toward finding viable alternatives to certification that would also promise improved specialty care.
Dr.
Small
(6), who
is sympathetic
to the Board
and
who
M.D.
HEIMAN,
Stockton
,
Calif.
Editor’s Note. We would like to point out that candidates can get feedback on the Boards by writing to Lester H. Rudy, M.D., Executive Director, American Board of Psychiatry and Neurology, Inc. , 1603 Orington Ave. , Suite 1320,
Evanston,
Ill. 60201.
Feedback
come of the oral portion quartiles on both portions
Patient SIR:
and
Responsibility
The
Jesse
and
experiences 0.
Cavenar,
Inquiry
into
Resistance”
panison
with
the
private
practice
the absence patients do Am
Canadian
includes
of the
outand
Psychotherapy
“Free”
reported
by James L. Nash, M.D., Free Psychotherapy: An (September 1976 issue) invite com-
M.D.
,
in
‘ ‘
situation,
is free under
where
universal
of a fee-for-service not feel like charity J Psychiatry
review
of the Boards as well as scores of the written exam.
133:12,
psychotherapy
Medicare.
social context, cases. For most December
1976
Clearly,
in
in
Medicare people, the 1471
LETTERS
TO
knowledge
THE
EDITOR
that the government
pays
the bills prevents
a feel-
illness
How does the patient who would express not paying his bills behave under Medicare? has
to deprive
ernment atrists
the
does here
therapist
ofhis
not pay for missed have
made
fee
contracts
LETTERS
mits.
Like
The
letter
TO THE
other
should
his hostility by The only way he
is not to come;
sessions. with
dude responsibility for attending Medicare pays: if they miss sessions
Thus their
most
patients
Am
J Psychiatry
/33:12,
transference deprived
they
of
this
difficulties, either of income or the need
psychi-
by making no demands. meet certain minimum
that
which
the
govin-
are
is the
directly
nature
EDITOR
material
are
welcomed
submitted
not exceed
December
and
1976
they
the resentment of a therapist
Any patient expectations:
will be published, they
must
references,
be subject
to the
for the
avoid
time.
counter-
of a therapist to be “giving”
in psychotherapy it is that
and
must not
the
issue. JOEL
including will
helps
Montreal,
for publication,
500 words,
billed
also
sessions. If they come, (for reasons other than
has been made with the Editor, and will not ordinarily be acknowledged.
1472
or snowstorms),
Limit-setting
ing of obligation.
iffound
suitable,
be typewritten
unless usual
per-
double-spaced.
a special
editing.
as space arrangement
Receipt
PARIS,
Que.
of letters
,
M.D. Canada
fee
are perceptibly different in quality from psychotic and netirotic symptoms” (emphasis added). For example, the actingout but voluntary patient with a ‘ ‘character neurosis’ ‘ seen in a university outpatient clinic or in psychoanalysis should not be confused with the individual with an antisocial personality disorder seen in a military hospital or prison.
We
have
shown
that
those
with
well-defined
personality
disorders are unable to develop and sustain psychologically soothing experiences and modes ofrelating (2, 5). They treat their inner life as concretely and impersonally as they do that of others. Attempts to establish emotional closeness characteristically make them edgy, even panicky. The psychiatrist is hard pressed to find anything such patients regard as sacred and to which he can appeal in forming a working alliance. Some of these patients have a limited capacity for expenience in this mode and can be helped to develop the ability. As they become more able to relate transitionally they begin to apprehend the nature and magnitude of their illness (5). Therefore, the likelihood that the unawareness of illness (anosognosia) shown by these patients is related to a primary cerebral disorder does not necessarily preclude experiential modification or compensation (1, 5).
To those edness severe
who
understand
the concept
oftransitional
relat-
and have personality
worked extensively with well-defined and disorder, our hypotheses offer many opportunities for development and testing. For example, one could (if resources were available) compare cortical biopsies of tertiary zones of the minor parietal lobe from personality disordered patients with controls. A cortical aberration in these areas would be consistent with my hypothesis.
TO
THE
EDITOR
has delineated many of the criticisms and challenges to it, has pointed out one specific criticism-the Board does not supply either adequate or useful feedback with regard to a candidate’s performance in either the written or oral examinations regardless of the candidate’s grade. The Board and their examinations are virtually a givenfait accompli, since
it is doubtful that to hand: therefore, spond
to Dr.
viable alternatives I believe that
Small’s
the
to certification Board should
are close now re-
criticism.
It is a well-established
fact
that feedback
is an effective
fa-
cilitator in learning, and it is unconscionable that the Board, which prides itself in establishing criteria for professional competence, does not point out the weaknesses and strengths of each of its candidates. It would seem a simple procedure, especially with the assistance of computer technology, for the Board to tell all candidates how they rank among their peers in the tested areas and to offer suggested readings in areas where deficiencies are noted in order to help the candidates improve their skills. This could be done in a way similar to that used in the Psychiatric Knowledge and Skills Assessment Program. It may even be desirable to set a goal of, for example, 80% of all practicing psychiatrists to be certified, instead of the approximately 60% who took and passed the Boards in 1975. Useful feedback on both written and oral examinations could possibly improve psychiatry’s standing in the certification numbers game as long as certification is still a sine qua non for recognized professional competence.
REFERENCES I
REFERENCES I . Horton PC, Coppolillo HP: Unconscious causality and the pyramid of science. Arch Gen Psychiatry 26:512-517, 1972 2. Horton PC, Louy JW, Coppolillo HP: Personality disorder and transitional relatedness. Arch Gen Psychiatry 12:193-214, 1973 3. Coppolillo HP: The transitional phenomenon revisited. J Am Acad Child Psychiatry 15:36-47, 1976 4. Freedman AM, Kaplan HI, Sadock BJ (eds): Comprehensive
Textbook Co. 1975 5.
Horton order.
ofPsychiatry,
2nd ed. Baltimore,
Williams
& Wilkins
.
2. 3.
Patterson DY: How to avoid taking J Psychiatry 132:79-80, 1975
the Boards
Fligsten KE: The Boards: candidate anxiety havior(ltrtoed). AmJ Psychiatry 132:976-977, Nigro SA: Back on the Boards (ltr to ed). 132:671, 1975
but save face.
Am
and examiner
be-
1975 Am J Psychiatry
4. Small SM: Recertification for psychiatrists: the time to act now. AmJ. Psychiatry 132:291-292, 1975 5. Chase RA: Proliferation of certification in medical specialties: productive or counter-productive. N EngI J Med 294:497-499,
is
1976
PC: The psychological treatment Am J Psychiatry 133:262-265, 1976
of
personality
dis-
6. Small I, Guide.
Carter
New
L(eds): The Psychiatric York, Medical Examination
Boards: A Preparation Publication Company,
1972, pp 45-48 PAUL
C.
HORTON
Meriden,
M.D.
F.
MICHAEL
Conn.
Feedback
on the Boards
SIR: There is a hint ofturbulence stirring in the psychiatric horizon, as is witnessed by recent letters and articles appearing in thefournal that address themselves to the issue of certification and recertification (1-4). Whether specialty certification is even productive in regard to improving the quality of health care-a raison d’#{234}treof the specialty Board-is questioned by Dr. Chase (5), who feels the consequences ofthis certification may distort an objective view of ‘ ‘the conflict between what protects the public from incompetence and what serves the self-interest of dedared certified specialists through exclusivity. “ Dr. Chase wonders if research could be directed toward finding viable alternatives to certification that would also promise improved specialty care.
Dr.
Small
(6), who
is sympathetic
to the Board
and
who
M.D.
HEIMAN,
Stockton
,
Calif.
Editor’s Note. We would like to point out that candidates can get feedback on the Boards by writing to Lester H. Rudy, M.D., Executive Director, American Board of Psychiatry and Neurology, Inc. , 1603 Orington Ave. , Suite 1320,
Evanston,
Ill. 60201.
Feedback
come of the oral portion quartiles on both portions
Patient SIR:
and
Responsibility
The
Jesse
and
experiences 0.
Cavenar,
Inquiry
into
Resistance”
panison
with
the
private
practice
the absence patients do Am
Canadian
includes
of the
outand
Psychotherapy
“Free”
reported
by James L. Nash, M.D., Free Psychotherapy: An (September 1976 issue) invite com-
M.D.
,
in
‘ ‘
situation,
is free under
where
universal
of a fee-for-service not feel like charity J Psychiatry
review
of the Boards as well as scores of the written exam.
133:12,
psychotherapy
Medicare.
social context, cases. For most December
1976
Clearly,
in
in
Medicare people, the 1471
LETTERS
TO
knowledge
THE
EDITOR
that the government
pays
the bills prevents
a feel-
illness
How does the patient who would express not paying his bills behave under Medicare? has
to deprive
ernment atrists
the
does here
therapist
ofhis
not pay for missed have
made
fee
contracts
LETTERS
mits.
Like
The
letter
TO THE
other
should
his hostility by The only way he
is not to come;
sessions. with
dude responsibility for attending Medicare pays: if they miss sessions
Thus their
most
patients
Am
J Psychiatry
/33:12,
transference deprived
they
of
this
difficulties, either of income or the need
psychi-
by making no demands. meet certain minimum
that
which
the
govin-
are
is the
directly
nature
EDITOR
material
are
welcomed
submitted
not exceed
December
and
1976
they
the resentment of a therapist
Any patient expectations:
will be published, they
must
references,
be subject
to the
for the
avoid
time.
counter-
of a therapist to be “giving”
in psychotherapy it is that
and
must not
the
issue. JOEL
including will
helps
Montreal,
for publication,
500 words,
billed
also
sessions. If they come, (for reasons other than
has been made with the Editor, and will not ordinarily be acknowledged.
1472
or snowstorms),
Limit-setting
ing of obligation.
iffound
suitable,
be typewritten
unless usual
per-
double-spaced.
a special
editing.
as space arrangement
Receipt
PARIS,
Que.
of letters
,
M.D. Canada
fee
