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. —Ed.
Several agencies such as the American Council of Graduate Medical Education Milestone Project1 and Canadian professional and academic organizations2 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.3 As a result, a growing number of North American psychiatric training programs have reduced the hours devoted to psychotherapy training.4,5˒6
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.7,8 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.9
Thus, the goals of psychotherapy education in medical school should be based on the following ideals:
1. Basic concepts of psychotherapy should be taught, with an emphasis on a strong and meaningful therapeutic alliance10,11; 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, supportive, psychodynamic, cognitive behavioral, dialectical behavior therapy, mindfulness, group/family, psychoeducational, 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.12-14
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 lead multidisciplinary treatment teams—an aim that can be greatly enhanced by training and experiences in psychotherapy.15
5. Innovative teaching techniques based on actual experiences in private and public practice settings should be pursued. Examples include technology-based approaches like website videos, online CBT, and telepsychiatry.16
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