It is extremely important for residents to develop critical thinking regarding all aspects of psychiatric treatments. Our residents learn the efficacy and risk/benefit ratio of not only somatic treatments but also psychotherapy.
One component of a program that is successful in training residents in a wide range of skills is providing them with exposure to a sufficient number of patients with a variety of psychiatric disorders in order to foster an appreciation of the fascinating diversity of psychiatric symptoms. Our rotations provide an excellent volume of patients with appropriate supervision. We are aware of the didactic limitations of either too few or too many patients, and we continually work toward the goal of maintaining the optimal number of patients.
Supervised treatment of a reasonable number of patients is necessary; however it is not sufficient to provide solid training in psychotherapeutic skills. Our approach to training residents in psychotherapy involves a combination of formal lectures, demonstrations, observation, and practice throughout the four-year training period.
The development of sound psychotherapeutic skills involves relationship elements that contribute importantly to outcome across therapy models, as well as learning how specific therapy models and interventions match to particular psychological problems. This latter aspect of training evolves as research demonstrates which therapies are effective in treating specific conditions.
Our didactic psychotherapy curriculum begins during the introductory summer course for the PGY1 residents with a discussion about pragmatic issues for psychotherapy with inpatients and a discussion about the patient-physician relationship.
During the inpatient psychiatry rotation in the PG1 year, residents improve their interviewing skills by conducting patient interviews in front of their colleagues and teaching attendings. In addition, residents learn basic psychotherapeutic skills and safety planning. Residents also observe faculty interviews. Several conferences during this year include specific discussions concerning inpatient psychotherapy and issues of transition to outpatient management. In addition, both pharmacotherapy and psychotherapy of patient management are discussed during daily attending rounds.
During the second year, residents continue to gain psychotherapeutic skills from supervised patient management coupled with didactics from daily teaching rounds and a hands-on seminar on Motivational Interviewing. In addition, they obtain substantial psychotherapy experience as they rotate through three different settings – chemical dependency at the VA, chemical dependency at Harris House, and the eating disorders rotation. On the consult service, experience is gained in certain types of brief therapies. Also, crisis intervention skills are enhanced from the ER experience.
PGY3 and 4
Substantial training in psychotherapy occurs during the third year when residents spend the entire year caring for both child and adult patients in the outpatient setting. Patients receive both psychotherapy and medications. Residents gain experience in behavioral and cognitive therapies, interpersonal therapy, group therapy, psychodynamic therapy, family therapy and supportive therapeutic approaches. Several structured didactics occur throughout the year and provide background for residents to implement psychotherapy in outpatient clinical practice:
Seminars in Psychotherapy
Seminars in Psychotherapy cover major psychotherapeutic modalities, including cognitive-behavioral therapy, dialectical behavior therapy, interpersonal psychotherapy and psychodynamic psychotherapy. The application of psychotherapy to couples, group settings and specific patient populations, such as those with trauma history, is also addressed.
The cognitive behavioral section of the course covers application to psychiatric disorders including depression, the major anxiety disorders, substance abuse, and personality disorders, as well as intervening effectively with the suicidal patient. Lectures on dialectical behavior therapy cover the skillful use of validation, emotion regulation skills, managing treatment interfering behavior and conducting chain analysis of problem behavior.
The psychodynamic psychotherapy curriculum covers ego psychology, object relations, and self-psychology, among other topics.
Another section of the course is devoted to Interpersonal Psychotherapy. These lectures teach how to complete an in-depth interpersonal inventory and help patients who are experiencing relationship conflicts, significant relational transitions and grief.
Group, family and couples psychotherapy are also discussed during the lecture series. Residents gain practical experience in both the adult and child clinics.
Ongoing Case Conference and Evidence-based Treatment
This conference focuses on a practical application of the psychotherapeutic approaches taught in “Seminars in Psychotherapy.” A case is presented to a psychiatrist or psychologist with the opportunity to follow the patient over several weeks.
As part of the ongoing case conferences, we include an interactive seminar that discusses principles of evidence-based analysis of pharmacological and psychotherapeutic treatment data and systematically reviews the evidence for the use of specific treatments in most of the major disorders seen in the outpatient setting.
Professor’s Case Presentations
The outpatient curriculum includes a professor’s case presentation rounds. A patient is presented to the professor and interviewed in front of the group. This allows special topics to be discussed, including diagnostic dilemmas and the management of difficult patients. This conference also provides an opportunity for the residents to interview a case in front of a group and receive feedback.
In addition to the above-described didactic training, residents spend two hours each week in clinical supervision. During this time, residents review and discuss with their supervisors the care they are providing to the patients. Residents have the opportunity to choose their supervisors. Numerous supervisors are available in the full-time faculty and part-time clinical faculty (private practitioners). This flexibility allows residents who are interested in more in-depth training in a specific modality of therapy to choose a supervisor with such expertise and work with that supervisor. Supervisors use audio or videotapes, process notes, or an informal dialog to review the resident’s patients.
In summary, our PGY3 outpatient curriculum is designed so that residents enhance their clinical skills and conduct excellent patient care in a diverse outpatient setting, using a variety of treatment options. Our residents learn to use both psychotherapy and pharmacotherapy in the care they provide to their patients. By the end of the 12-month outpatient experience, they have developed the knowledge and skills necessary for them to successfully treat patients in a busy outpatient setting.
Finally, residents continue to refine their psychotherapeutic skills during the PG4 year as they continue to take care of long-term patients. In addition, residents who wish to have more training in psychotherapy may opt to utilize their elective time to gain more experience in this area.