TIFT #120: Teaching Psychotherapy

Today's post is to share a recent experience teaching psychotherapy to psychiatry residents from raw beginners to those with some experience. A group of us from the Psychotherapy Caucus, a special interest group of 1500 psychiatrists within the American Psychiatric Association, developed and presented a three-hour remote training to each of six residencies around the country. We wanted to show them the infrastructure of psychotherapy while giving them practice in using what they learned.

Where training is today

The current state of the art in psychotherapy training emphasizes three principles. First, training should be multi-component, meaning didactics, supervision, observation of experienced mentors, practice with each other, etc. A second element that satisfies today’s yearning for “evidence-based” is incorporating “common factors,” relationship factors proven to correlate with therapeutic success. And finally, “deliberate practice,” meaning the use of taped sessions to identify and work, one at a time, on achieving specific goals for improvement. These are all accepted ways to address the nonspecific needs of clients, but none of them deals with the infinite variety of problems our clients bring to us for help. That’s where there is a problem and a need.

The current fragmentation of psychotherapy theories and orientations takes a toll. Faithful adherence to a single therapy limits the techniques one can confidently use, while no one therapy covers all clients and problems. Learning to work with the breadth of clients’ problems requires learning multiple approaches and is too complicated and overly confusing. In the end, too many therapists do what a colleague called “how-ya-doin” therapy, just being a good listener.

The incompatibility of existing theories is a historical artifact, due to the era of their development, when there was literally no science to explain how the mind/brain works. Conjecture was all there was, and it lead remarkable founders each to a very different model. Another result was that classical theories are relatively silent on the low-level mechanisms by which technique actually brings about change. That’s a shortcoming, but also an opportunity. Only in the 21st century, has it become possible to build a universal, “nondenominational” framework, based on science from outside the field of psychotherapy. This, finally makes it possible to explain how communication and relationship are able to build conditions for change. The framework we used is explained in TIFT #101.

Making the teaching as compact as possible

The idea was to arm trainees with powerful ideas so they could understand what needed to happen and how their communications and relationship, the basic tools of the trade, could move the process forward. Then we would give our groups time to practice using the ideas. Knowing that residency training directors and residents have important limitations on teaching time, we decided on three hours overall, one for the didactic material and two to workshop the practical application. 

Over the past year, I have gained experience presenting the framework in less and less time. I presented it in Philadelphia in 90 minutes, then I had a chance in Marrakech to do it in twenty. That is when I boiled my presentation down to the material in TIFT #101. I had to read it to keep it that short, but it worked and has since been published (Smith 2024).

For the practicum, the key was to identify a single task the trainees could focus on, seeking accurate empathy. Not only is that a means for supporting common factors by encouraging a strong therapeutic alliance, but it also fulfills the conditions for memory reconsolidation, namely, activating the old pattern in the limbic system, while delivering a new, disconfirming perspective. To make such an abstract idea concrete, we presented the concept of seeking ever-deepening answers to the Five Key Questions developed and downloadable at howtherapyworks.com (See link at the end of TIFT #101). To make them easy to remember, we gave the mnemonic, EDTRA: “Extra with the X replaced by D for Dread.”

Method

Six residency programs responded to a message on the listserv of the American Association of Residency Training Directors, AADPRT and scheduled time for groups of residents ranging from first years only, to a mixture of all four years of residency training. Training was provided either in three one-hour online sessions or a single three-hour workshop. First they were asked to take a 5 question multiple choice clinical quiz based on the applying the five questions to a case vignette. Next an hour long didactic by Dr. Smith outlined the framework. After a short break, the practicum consisted of discussion of case material provided by the trainees in the light of the five questions. An early group proposed a novel learning format in which a resident role-played a patient and Dr. Smith was asked to conduct an interview based on the five questions. This proved popular with subsequent groups as well. At the end of the second hour, the same brief clinical quiz was administered to determine any change in scores. A few days later, residents were contacted by email to request numerical and narrative feedback. 54 residents in all responded to the request for feedback. 

Results

As observed by the presentation team, residents ranged from highly to moderately engaged. Clinical material provided by residents reflected the difficult cases they are seeing, particularly in inpatient care. 

Of 54 participants who gave an email address here is the data:

1. Scores on pre/post test: 29% of residents showed an increase in scores (0-5/5).
2. In their rating of their knowledge of psychotherapy, (Values 1-5), 20% showed an increase.
3. Scores were not correlated with PGY year.

Narrative Feedback

Suggestions for Improvement 

Discussion

Overall, the response from residencies met our expectations and the engagement of residents. PGY 1s (Post Graduate Year), especially PGY 1s, who had no previous psychotherapy teaching, exceeded our expectations with regard to engagement and in-session feedback. As the purpose of the pilot project was a proof of concept, we consider it successful in demonstrating that a practical, cross-theoretical framework can be taught in three hours or less to the point of being useful to residents to help them begin to understand the universal infrastructure of psychotherapy and apply it to their work. 

Weaknesses in the pilot project are that the pre/post test was not rigorously validated and was not correlated with PGY (post graduate year). In addition, no control group was identified from which to generate comparative statistics.

Future Plans 

Based on feedback regarding shortening of the program, a determination needs to be made if this is due to the material being highly accessible or to the format of student-supplied examples to work on. An additional option would be to "flip the classroom," assigning an article (Smith 2024) giving the didactic portion of he presentation prior to a more interactive class, then focusing class on practical application using pre-chosen clinical vignettes. Another option is to focus on a "train the trainers" program so that training programs can incorporate the material into classes and supervision.

The group would greatly appreciate thoughts by readers involved in training as teachers, supervisors, or recipients. Please use the comment section below.

Jeffery Smith MD 

Reference

Smith, J. (2024). A Modern Conceptual Framework Eases Training and Sharpens Practice. Dynamische Psychiatrie / Dynamic Psychiatry 57(3-4) 101-111.

Photo Credit: Agence Olloweb, Unsplash