April 16, 1999

It is certainly no secret among psychiatrists that psychotherapy as a treatment modality has been under siege since the success of the managed care juggernaut. Considerable attention is now being focused on one serious consequence of this-the inability of educators to provide young psychiatrists with the skills and knowledge needed to become effective psychotherapists.

More than 150 psychiatric educators gathered in Santa Monica, Calif., last month to share strategies for remedying this situation and better incorporating psychotherapy into their training curricula.

Sponsored by APA's Commission on Psychotherapy by Psychiatrists, the conference was designed for educators and training supervisors who are "challenged by the need to teach multiple models of psychotherapy in the face of pressures of time, the abundance of clinical material to be digested, and questions about the position of psychotherapy in psychiatric education and practice," explained Marcia Goin, M.D.

Goin, a member of the APA Board of Trustees, was one of the presenters at the workshop and is a consultant to the psychotherapy commission.

"Our intention was to kindle enthusiasm and build a cadre of teachers to revitalize psychotherapy training, which we felt has suffered some demoralization lately in the face of tough environmental pressures," explained Norman Clemens, M.D., chair of the Commission on Psychotherapy by Psychiatrists.

Presenters at the two-day meeting were charged with defining the educational goals for a particular psychotherapeutic method, comparing it with other forms of psychotherapy, describing strategies for teaching it, and explaining ways to measure its outcome.

John Markowitz, M.D., presented a residency training curriculum for teaching interpersonal psychotherapy based on the one he uses at New York Hospital-Cornell Medical Center. He pointed out that while interpersonal psychotherapy is one effective treatment modality, educators need to teach several psychotherapeutic methods so they can optimally address differential therapeutics. He and David Goldberg, M.D., emphasized the benefits that trainees derive when the videotaping of therapy sessions is an integral facet of training and supervision. Goldberg, director of residency training at the University of Connecticut Health Center, also discussed critical issues in the supervision of psychiatry residents.

Bernard Beitman, M.D., chair of the psychiatry department at the University of Missouri at Columbia, described the Missouri Modules, "an integrative approach to psychotherapy that captures common factors across the schools and key elements of the major perspectives." Beitman noted that the six-module program, which includes outcome measures, is used in PGY-2 and incorporates case vignettes, videotapes, and session transcripts, some of which are used as homework assignments. The program consists of 12 months of one-hour weekly seminars and is proving to be an effective way to combat psychotherapy training that is increasingly relegated to "manual-based training" or a smattering of seminars and case conferences.

Goin addressed long-term psychodynamic psychotherapy, which, she stressed, is too important a modality to be sacrificed in the face of managed care pressures. "The skills and insights gained are integral to all aspects of treatment planning, psychopharmacology, all models of psychotherapy, as well as consultation and psychosocial rehabilitation," said Goin, a clinical professor at the University of Southern California/Los Angeles County Medical Center.

She outlined a model for clinical case supervision that included a psychodynamic evaluation of the patient by using the McGlashan Semi-Structured Interview and involving clinical supervisors in processing this material throughout the treatment.

Conference chair Jerald Kay, M.D., focused on the sometimes contradictory requirements of teaching residents about the use of treatment that combines medication and psychotherapy while preparing them to function in a managed care world that often limits them to the medication-management side of a split-treatment paradigm.

He cautioned the psychiatric educators that despite its popularity with managed care leaders, there are no data proving that split treatment can boast any efficacy in treating mental illnesses. Nonetheless, research validating the effectiveness of treatment that combines medication and psychotherapy is, except for its use in schizophrenia and bipolar disorder, still "equivocal," said Kay, who is chair of the psychiatry department at Wright State University in Dayton, Ohio.

He cited several questions that he and his colleagues need to answer to provide residents with optimal training about how to combine psychotherapy and medication treatment. These include when to begin with psychotherapy and then add medication and when to do the reverse, which illnesses respond best to combined treatment and to which forms of psychotherapy, and what cost-effectiveness can be demonstrated for combined treatment.

Another presenter, Jesse Wright, M.D., a psychiatry professor at the University of Louisville, discussed a 20-session course that instructs trainees in the theory and techniques of cognitive-behavior therapy. The course focuses on teaching the use of this modality with depression and anxiety-disorder patients in particular, he noted, and concentrates on the PGY-2 year, though he suggested that additional supervision in the technique could be included in PGY-3 and PGY-4.

Judith Gold, M.D., a professor of psychiatry at the University of Queensland in Australia, described issues in and a model course for teaching brief psychodynamic psychotherapies to residents.

"There was a consensus that the meeting was a great success," Goin said, "and a very necessary subject" for future workshops and educational sessions.

Clemens told Psychiatric News that the turnout "exceeded the commission's wildest expectations. It showed us that there are a lot of people in the training programs who are determined to keep strong and healthy the psychotherapy part of our identity as psychiatrists."