Coming to the end of training and realizing that my therapy training was terrible

[reca]

How do I go about remedying this? I started residency really interested in therapy but matched at a program that pays lipservice to therapy training. We get a handful of therapy lectures and then our therapy supervision consists of just talking about the patients with a supervisor once a week. I honestly feel like I've got zero therapy training. What resources can I use to fix this? Afaik, there aren't any in person therapy training institutes in my city that I could take advantage of.

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[liquidshadow22]

Cbt, Act, cpt, ipt. You can easily buy therapy manuals and teach yourself this.

 

[romanticscience]

Psychotherapy & Counseling Videos

The best teaching & training videos in psychotherapy, counseling and addiction treatment for psychotherapists, counselors, and social workers. CE available.

www.psychotherapy.net

I supplemented my training with some of those videos. It was very interesting and helpful to see master clinicians actually doing therapy.

 

[tr]

Wow I strongly disagree with the above. Someone who is already an experienced therapist might reasonably pick up a new modality from a manual plus video, but if you're starting from zero there's no way that's going to work. You have to learn by doing and being observed and corrected by an experienced therapist. I'd do some intensives to start with. After that maybe pay someone local for ongoing supervision.

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[Psychresy]

What does good therapy training look like in a training program?

 

[Bartelby]

What does good therapy training look like in a training program?

I would say good therapy training includes:

-didactic teaching about psychotherapy theory, which should include case examples;
-ongoing group discussions of psychotherapy theory and practice, which should include group discussions of difficult cases or places where you get stuck;
-doing a sufficient number of supervised cases (ideally 1-2 in PGY2 to get the basics going, and then a significant load in PGY 3-4).

The quality of supervision is absolutely key. If you are getting supervised by someone who doesn't really do therapy you are likely to see your sessions quickly devolve into "supportive" and nonspecific work, the equivalent of chatting about someone's week. You need to have someone who has real experience with therapy overseeing and directing your work, and you need to work in a particular frame (psychodynamic, CBT, DBT, ACT, etc.). You should try out at least a couple of different frames in order to begin to appreciate the strengths, weaknesses, and applications of each.

OP, it sounds like your supervision experience was not great. I think remedying that is the place to start. Find someone good in your community (psychologist or psychiatrist) willing to supervise, and combine self-directed learning with regular oversight of your work. This can be recorded (with patient consent) or discussion-based, your supervisor should be able to guide you.

I very much agree with tr, we should not be teaching ourselves therapy on our patients. Our job is to apply working systems of therapy, not to perform guesswork.

 

[Auvelity]

Cbt, Act, cpt, ipt. You can easily buy therapy manuals and teach yourself this.

Which ones can you recommend?

 

[robellis]

Most psychiatrists are similar to you, OP, most did not get good training and do not do therapy. If you’re okay with not doing actual therapy and sticking to being supportive and having a “therapy” approach but rather leaving the real therapy to psychologists, you will fit right in to the community setting. If you actually want, as an attending, to do hour long therapy sessions with patients, I agree with the suggestions above you have a lot of work to do.

 

[psychacad]

There are prestigious institutes that offer online training with supervision. The White Institute and Columbia are two on top of my head, and I am sure there are more with covid. But yes, the key is supervision. Reading from a manual won't teach you therapy.

 

[clozareal]

What does good therapy training look like in a training program?

1. Minimum modalities are CBT, psychodynamic psychotherapy, and motivational interviewing (or it's adaptations: motivational enhancement therapy, behavioral change counseling, etc). Bonus points for IPT, DBT, ACT, psychoanalytic, EFT/Gottman, EMDR, CPT/PE, MBCT, IFS, hypnotherapy, MBT, schema-focused, and for those interested in CAP: Family, Play, Attachment-based, Infant-parent, PMT, PCIT.
2. One hour of individual/group supervision for one hour of each modality of therapy every week. The quality of supervision is the most important. Getting trained by psychologists generally is better than getting therapy supervision from MDs because they have more hours of training and do the work much more often than MDs do. With that being said, some of the best therapy supervision I've had were from MDs.
3. Video recordings of yourself doing therapy and getting feedback on strengths and improvement opportunities from supervisors about your performance as well as helping to formulate the different mental states of the patient that you can't see without video/live.
4. Going over process notes and case transcripts with your supervisor. You can comb through more nuances this way, discuss the timing of different interventions, and focus on defensive avoidance when certain topics are brought up rather than getting general impressions from your recall of how the session went.
5. Learning how to properly formulate a patient and how that informs your interventions and treatment plan. Learn different case formulation methods because it depends largely on the therapy modality framework. Automatic thoughts and core beliefs in CBT are mostly different (although with some overlap) than the developmental focus and focus on transference/countertransference in informing recurrent themes/patterns of psychodynamic psychotherapy.
6. Formal didactics on foundational topics within that field of modality along with discussions of pivotal papers or book chapters in each field. It's a shame when psychiatrists who work with borderline personality disorder haven't read any papers by John Gunderson or when those who do psychodynamic psychotherapy haven't read anything from Jonathan Shedler, for example.
7. At least 10 different weekly individual cases during a 4-year residency.
8. Exposure to real group psychotherapy, not just twelve-step programs. Bonus points for co-facilitating. Learn how they are different than just doing individual therapy with multiple people and how to utilize other group members.
9. Getting developmentally appropriate cases for trainees. The cases residents tend to get are train wrecks. The best initial cases tend to be psychologically-minded healthy individuals who recently were diagnosed with a mild psychiatric illness that can respond well to therapy and not on any medications. That will help boost your self-esteem and confidence in performing therapy and it should gradually get more difficult. The worst is having a severely personality disordered patient with severe childhood trauma, substance use, and on a dozen medications to do therapy with as your first therapy case. Your program should protect you from this if it values your education.

 

[InterventionalSpacePsych]

Does UPMC, Yale, Brown, UCLA offer equal psychotherapy training? It's so hard to judge from the virtual and online resources. Help is appreciated!

 

[Candidate2017]

We aren't in the heyday of psychotherapy training in psychiatry. Supervisors are hit or miss. Some are good at meds, some are good at therapy, some are no good at anything. Read, be curious, examine every interaction from a psychoanalytic perspective, get your coresidents' opinions about intriguing cases, pay a PhD therapist for supervision.

It's only natural to see things clearer and differently toward the end of training, including realizing weaknesses in training. If anything, this is a sign of becoming a good psychiatrist.

 

[Psychresy]

Is it possible for one to still be a good and effective psychiatrist if their training was substandard and/or they are not therapeutically inclined?

 

[WisNeuro]

Is it possible for one to still be a good and effective psychiatrist if their training was substandard and/or they are not therapeutically inclined?

Very different questions, with very different and involved answers.

 

[clausewitz2]

Does UPMC, Yale, Brown, UCLA offer equal psychotherapy training? It's so hard to judge from the virtual and online resources. Help is appreciated!

You can certainly get reasonable psychotherapy training at UPMC, but you do have to be a bit of a self-starter. If you're the sort who's only going to be doing things they're required to or organized for you, you are going to have a pretty sparse experience.

If, however, you're the kind of person who will design and arrange their own electives and have fun while doing it, the program's heaps of elective time makes getting good and varied training very feasible.

 

[NickNaylor]

If you're really interested in developing your psychotherapy skills, as a practicing psychiatrist you're probably going to have to pay for the pleasure - whether it be through formal training courses (e.g., the Beck Institute for CBT) or actually having therapy patients that you then pay a practicing therapist for supervision for. As @tr mentioned, I agree that simply watching videos or reading a manual is unlikely to be a substitute for actual psychotherapy training if you don't already have a pretty strong foundation of therapy training, which it doesn't sound like you feel that you have.

The good news is that, as others have mentioned, I don't think this is too important unless you intend to actually see therapy patients in your practice. Assuming that's not the case, I think that being passingly familiar with basic psychotherapeutic approaches and being able to recognize what clinical concerns are amenable to psychotherapeutic intervention - and being able to speak competently about psychotherapeutic treatments so that you can effectively counsel patients - is probably sufficient.

 

[psychacad]

Disagree that therapy skills are only useful if you're doing therapy. They will come in very handy when you want to develop rapport which is more than half the battle in psychiatry, when you need to handle the difficult personality patient, spot and deal with your countertransference issues or even with the noncompliant pts with bipolar or schizophrenia. This artificial separation between "med management" and psychotherapy is one of the biggest shams of modern psychiatry (wouldn't be suprised if insurance companies/$$ are behind it like most things), and imo a good training in psychotherapy should be fundamental in residency, much as the same as learning about drugs.

 

[tr]

At the very least, if you know no other modality, and even if you intend to have an entirely psychopharm-based practice, you should acquire a reasonable competency with motivational interviewing.

 

[Stagg737]

Is it possible for one to still be a good and effective psychiatrist if their training was substandard and/or they are not therapeutically inclined?

If they're not therapeutically inclined? Yes. If they had substandard training (I'm assuming in psychotherapy and not overall), yes but I think it would be harder. There are a lot of aspects and concepts of psychotherapy that are used even during med-check encounters that every psychiatrist should be aware of and able to recognize or perform. The patients' thought processes and how you interact with them should be things you're aware of during encounters, and a lot of that can best be learned when studying psychotherapy imo as you NEED to be aware of these things in that setting.

At the very least, if you know no other modality, and even if you intend to have an entirely psychopharm-based practice, you should acquire a reasonable competency with motivational interviewing.

100% agree, even minimal skills here can be life-changing for some patients. I'd also argue that a basic grasp of actual supportive therapy and not just the "there, there" encouragement is a must as well.

 

[birchswing]

Disagree that therapy skills are only useful if you're doing therapy. They will come in very handy when you want to develop rapport which is more than half the battle in psychiatry, when you need to handle the difficult personality patient, spot and deal with your countertransference issues or even with the noncompliant pts with bipolar or schizophrenia. This artificial separation between "med management" and psychotherapy is one of the biggest shams of modern psychiatry (wouldn't be suprised if insurance companies/$$ are behind it like most things), and imo a good training in psychotherapy should be fundamental in residency, much as the same as learning about drugs.

That sounds remarkably similar to customer service.

At the very least, if you know no other modality, and even if you intend to have an entirely psychopharm-based practice, you should acquire a reasonable competency with motivational interviewing.

That sounds remarkably similar to sales.

 

[Merovinge]

At the very least, if you know no other modality, and even if you intend to have an entirely psychopharm-based practice, you should acquire a reasonable competency with motivational interviewing.

Ergh, I fall on the less psychotheraputically inclined younger generation and this still pains me. Being a psychiatrist without a few years of solid CBT in this day and age seems criminal with how many behavioral interventions have high effect sizes for relatively low effort. Not having a working understanding of 3rd wave techniques makes a big difference with rapport (so many people are interested in mindfulness in particular these days). I can't imagine being able to set a reasonable treatment frame with disordered parents (or PD patients for you adult folks) without the great dynamic training I got. 4 years of training should be enough time to master the pharmacology/medicine and become competent with at least 1 real domain of therapy.

 

[Candidate2017]

That sounds remarkably similar to customer service.

That sounds remarkably similar to sales.

Customer service means the patient is always right, which is more akin to hospital admin, SW therapists, primary care, and bad psychiatrists.

Sales, however, has overlap with good psychiatry because it incorporates a lot of psychological principles. It's possible someone with weak therapy training but interested in just med management could get more bang for their buck by reading a couple good books about sales and negotiation than CBT workbooks. Arguably, sales is more evidence-based and results-oriented than any therapeutic modality since outcomes in sales are easily and always measured by two metrics: was the sale made and how much money.

 

[birchswing]

Customer service means the patient is always right, which is more akin to hospital admin, SW therapists, primary care, and bad psychiatrists.

Sales, however, has overlap with good psychiatry because it incorporates a lot of psychological principles. It's possible someone with weak therapy training but interested in just med management could get more bang for their buck by reading a couple good books about sales and negotiation than CBT workbooks. Arguably, sales is more evidence-based and results-oriented than any therapeutic modality since outcomes in sales are easily and always measured by two metrics: was the sale made and how much money.

Customer service has metrics, too. You're constrained in how happy you can make a customer (one of the metrics) based on competing metrics (upselling service protection plans, time spent on the phone, whether they return the product or not, etc.). If you had a customer service job where you got to tell the customer they were always right, it would be much easier!