Thomas J. Craig, MD, MPH

This is the second in a series of articles examining the need for psychotherapy training in psychiatric education. Part 1 examined the issues that have caused psychotherapy to take a back seat in psychiatry as a whole as well as psychiatric education: 

Rescuing an Essential Component of Psychiatry: Psychotherapy Training in Psychiatric Education

Several agencies such as the American Council of Graduate Medical Education Milestone Project

 and Canadian professional and academic organizations

 have supported the continued inclusion of psychotherapy training in psychiatric residency programs. Others, however, have been critical of such efforts and even have openly proposed that psychotherapy be left in the hands of non-physician practitioners, despite the difficulties of coordinating clinical care among different health care professionals.

 As a result, a growing number of North American psychiatric training programs have reduced the hours devoted to psychotherapy training.

Essentials of psychotherapy teaching and training

Planning for the future of psychiatric training needs to weigh the realities of academic and service demands against the need for a harmonious view of medicine and psychiatry that includes an authentic humanistic component. Agile and effective curricular arrangements and constructive cooperation among experts are needed to promote competence in diverse approaches aiming at closing the gap between biomedical science and humanism and, thereby, reinserting a dialogue in a field lately undermined by sour polemics.

 The teaching and learning of psychotherapy must pursue the balance of the seemingly contradictory aspects of the psychiatrist’s identity (ie, neurosciences versus psycho-socio-cultural knowledge); not only can these aspects coexist successfully but they also can enhance one another. After all, learning to tolerate uncertainty must be a crucially relevant principle of psychiatric residency training in general and of psychotherapy training, in particular.

Thus, the goals of psychotherapy education in medical school should be based on the following ideals:

 should be taught, with an emphasis on a strong and meaningful therapeutic alliance

; objectives, theoretical principles, practical aspects, supervision and evaluation, as well as manual-based-therapeutic techniques adapted to and combined with multidisciplinary teamwork, adequate assignment of responsibilities, and coordination of management and follow-up should be included.

2. Psychotherapy must be taught throughout the four residency years with progressive complexity based on preferences made explicit by the trainee no later than the second year. No more than three choices are suggested, from modalities such as brief, 

, etc., and based on cogent information about distinctive characteristics (eg, processes, effectiveness, outcomes, etc.).

3. Personal disposition and technical requirements, (including access to adequate bibliography, internet-based information, and capable teacher-supervisors) as well as clinical case studies focused on different variables such as age, socioeconomic, and cultural background also should be included. Single conceptual formulations can be chosen in cases of individual psychotherapy, and contractually time-limited groups would empower the trainees’ ability to develop empathetic understanding of patients and their surroundings.

4. At least one fifth of the time during the first two years of residency should include individual or group supervision, real and clinical-simulation cases and discussions, journal/article reviews, and report on personal experiences; these areas should take one-third or one-fourth of the last two years. This aspect of the training must include the preparation of the psychiatrist to 

-an aim that can be greatly enhanced by training and experiences in psychotherapy.

5. Innovative teaching techniques based on actual experiences in private and public practice settings should be pursued. Examples include 

 like website videos, online CBT, and telepsychiatry.

6. Trainees with a priority interest in psychotherapy should consider one-year post-residency fellowships. Personal therapy during training also should remain as an option.

7. Demonstration and evaluation of core formative and summative competencies must be essential components of solid curricular designs for comprehensive psychiatric training programs.

The preceding goals can best be accomplished in institutions that seek and provide truly comprehensive training to future psychiatrists. Efforts should include assessment of the quality and quantity of human resources, as well as a critical appraisal of the support provided.

 Effective training in psychotherapy requires particular tenacity, consistency, and firm vocational roots on the side of students/trainees. These attributes will be useful in dealing with stigma-carrying critical statements and attitudes, stereotyped concepts, and prejudicial thinking. Like the psychotherapeutic process itself, psychotherapy training is a continuous fight against a polarization dictated by known and unknown adversaries.

 A continuous research-inspired perspective, based on evidence-based objectives, should nourish all the phases of such training.

For nearly six decades, world of psychiatry has been awaiting clinically useful breakthroughs from genetic, molecular, and neuroimaging research. Despite many exciting and promising advances, very little material directly applicable to the clinical understanding or management of most disorders has emerged. Instead, a kind of “pharmacocentric” biological theorizing has arisen from efforts to define the pharmacodynamics of psychotropic drugs, with limited success in attempts to identify pathophysiological or etiological routes of psychiatric disorders.

It is imperative to rescue one of the essential components of a genuine psychiatric vocation, training, and clinical work. Psychiatrists in training will experience great difficulties in acquiring essential clinical skills and values if they lack essential psychotherapy teachings. These skills include ability to listen, to think, and to feel, all guided by genuine curiosity and maturing objectivity.

 The therapeutic alliance is more than an empathetic connection: it is an integral learning process about the essence of human beings seeking help beyond prescription renewals, hoping for a more intense clinical scrutiny, and participating in a joint search of reasonably individualized solutions to complex problems. The possibility of involving patients and families in a constructive cooperative process of recovery is, as well, an invaluable component of such comprehensive assessment and clinical care.

Psychotherapy training not only entails treatment techniques but also allows for a deeper understanding of behavioral principles, a well-guided diagnostic process, and even insight into the patient’s response. A most serious risk is that psychotherapy-deprived or, more generally, psychologically under-informed psychiatric care, can become a woefully incomplete, sterile, pill-pushing, technoid-robotic activity-a Brave New World of rapidly proliferating mechanistic interventions jumping on the bandwagon of quickly increasing profits.

 Moreover, such trends can be highly demoralizing to the psychiatrist and may contribute to professional dissatisfaction and early burnout.

This could well be a critical moment in the history of our discipline. If the declining status of psychotherapy teaching in some academic centers prevails, psychiatrists could be reduced to technicians in a new mold, unprepared to satisfy the human needs of empathy, support, and understanding.

 Solutions may emerge from the encouraging, persistent interest of most trainees who view psychotherapy as reflection of a greater integration of knowledge and a crucial component of their professional identity and future practice.

 This outcome requires a sustained action of academic centers and professional organizations to nourish curricular innovations, studies, discussions, and demonstrations of the advantages of a harmonious management of today’s scientific advances and the durable essentials of truly human interactions.

 is Emeritus Professor of Psychiatry, Mayo Clinic School of Medicine, Rochester, MN; and Honorio Delgado Chair, Universidad Peruana Cayetano Heredia, Lima, PerÃº. Dr Craig is a former member of the 

American Psychiatric Association, Clinical Practice Guidelines Committee, Washington DC. Dr Fitz is a former Faculty member of Tulane University School of Medicine, Dpt. of Psychiatry in New Orleans. Dr Baldessarini is Professor Emeritus of Psychiatry, Harvard University Medical School, and former Director of Research Mc Lean Hospital, Boston.

Neuroscience and Humanistic Psychiatry: a residency curriculum

Psychiatry Residency Education in Canada: Past, Present and Future

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5. Kovach JG, Dubin WR, Combs CJ. Psychotherapy training: Residents’ perceptions and experiences. 

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13. Cardoso Zoppe EH, Schoueri P, Castro M, Neto FL. Teaching psychodynamics to psychiatric residents through psychiatric outpatient interviews. 

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19. Gajic T, Stamatovic-Gajic B, Lopicic Z. Psychodynamic psychotherapy in psychiatry: the missing link? 

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The goals of psychotherapy education in medical school should be based on these seven ideals.

A Critical Moment in Psychiatry: The Need for Meaningful Psychotherapy Training in Psychiatry

This is this is the first of a two-part discussion on the importance of psychotherapy training. Part 2 explores seven goals to implement into psychotherapy education in medical school: 

Throughout its history, psychiatry, probably more than any other medical specialty, has dealt with periods of drastic changes and adaptation demands affecting the theory and practice of the specialty. This situation has ignited heated 

, ideological battles, and intercultural collisions.

 Crises of this nature may be inevitable in a field that deals with elusive and complex human problems: mental illnesses, their affective and behavioral expressions, and their biological, psychological, and socio-cultural roots.

Substantial tension has arisen repeatedly over the past two centuries between biomedical and humanistic-psychological approaches to defining disorders, understanding their causes, and organizing techniques and systems of clinical care.

 Changes in theories and practices have deeply affected the organization of the field and induced a variety of challenges that, arguably, are more frequent than in other medical specialties.

A topic of current discussions across the world is the place and role of the psychotherapy theory and practice in psychiatric education and training.

 century in the wake of a decisive historical marker that many authors called the 

- the advent and development of psychoanalysis

-psychotherapy knowledge skills were more or less widely accepted as essential core components in educating medical students and future psychiatrists. Freud’s approach considered human suffering arising from emotional wounds triggered by family and society as a central factor in the development of many psychiatric disorders and, most importantly, supported its recognition, understanding, acceptance, and efforts at resolution as critical components of a successful clinical intervention.

Psychoanalysis (and later its psychodynamic modalities) won academic recognition and came to dominate psychiatric training programs in European and American medical schools.

 century, however, efforts to redefine and promote descriptive and biomedical/neuroscientific models of psychiatric diagnosis and treatment have gradually gained ground, strongly encouraged by the considerable therapeutic power of new psychopharmacological agents.

There are two reasons to consider the topic of psychotherapy education: 

 to make applied psychopharmacology the primary basis of psychiatric treatment. Missing in such an approach is a thorough assessment and subsequent knowledge of the complex experiences and circumstances of patients with psychiatric illness.

2. Invoking financial and time-constraint reasons, some psychiatric training programs have moved away from providing specific psychotherapy training as a core component of the psychiatrist’s work.

As part of this discussion, this article will explore the multiplication of psychotherapeutic schools and the vicissitudes of their curricular presence and practice, the historical oscillations between acceptance and rejection, and the factors contributing to one and the other.

Unsteadiness of the psychiatry-psychotherapy relationship

As previously noted, the first several decades of the psychoanalytic or psychodynamic revolution were marked by the relatively rapid acceptance of a perspective that promised plausible and clinically useful methods of describing, understanding, and treating mental illnesses. It was widely considered a liberating movement against earlier dogmatic and less tolerant approaches toward mental illness. However, this movement largely ignored a biomedical perspective, much needed epidemiological and psychopathological perspectives, as well as neuropathology and pathophysiological data. Not surprisingly, such an exclusively psychological and greatly subjective approach spawned many branches and led to considerable fragmentation and conflicts, probably explainable by some of the very ingredients the doctrine helped to unveil.

Thus, the re-awakening efforts to establish a biomedical-based psychiatry and to understand the pharmacodynamics of effective psychiatric medications, together with the introduction of impressive new molecular, genetic, and neuroimaging technologies in the last decades of the 20

 century, plus diagnostic systems guided by solid descriptive-phenomenological principles,

 provided significant support to a substantial improvement in psychiatric education and the practice of clinical psychiatry, despite leaving out many unfulfilled expectations.

Furthermore, greater dichotomizations in the field were paradoxically reinforced by advances in sociocultural disciplines and their connections with clinical psychiatry.

 about biomedical concepts in psychiatry, but also contributed to confusion and ambiguity about an appropriate balance between scientific and humanistic considerations. Psychotherapy, as a concrete tool for the understanding of individual patients and their treatment, has suffered in the process.

The major change in practice patterns included a growing dependence on a rapid diagnostic assessment followed by selection of seemingly appropriate medicinal treatment. A largely unanticipated result was a diminished emphasis on the clinical importance to understand the uniqueness and complexity of individual patients. Additional major contributing factors were structural and economic considerations: fewer patients needed prolonged institutional care, and many could be evaluated quickly and then become subjects of occasional, brief follow-up visits.

Similarly, the training of more non-medical mental health professionals-some with prescribing privileges (notably psychiatric nurse-specialists) and others with expertise in psychotherapy-provided more accessible and less expensive clinical services backed by controlled trials or tested protocols. It has become increasingly clear that these various practical and economic considerations have contributed to the diminishing role of psychotherapy as a dominant training aspect of contemporary clinical practice.

The case against psychotherapy training in psychiatry

It has been reported that psychiatric trainees who disagree with the need for psychotherapy training are a silent majority. Some observers note that only around 11% of outpatient psychiatrists continue to practice psychotherapy extensively after residency.¹â´ It is further argued that general medical knowledge, training in biostatistics, and the assessment of research findings required for an evidence-based practice are increasingly essential components of psychiatric training.

Consequently, a substantial curtailment of the psychotherapy curriculum has taken place in some training centers-even to the point of entirely eliminating it in the early residency years-while sometimes offering alternatives that include psychotherapy training as an elective in the fourth year and an elective fifth year of psychotherapy fellowships.

Many older psychiatrists are appalled by what they perceive as a decline in basic interviewing skills among their younger colleagues. In turn, many patients also complain about extremely and 

increasingly impersonal medication-check visits

 in which the bulk of an already very limited time is spent computer-documenting interactions with the physician. The most pervasive consequences of such are: the dehumanization of the doctor-patient relationship, the decline of empathy as a basic ingredient of the clinical encounter; the loss of a holistic approach to each patient’s condition; and an increasing prevalence of stereotyped, insufficiently individualized diagnostic and treatment protocols.

 Even among educators and trainees interested in teaching and learning psychotherapy, there is an underlying sense that enthusiasm and support for psychotherapy training is waning (despite encouragement by organizations and agencies that regulate and supervise psychiatric training in North America and Europe, ie, the American Council of Graduate Medical Education [ACGME] in the US²â·).

It seems that the resulting professional or medical identity of young psychiatrists no longer reflects comprehensiveness but rather a body-mind fragmentation arising from reductionistic conceptualizations.

 is considered too much when we possess technological tools to record the patient’s story, and 

 seems to be increasingly displaced by efforts to arrive at a formalistic diagnosis for which an inevitable pharmacological response is applied. Clinical follow-up is not a systematic and personalized dialogue aimed at measuring progress, but an actuarial listing as deficient or excessive as in a factory’s assembly-line scenario.

In short, the following is a list of factors that may be contributing to the questioning or even abandoning psychotherapy as an important component of the training, identity, professional competence, and job satisfaction of psychiatrists:

The time demands to adequately cover all the knowledge and expertise that a future psychiatrist must acquire during training present serious logistic challenges. Efforts to teach the latest clinical research findings (mostly neurobiological in nature) currently capture most of the formal content of training programs. Increasingly, diagnostic training is based on manualized approaches and assessment instruments consisting of symptom checklists rather than an individualized exploration of psychopathology.

 In the name of productivity, increasing numbers of patients are evaluated and treated in various settings with brief doctor-patient contacts in which much of the professional’s time is spent entering information into rigid and narrowly constrained electronic databases. This obviously discourages or severely limits a narrative documentation, summaries, and formulations that pursue an empathetic understanding of the individual patient’s challenges, strengths, and weaknesses.

 Current psychiatric research reports emphasize seemingly scientific biomedical topics more than descriptive or epidemiological studies; topics related to relevant psychological, social, or cultural areas are largely ignored as a result.

 A somewhat paradoxical reality today is that “seeing a doctor” (even if for a short time) or “getting a prescription” as soon as possible seem to be higher in the list of patients’ expectations than a desire to “tell their story” within an accepting and supportive environment. Such expectations seem to reflect the patients’ efforts to adapt to overcrowded clinical settings that directly or indirectly emphasize a high productivity model, ie, an excessively elevated number of patients seen per hour.

 Practical realities support the impression that a psychopharmacological approach to clinical care is relatively efficient in terms of time and costs; in turn, this fosters the possibility of becoming an attractive business in contrast to a time-consuming psychotherapy-based practice. However, such models appear to be based on a willingness to seek and accept: a minimal knowledge of complex clinical problems; a declining interest in clinical outcomes as well as patient’s and clinician’s satisfaction and morale; or even financial losses related to early dropouts and missed appointments.

 Growing numbers of non-psychiatric or non-medical professionals (eg, psychologists, physician assistants, social workers, nurse practitioners, psychiatric nurses, educators, and religious and other counselors) practice various forms of psychotherapy and can provide therapy at a lower cost than psychiatrists. The proliferation of psychotherapeutic schools, each and all of them advocating not only effectiveness but also rapid responses, minor costs, and favorable long-term outcomes, is another important factor. This diversity of psychotherapy providers may have resulted in the weakening of psychotherapy teaching in psychiatric residency training programs.

7. Changing practice patterns in general medicine.

 Even though a high proportion of problems seen by non-psychiatric physicians (eg, primary care doctors) are essentially behavioral or emotional in nature, there has been a decline in time per visit and a tendency to avoid dealing with such problems; this further diminishes the interest in psychosocial approaches throughout medicine in general. The risk is a greater avoidance of clinically responsible, comprehensive knowledge of individual patients, and a lack of concern for their emotional, social, and practical needs, including medication-modifiable symptoms.

What does this mean for the field of psychiatry, future psychiatrists, and patients? The next article will explore the characteristics of appropriate psychotherapy training programs to enable psychiatrists to continue to provide top quality mental health care.

American Psychiatric Association, Clinical Practice Guidelines Committee, Washington DC. Dr Fitz is a former Faculty member of Tulane University School of Medicine, Department of Psychiatry in New Orleans, LA. Dr Baldessarini

 is Professor Emeritus of Psychiatry, Harvard University Medical School, and former Director of Research Mc Lean Hospital, Boston.

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A diminished interest in psychotherapeutic interventions runs the risk of missing patients' emotional, social, and practical needs (including medication-modifiable symptoms) and, thus, less clinically responsible care.

Author | Thomas J. Craig, MD, MPH

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