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Psychotherapy training has been losing ground in psychiatry residency training programs, a result of restrictions imposed by managed care companies on the practice of psychotherapy by psychiatrists, as well as the continuing strength of pharmacological treatments. A training program developed at the University of Missouri-Columbia is designed to reverse this trend.
It is one of several initiatives supported by the APA Commission on Psychotherapy by Psychiatrists.
Key figures in the program are Bernard Beitman, M.D., a professor and chair of the department of psychiatry and neurology at the University of Missouri-Columbia, and Dongmei Yue, M.D., an assistant professor of psychiatry at China Medical University in Shenyang, China.
The program was developed based on the premises that psychotherapy training programs require a uniform introduction to psychotherapy that incorporates the basic, generic concepts common to the major schools of psychotherapy, and that the program must accomplish this training in a time-efficient manner. The program also aims to help trainees acquire a mastery of multiple treatment approaches and adjust their therapeutic approaches to meet patient needs, according to the authors.
"An additional goal is to educate trainees to think and perhaps to behave integratively. . .in their clinical pursuits," said Beitman. "Trainees are encouraged to examine their own thinking and to apply critical research attitudes to what they do and how they do it. They learn to measure their effectiveness and respond to these evaluations with a sharpening of behavior and thinking."
The new program consists of six modules taught over 43 sessions in a weekly format, with minimal reading but extensive homework involving case vignettes, transcripts, and videos.
The program is generally offered in the second year, before residents enter their outpatient training years.
Supervisors are informed of the content of the modules and encouraged to organize their supervision with this content in mind. "A fundamental aim is training in the activation and use of each trainee's observing self," Beitman explained, "under the assumption that greater access to self-awareness is a crucial variable in therapeutic effectiveness for both therapist and patient."
The modules are intended to follow the general stages in the development of the psychotherapy relationship. In addition to pre- and post-module activities, they are presented in the following sequence:
| Module 1: | Response modes and intentions of the therapist. |
| Module 2: | The working alliance, components of the therapeutic relationship. |
| Module 3: | Inductive reasoning to determine patterns of thought, feeling, and/or behavior that are within the patient's ability to influence and that, if changed, would lead toward a desirable outcome. |
| Module 4: | Strategies for change, including relinquishing the old pattern and initiating and maintaining the new one. |
| Module 5: | Forms, sources, and management of resistance. |
| Module 6: | Transference and countertransference and the methods of handling these responses. |
Using a measure of trainee self-confidence as a psychotherapist (the Counselor Self-Estimate Inventory), the authors reported a statistically significant increase in trainee self-confidence, beginning with and maintained after Module 4, in their preliminary results from the program, which began in 1995.
Interestingly, this preliminary group of residents reported a drop in self-confidence as therapists after the first module, which focused on verbal response modes and intentions, suggesting, the authors speculate, "that at this point they began to discover what they did not know they did not know." The results reached and maintained statistical significance after Module 4, "by which time they had learned the basics of the change process and related techniques. This latter finding suggests that their confidence can be greatly increased when they learn how to help patients change."
The preliminary study lacks a control group, the authors note, to help explain the possible influence of other factors in psychiatric residency training programs that could contribute to the increase in the trainees' self-confidence as therapists. They add, however, that their report "falls more closely under program evaluation than formal research. Like clinical outcomes measurement, training program evaluation emphasizes service delivery (in this case adequacy of training) over controlled trials. The positive results. . .could be a product of the enthusiasm of the originators rather than the content and process of the program itself." To address this shortcoming, they have implemented a multisite evaluation of the program, including an additional site as a control group.
Another limitation of the study, its designers acknowledged, is its failure to report the degree to which the training program influences subsequent patient care. They are collecting and analyzing data on patients seen at the pre-module stage compared with those seen at the post-module stage to gain objective information as to if and how trainees change their conduct of psychotherapy. "What we really want to see is whether or not this program influences trainee involvement in psychotherapy as practitioners and the degree to which it influences clinical effectiveness after completing their residencies."
Representatives of several sites met in April to learn how to use the modules. The program initiated at the University of Missouri-Columbia in 1995 is now under way in the psychiatry departments at Stanford University, the University of Michigan, George Washington University, the University of Southern California, and the University of Missouri-Kansas City. Wright State University will serve as a control group setting.
Residency administrators at other sites have also indicated plans to use variations of the Missouri program. Manuals for trainees and for trainers will be published by W.W. Norton in the spring of 1999.