Disappointed at the lack of therapy training at my program

[psychgirll]

It's slowly becoming clear to me that my program doesn't care too much about teaching residents about therapy. There are "teaching sessions" during which a therapist will run the session and no therapy is being taught at all! It's basically casual conversation among the group. We have already had sessions of psychodynamic and even supportive therapy without any discussion about what these therapies are all about! Of course I self-study so you can imagine my disbelief when leaving this "psychodynamic session" which was basically a "tell me about yourself" session. I've discussed this with the other interns and they are very disappointed as well. I remember the PD saying during the interview that "psychiatry is going away from therapy and so we don't teach much therapy here" so that did change where I ranked the program but the match is the match...*Overall, I do love the program..this is just one deficit. Also, I've heard there won't be much opportunity even during outpatient clinic during 3rd year. Sooooo... I'm asking for any resources to use from videos to books. I don't want to leave residency feeling uncomfortable with my therapy skills!!!

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[hamstergang]

I'm asking for any resources to use from videos to books. I don't want to leave residency feeling uncomfortable with my therapy skills!!!

If you want skills, you need to practice. Videos and books are nice (and I would say very useful), but are far from sufficient on their own. I don't have any useful suggestions, though. If your program doesn't give you patients for psychotherapy, then how can you get the practice?

 

[smalltownpsych]

It's slowly becoming clear to me that my program doesn't care too much about teaching residents about therapy. There are "teaching sessions" during which a therapist will run the session and no therapy is being taught at all! It's basically casual conversation among the group. We have already had sessions of psychodynamic and even supportive therapy without any discussion about what these therapies are all about! Of course I self-study so you can imagine my disbelief when leaving this "psychodynamic session" which was basically a "tell me about yourself" session. I've discussed this with the other interns and they are very disappointed as well. I remember the PD saying during the interview that "psychiatry is going away from therapy and so we don't teach much therapy here" so that did change where I ranked the program but the match is the match...*Overall, I do love the program..this is just one deficit. Also, I've heard there won't be much opportunity even during outpatient clinic during 3rd year. Sooooo... I'm asking for any resources to use from videos to books. I don't want to leave residency feeling uncomfortable with my therapy skills!!!

Who provides the psychotherapy at this place? You could always make friends with one or two of them who have some skills and learn a bit from them. I love to talk about therapy strategies and conceptualizing with colleagues and some of my most productive learning was over lunches.

You could also look into books on psychotherapy. Some of my favorites are Marsha Linehan's new work the DBT Skills Training Manual, Second edition and Object Relations therapy for Borderline PD by Otto Kernberg. Both of these have some very practical information that can be applied in sessions. I also think it is important to really understand what therapy is and how it works from an interpersonal neurobiological standpoint. If you really understand how the other's affective regulation system is malfunctioning and how this interacts with cognitions and behaviors, then you can begin applying techniques from several modalities. A great book for beginning to understand this is the Talking Cure. Another good source of information are probably some of the books on the topic from Alan Schore although I have only read the classic 1999 text Affect Regulation and the Origin of the Self so far.

 

[Psychobabbling]

Can't practice what you don't know what to practice. It would be similar to being told to obtain a history, but never taught what's in a history.

There is a website, the name escapes me, that has videos of Kernberg, Linehan...I think it's psychotherapy.net / I've watched some clips from there, which seem, incredibly useful. There's a few where Kernberg, Linehan and a CBT therapist interview the same patient separately and go through what they are thinking, why they said one thing vs another. Very cool stuff

 

[smalltownpsych]

Can't practice what you don't know what to practice. It would be similar to being told to obtain a history, but never taught what's in a history.

There is a website, the name escapes me, that has videos of Kernberg, Linehan...I think it's psychotherapy.net / I've watched some clips from there, which seem, incredibly useful. There's a few where Kernberg, Linehan and a CBT therapist interview the same patient separately and go through what they are thinking, why they said one thing vs another. Very cool stuff

I think you can actually get a lot of the stuff on youtube. At the conference I was at last week, Dr. Linehan talked about her stuff being put out in youtube and that some of her patients were watching them and found them helpful. Hmmm, could I bill for sessions where a patient watched me on video while I did something more productive like posting on SDN?

 

[Doctor Bagel]

Admittedly, your PD's statement is a bit concerning, but I wouldn't worry too much based on intern year didactics. Intern experiences are predominately all inpatient, and it's reasonable that a program would provide at most a rough overview of psychotherapy didactics during that period. Give your program a chance and see how things play out once you start in outpatient clinics. Also remember that you can find some of these experiences on your own if you're proactive. If your community has a psychoanalytic institute, check out the classes there -- they often have free/very cheap offerings for trainees.

 

[nitemagi]

It's a real issue, at many programs.

Start with the basics -- do you know how to develop rapport with all types of people -- hostile, manic, psychotic. Learn to work with your voice, posture, attitude, and so on. That's the first and most important skill IMO.

Figure out what kinds of therapy you want to learn. Find mentors -- local, Skype, whatever. If possible, videotape your sessions (with permission), and get supervision on those videotapes.

Frankly, without knowing your PD, the statement that psych is moving away from therapy is both a cop-out and a self-fulfilling prophecy.

 

[splik]

i have no idea what the therapy training at your program is like but you are not going to be learning psychotherapy as an intern. At this level you should be focusing on developing your interviewing skills, and basic psychological formulation. most programs don't have anything related to psychotherapy in their intern year anyway.

If you are interested in learning about the psychodynamic interview I recommend Michels and Mackinnon's The Psychiatric Interview in Clinical Practice. an old copy will suffice

For learning case formulation I would recommend:

Campbell WH,, Rohrbaugh RM. The Biopsychosocial Formulation Manual: A guide for mental health professionals. New York: Routledge, 2006

and

Johnson L, Dallos R. (Eds.) Formulation in Psychology and Psychotherapy: Making Sense of People’s Problems. New York: Routledge, 2014

Most beginning residents have absolutely appalling interview skills and worse, don't have a clue just how bad they are.

 

[Ceke2002]

Who provides the psychotherapy at this place? You could always make friends with one or two of them who have some skills and learn a bit from them. I love to talk about therapy strategies and conceptualizing with colleagues and some of my most productive learning was over lunches.

You could also look into books on psychotherapy. Some of my favorites are Marsha Linehan's new work the DBT Skills Training Manual, Second edition and Object Relations therapy for Borderline PD by Otto Kernberg. Both of these have some very practical information that can be applied in sessions. I also think it is important to really understand what therapy is and how it works from an interpersonal neurobiological standpoint. If you really understand how the other's affective regulation system is malfunctioning and how this interacts with cognitions and behaviors, then you can begin applying techniques from several modalities. A great book for beginning to understand this is the Talking Cure. Another good source of information are probably some of the books on the topic from Alan Schore although I have only read the classic 1999 text Affect Regulation and the Origin of the Self so far.

You have no idea how much I wish you could meet my Psychiatrist, I think the two of you would get on like a house on fire.

 

[whopper]

"psychiatry is going away from therapy and so we don't teach much therapy here"

This is concerning to me as well. Good psychotherapy training should be in any program, even non psychiatry because there is an art and science to telling a patient he has terminal cancer and trying to offer support through such as tough situation.

IMHO there's fast-food industrial assembly-line psychiatry (not literally). This is the psychiatry where you're only concerned about admissions, discharges, medicating, and getting them in and out of the office. If a program is not emphasizing psychotherapy well it makes me fear they're gravitating towards the assembly line psychiatry.

 

[Armadillos]

I would just chime in with some perspective that historically psychiatrists did a traditional medicine intern year so your already getting significantly more psych exposure than your predecessors did at this stage. Maybe the "getting to know you" feel of the intern year seminar is going to make for better experiences down the road?

 

[smalltownpsych]

Learning psychotherapy skills are essential to practicing good psychiatry even of you don't provide the therapy. One reason is that a big part of the skill set is conceptualizing and the better you are at that then the more aligned you will be with the patients. Even when I give them negative feedback, it fits and the patient is more likely to take it. Even addressing something like medication compliance requires some therapy skills. How to set appropriate boundaries in session is key, as well. When the patient asks for advice about some personal life issue, how do you answer that? How do you handle it when the patient complains about their individual therapist? What about transference issues, need for empathic validation, counter-transference, helping the suicidal patient off the ledge, addressing chemical addiction and med seeking behaviors, family dynamics? It seems to me that if a psychiatrist has no skills in any of these areas and all they really know are effects of medications, then maybe they should change their title to something like pharmacologist.

 

[milesed]

What year are you in training? My program did all of the therapy training in PGY3 and almost nothing else that year (unless on call). You may not have gotten to it yet.

The Linehan book mentioned is great and only $14 on amazon used.

while you're there, pick up a CBT book by Judith Beck or other manuel type book that you can just work through with a regular patient.

 

[WingedOx]

This is concerning to me as well. Good psychotherapy training should be in any program, even non psychiatry because there is an art and science to telling a patient he has terminal cancer and trying to offer support through such as tough situation.

IMHO there's fast-food industrial assembly-line psychiatry (not literally). This is the psychiatry where you're only concerned about admissions, discharges, medicating, and getting them in and out of the office. If a program is not emphasizing psychotherapy well it makes me fear they're gravitating towards the assembly line psychiatry.

Hell, honestly if you're good, you can do some quick CBT type stuff in the span of a 20 min med check.

At my new job I'm gradually realizing I'm going to have to decondition my patients away from the expectation that "new symptom = medication change" every time. It's lazy psychiatry.

 

[Shikima]

Hell, honestly if you're good, you can do some quick CBT type stuff in the span of a 20 min med check.

At my new job I'm gradually realizing I'm going to have to decondition my patients away from the expectation that "new symptom = medication change" every time. It's lazy psychiatry.

I would invest more with MI to ensure treatment compliance and avoidance of substances.

 

[675015]

I agree with a common theme of this thread. I wouldn't worry about the lack of therapy training as an intern. Intern year isn't about therapy. In fact, that you are even having ANY sessions related to therapy as an intern means that your program is ahead of the curve in teaching therapy compared to other places!

 

[Junglee135]

If your program is ACGME certified and compliant, you will have at least 1-2 psychotherapy cases at minimum, if not more by the time you're done. Per ACGME requirements for psychiatry "Resident experience in outpatient psychiatry must include 12 months FTE of organized, continuous, and supervised clinical experience. (Core) IV.A.6.a).(7).(a) Each resident must have significant experience treating outpatients longitudinally for at least one year, to include: (Core) IV.A.6.a).(7).(a).(i) initial evaluation and treatment of ongoing individual psychotherapy patients, some of whom should be seen weekly; (Core)". I think the minimum requirements are supportive, psychodynamic, and CBT (might be wrong)

Even in my relatively therapy-oriented residency program, we didn't do any actual psychotherapy our intern year other than lectures. Most of the clinical training was 2nd/3rd/4th year. Most programs train during 3rd year or both 3rd/4th year. If you are interested in therapy, try to negotiate more time during 3rd or 4th year where you do psychotherapy - and negotiate hard for it! Ask for 4 psychotherapy patients instead of 2. See if you can co-lead a psychotherapy group with a social worker, MFT, or psychologist. Go to seminars at a local psychoanalytic institute, or ACBS chapter - they may have free or discounted opportunities for trainees. For more formal training, some psychiatrists do further training in dynamic therapy and/or analysis after residency through analytic institutes (although I am sometimes skeptical about some places' shunning of evidence based psychotherapy practice), and I think there are more academically oriented fellowships out there for psychotherapy training as well.