Psychotherapy Training in Residency Programs in Demand and in Peril

Psychiatry residents want and need solid training in psychotherapy in order to best serve their patients and to remain competitive in the mental health marketplace, concluded a March conference sponsored by the American Psychiatric Association's Commission on Psychotherapy by Psychiatrists (COPP). The event, entitled "Integration and Specificity in Psychotherapy Education," drew 120 training directors, residents and faculty from around the country, and represented approximately 40% of U.S. residency training programs.

According to COPP chair Norman A. Clemens, M.D., while many residency programs offer exposure to cognitive-behavioral, psychodynamic and supportive therapies, residents are not adequately prepared to competently use them to treat patients. In a recent article, Clemens added that exposure to family therapy, group therapy and interpersonal therapy is even rarer, and that there is significant variability in the quality and intensity of psychotherapy training among residency training programs (Clemens, 1999).

COPP vice chair Glen Gabbard, M.D., Bessie Walker Callaway Distinguished Professor at the Menninger School of Psychiatry and Mental Health Sciences, is similarly concerned and feels that there is an ongoing lack of emphasis on the integration of biological and psychosocial therapies in training programs (Gabbard, 1997). "Patients should be thought of both in psychological and biologic terms to avoid fragmenting the patient and the treatment," wrote Gabbard. "Moreover, psychodynamic psychiatry should not be regarded as anti-biologic. Psychodynamic and biological approaches generally work synergistically to enhance treatment outcomes and preserve the patient's holistic experience."

Gabbard believes that managed care has encouraged this dichotomy through the frequent practice of splitting a patient's treatment between a psychiatrist for pharmacotherapeutic interventions and nonmedical mental health care professionals for talk therapy. Moreover, Gabbard told Psychiatric Times, the advent of effective psychopharmacological treatments and growing advances in genetic research and imaging technologies have encouraged many psychiatrists to adopt a primarily biological view of the genesis of psychiatric illness-often at the expense of psychosocially oriented practice.

Still, there is good news, said Clemens. Surveys conducted by COPP and the American Association of Directors of Psychiatric Residency Training show that the demand for solid psychotherapy training is strong among residents. Better training in short-term, structured and problem-oriented treatments is particularly sought after, since these modalities have been systematically evaluated and, therefore, are more likely to be reimbursed by managed care companies.

Developing Training Programs

The issue of what to teach and how to teach it in the era of managed care, federal health care regulations and effective, new pharmacological agents has been comprehensively examined by Bernard D. Beitman, M.D., professor and chair of the department of psychiatry and neurology at the University of Missouri at Columbia. Beitman, along with colleague Dongmei Yue, M.D., resident at University of Missouri at Columbia and formerly an assistant professor at the department of psychiatry of China Medical University in Sheyang, China, have examined psychotherapy training programs.

"As training programs in psychopharmacology become increasingly more standardized in an effort to provide information in time-efficient ways, training in psychotherapy should also be considered for basic standardization for the same reasons," write Beitman and Yue in an upcoming article (Beitman and Yue, in press). "Psychotherapy is a crucial element of resident education; its generic components are well-established. This program offers a possible answer to the need for a time-efficient training program in the basics of psychotherapy."

Beitman and Yue believe that U.S. residency training programs for psychiatrists lack a systematic, integrated approach that is simultaneously clinically and research-based (Beitman and Yue, in press). For example, most U.S. residency training programs allow instructors and supervisors to present their own perspectives, "implicitly suggesting that trainees should put the ideas and techniques together in a way that suits them personally."

A second increasingly common type of program relies on a manual-based training model. This type of training is effective in presenting a variety of different theoretical perspectives along with the necessary nuts-and-bolts skills, such as the use of cognitive therapy in the treatment of depression. Unfortunately, write Beitman and Yue, "a manual-focused training program limits understanding of other possible approaches for those patients who have more complicated presentations than those addressed by protocol-prescribed approaches."

In response to these concerns, Beitman and Yue have developed a series of training modules that gather core concepts and techniques common to the major psychotherapeutic schools (Beitman and Yue, in press). The goal of the modules is to give residents a solid grounding in psychotherapy basics while requiring them to use established research protocols to sharpen inductive reasoning and to measure their therapeutic competence over the course of their work with patients.

Modules are presented at hour-long seminars held each week over the course of the 12-month program. Residents learn about concepts including, but not limited to, transference, countertransference and resistance. At the same time, residents are required to use a variety of standardized measures that gauge everything from how well they manage therapeutic boundaries to which verbal interventions they use in a given patient interaction. Trainees are also asked to review their answers and explain differences between sets of responses given during each module.

This training technique currently is being used at seven U.S. sites. Moreover, there are plans to implement the modules later this year in Spain, Canada and several additional U.S. locations.

Meeting the Needs of Patients

Psychiatry residents aren't the only ones clamoring for solid training in psychotherapy, even though managed care often places significant restrictions on reimbursement rates and frequently mandates that psychotherapy patients be seen by nonmedical mental health care providers. According to Gabbard, "many patients are starting to experience a 10- or 15-minute medication check as dehumanizing... They come to another doctor and say, 'I want someone who'll listen to me and talk to me.'"

Gabbard believes the level of patient outrage over restrictions on treatment, coupled with considerable discomfort over the dissemination of intimate information about their lives, has resulted in a consumer revolution of sorts. "Many patients are totally fed up with having managed care dictate their treatment...They're willing to pay out of pocket for a good psychiatrist doing psychotherapy." That also applies to finding a psychopharmacologist who is able and willing to talk with them about feelings that may arise around the taking of medication, he added.

Chelsea Chesen, M.D., a second-year house officer in the Creighton-Nebraska Psychiatry Residency Program, started her residency with a keen focus on psychopharmacology but soon realized that it wasn't going to be enough. After she started seeing patients she realized that there were necessary skills that she didn't possess from her training.

"If you're not able to work with patients on a variety of different levels, you're not doing them any justice," Chesen said. "You realize that things pop up that can be very messy and overwhelming and frustrating, and all of your past training in medical school is poor preparation for handling those moments."

For Chesen, one of those "moments" occurred when a patient carried a shopping bag full of psychotherapy books up eight flights of stairs to a session, emptied it onto the table and said, "You might want to have these books."

"What do you do when a patient brings a library?" Chesen asked. "That is the perfect example of where you must be able to address the kind of complex issues that are behind something like that [behavior]," she explained.

Chesen, who hopes to continue working in academic medicine and eventually join her father in his Lincoln, Neb., psychiatric practice, points to excellent supervision as an essential part of her education as a therapist in training. "I don't think I had any clue before about how much pain there really is in people's lives," she said. "When you're the one who gets saddled with that all day, it can be overwhelming if you don't have someone in a supervisory role to help you through it."

Carl Greiner, M.D., director of residency training at Chesen's residency program, concurs. According to Greiner, who also serves as professor and vice chair for education at the program, it strives to balance solid didactic training with practical clinical experience. "So much about medicine seems to be about talking, about directing," he said. "I think one of the most important lessons is about being quiet...Part of the task of becoming a therapist is learning the difference between being a helpful friend and being a professional."

Solid psychotherapy training is not solely imperative for psychiatrists who plan to specialize in talk therapy modalities, according to Gabbard (Gabbard, in press). For example, experiential activities involving group dynamics with peers, as well as formal training in group therapy with patients is excellent-and much needed-preparation for work in institutional settings, where the often-potent effects of unconscious dynamics among staff can assert themselves. Training in group dynamics also makes good financial sense, said Gabbard, as the cost-effective nature of groups is likely to increase their popularity as a treatment alternative.

Market Forces

However, despite a clear show of interest by residents in psychotherapy training, Greiner and others interviewed for this article said they are extremely concerned that market forces and ongoing favoritism toward strictly biological modalities pose a serious threat to the wholehearted integration of psychotherapy into training curriculae. Also at risk is programs' ability to attract and keep volunteer faculty, said Greiner and David Goldberg, M.D., executive director of the American Association of Directors of Psychiatric Residency Training and director of the Institute of Living/University of Connecticut Psychiatry Residency Program.

"In order to enable a psychotherapy program to be at all substantial, it's got to have the support of the [department] chair," Goldberg said. "There needs to be time in the curriculum to teach it, which is increasingly competed for. Secondly, there needs to be a culture within the department that values psychotherapy and the broader view of what psychiatry is so that faculty and residents will really be committed to having that be part of the work."

Goldberg said market forces also are affecting the number and type of clinical training opportunities for residents. "The more the clinical work of the resident is paired with a managed care clinical system, the more difficult it is to do any more sustained psychotherapy," he said. As for clinical supervisors, more and more senior clinicians are deciding that they cannot continue to volunteer their time as mentors as they fight for their own economic survival in an era of shrinking reimbursement rates, said Goldberg. The other experts interviewed for this article agreed with this notion.

A shrinking corps of professional role models may be hurting psychotherapeutically oriented young psychiatrists in other ways. "The residents, in some ways, track the attendings," said Greiner. "Most attendings need to show that they're financially solvent, and the way they do that is to see many more patients for psychopharmacology."

Indeed, Gabbard said he is aware of some residency programs in which psychologists, not psychiatrists, are doing the vast preponderance of psychotherapy and talk therapy instruction. Therefore, more psychiatrists are needed to mentor residents not only on how to begin the process of becoming a good therapist, but also to model the importance of integrating biological and psychosocial perspectives.

Gabbard is convinced that solid training in talk therapies is key not only to a well-rounded education, but also to providing all psychiatrists-regardless of their area of specialization-the unique marketplace niche as specialists in both biological and psychosocial approaches to the treatment of mental illness. To neglect the importance of both aspects of psychiatry in the current managed care climate is, he said, to put psychiatrists at risk of becomingly increasingly eclipsed by internists and primary care physicians and/or by nonmedical mental health care professionals.

References:

References

1.

Beitman BD, Yue D (in press), A time-efficient, research-based, outcomes-measured psychotherapy training program. Academic Psychiatry.

2.

Clemens N (1999), Residency training in psychotherapy: alive and kicking. Psychiatric News 34(3):16, 21.

3.

Gabbard G (1997), Training residents in psychodynamic psychotherapy. In: Acute Care Psychiatry: Diagnosis and Treatment, Sederer L, Rothschild A, eds. New York: Williams & Wilkins, pp 481-491.

4.

Gabbard G (in press), The psychiatrist as psychotherapist. In: Psychiatry in the New Millenium, Weissman S, Sabshin M, Eist H, eds. Washington, D.C.: American Psychiatric Press Inc., pp 169-184.