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

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.

COMMENTARY

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 alliance^10,11; 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

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.^4,5

7. Demonstration and evaluation of core formative and summative competencies must be essential components of solid curricular designs for comprehensive psychiatric training programs.¹⁷

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.¹⁸ 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.^2,6,19 A continuous research-inspired perspective, based on evidence-based objectives, should nourish all the phases of such training.^20-22

Conclusions

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.^23-25

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.²⁶ 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.^27,28 Moreover, such trends can be highly demoralizing to the psychiatrist and may contribute to professional dissatisfaction and early burnout.²⁹

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.³⁰ 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.^{6, 20,31} 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.

Dr Alarcón is Emeritus Professor of Psychiatry, Mayo Clinic School of Medicine, Rochester, MN; and Honorio Delgado Chair, Universidad Peruana Cayetano Heredia, Lima, Perú. 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.
 

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