Therapy training during residency.

[psychma]

Do most residency programs today offer basic training in CBT, etc or for those of you who practice therapy did you have to secure training on the side? Did you have to pay for the training/supervision?

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[TexasPhysician]

All provide training, but the quality can be worlds different between programs.

 

[ObsequiousAplomb]

Residency programs generally cover the supervision that occurs as part of the residency training. Most people continue to obtain supervision to some degree after completing residency training, and that can be quite reasonable to afford.

 

[splik]

THE ACGME which accredits residency programs has some minimum standards for psychotherapy which includes training in supportive, psychodynamic and CBT. However, some programs provide lip service with only meeting the bare minimum, and others provide more extensive opportunities. Some programs are more heavily psychodynamic with less CBT training and vice versa. Supervision is free for residents. I received 3 years of weekly psychoanalytic supervision from one analyst, 2 years from another analyst, 2 years of weekly CBT supervision, 1 year of hypnotherapy supervision. I also did a 1 yr supportive psychotherapy group with supervision. We recorded sessions which were reviewed by supervisors and had some sessions reviewed in real time through 1 way mirror. In addition, we had weekly caseload supervision, supervision for child psychotherapy cases and did a social skills group for autistic children, I did training in CPT and DBT, we had basic and advanced seminars in CBT and psychodynamic psychotherapy, a supportive therapy seminar, a 4 year process group, 1 year group supervision from an analytically oriented psychiatrist, and were required to have personal psychotherapy as well (also covered by the program or at a reduced rate). There were also additional electives in specific psychotherapies and some people elected to do the psychoanalytic psychotherapy or full psychoanalysis training (they had to pay for this) at the local institute. There were other courses in ACT, FAP, couples therapy, integrative therapy, interpersonal therapy etc available as well.

 

[clausewitz2]

THE ACGME which accredits residency programs has some minimum standards for psychotherapy which includes training in supportive, psychodynamic and CBT. However, some programs provide lip service with only meeting the bare minimum, and others provide more extensive opportunities. Some programs are more heavily psychodynamic with less CBT training and vice versa. Supervision is free for residents. I received 3 years of weekly psychoanalytic supervision from one analyst, 2 years from another analyst, 2 years of weekly CBT supervision, 1 year of hypnotherapy supervision. I also did a 1 yr supportive psychotherapy group with supervision. We recorded sessions which were reviewed by supervisors and had some sessions reviewed in real time through 1 way mirror. In addition, we had weekly caseload supervision, supervision for child psychotherapy cases and did a social skills group for autistic children, I did training in CPT and DBT, we had basic and advanced seminars in CBT and psychodynamic psychotherapy, a supportive therapy seminar, a 4 year process group, 1 year group supervision from an analytically oriented psychiatrist, and were required to have personal psychotherapy as well (also covered by the program or at a reduced rate). There were also additional electives in specific psychotherapies and some people elected to do the psychoanalytic psychotherapy or full psychoanalysis training (they had to pay for this) at the local institute. There were other courses in ACT, FAP, couples therapy, integrative therapy, interpersonal therapy etc available as well.

Man I wish I could have gotten training in FAP when I was still a resident. It is the modality I am most interested in understanding better that I will probably never get around to actually learning properly.

 

[Celexa]

This question is WIDELY variable. Shamefully variable, in my opinion. Many programs barely do the lip service with residents not getting true significant 1:1 supervision.

Others provide diverse training. At my program you were expected to learn psychodynamic and cbt, as well as the basics of couples and family. Depending on personal inclination and preference you could learn DBT (group and individual), IPT, ACT, as well as specialized/protocoled CBT such as ERP. Because we had such high quality therapy training, principles of it were also integrated into our med clinics, ie psychodynamic prescribing.

We did not have to pay for any supervision in residency. Some of my colleagues who opened therapy heavy private practices do pay for additional supervision now that they are out of training so they can continue to hone their skills.

 

[comp1]

You won't be paying for supervision in residency. You pay for supervision after residency. However...that's more psychodynamic. I'm not sure if people actually pay for/have CBT supervision in specific after residency. It's...kinda concrete. CBT training is required by ACGME and like most things, the amount will vary extensively. I personally found CBT horrifically boring from both sides and had a lot of trouble with it, but there certainly are programs that are really into it. If you're absolutely convinced this is something you want to do, look for faculty who have published a lot on it as at least some sort of starting point.

 

[dl2dp2]

You won't be paying for supervision in residency. You pay for supervision after residency. However...that's more psychodynamic. I'm not sure if people actually pay for/have CBT supervision in specific after residency. It's...kinda concrete. CBT training is required by ACGME and like most things, the amount will vary extensively. I personally found CBT horrifically boring from both sides and had a lot of trouble with it, but there certainly are programs that are really into it. If you're absolutely convinced this is something you want to do, look for faculty who have published a lot on it as at least some sort of starting point.

The more interesting aspects of CBT come from CBT for Core Beliefs/Schema-focused CBT. One could certainly use supervision for that, targeting more complex comorbid personality disorders, etc. Techniques are also more elaborate (limited reparenting, cognitively directed psychodrama, etc). Motivational interviewing is not part of residency but is often covered in some parts.

 

[comp1]

I'm definitely not saying I had the best CBT training or other experiences. I'm guessing it is possible to make it interesting. I've definitely never heard of anyone paying for CBT training post residency, although also that could be possible. I have many personal friends who have paid for psychodynamic psychotherapy supervision post residency.

 

[Celexa]

I'm definitely not saying I had the best CBT training or other experiences. I'm guessing it is possible to make it interesting. I've definitely never heard of anyone paying for CBT training post residency, although also that could be possible. I have many personal friends who have paid for psychodynamic psychotherapy supervision post residency.

Really well done specialized CBT (ie for severe OCD, certain trauma therapies) is a very high level skill as there is a great deal of nuance in choosing the exposures and then managing the patients distress effectively. There are therapists I worked with and respect who would certainly be worth paying for additional supervision with. DBT also, can look simple but in pracrice is absolutely not.

I think most of the psych residencies that have held on to therapy training leaned psychodynamic to begin with, for various historical reasons, and so the very high level CBT is not something you get as much exposure to.

Don't get me wrong, I found much of CBT to indeed be quite boring and have a much more psychodynamic orientation myself but I respect my highly skilled CBT colleagues and the amount of work it takes to get those skills.

 

[WisNeuro]

Really well done specialized CBT (ie for severe OCD, certain trauma therapies) is a very high level skill as there is a great deal of nuance in choosing the exposures and then managing the patients distress effectively. There are therapists I worked with and respect who would certainly be worth paying for additional supervision with. DB also, can look simple but in pracrice is absolutely not.

I think most of the psych residencies that have held on to therapy training leaned psychodynamic to begin with, for various historical reasons, and so the very high level CBT is not something you get as much exposure to.

Don't get me wrong, I found much of CBT to indeed be quite boring and have a much more psychodynamic orientation myself but I respect my highly skilled CBT colleagues and the amount of work it takes to get those skills.

There's "workshop CBT" and then there is real CBT. Unfortunately, many people "doing CBT" are "workshop CBT" people. This is why I think there are so many people out there who dislike CBT from a patient side, they've just had really bad CBT from people who were not properly trained or supervised in anything but the most surface level techniques of CBT.

 

[Stagg737]

I'll add an experience from the other end of the spectrum. I attended a more biologically focused program (legitimately focused heavily on Med/Psych and procedural interventions) and psychotherapy training was the weakest point of the program imo. My psychotherapy supervision and didn't begin until PGY-3 during outpatient and I did 2-3 hours of psychotherapy weekly with an hour of weekly supervision. Yes, there were other aspects of psychotherapy "supervision" worked into residency here and there as well as didactics and opportunities for electives, but core training was minimal and extra experience had to be sought out. I'll add, that the COVID pandemic hit the US in March of my PGY-2 year, so the structure of our supervision and training was significantly impacted and larger group discussions, supervision, and recordings were not utilized like they previously had been. Even the previous training was on the minimal side though, and I had to seek out extra supervision and training from our psychology attendings to feel more comfortable with certain modalities (mostly the psychodynamically oriented ones).

The more interesting aspects of CBT come from CBT for Core Beliefs/Schema-focused CBT. One could certainly use supervision for that, targeting more complex comorbid personality disorders, etc. Techniques are also more elaborate (limited reparenting, cognitively directed psychodrama, etc). Motivational interviewing is not part of residency but is often covered in some parts.

Ymmv. Where I trained we probably got more formal training in MI than any other modality. Where I went also had an addictions fellowship and was pretty heavy on pain/addiction medicine though, which definitely played a role there.

 

[psychma]

It sounds like some of you have had amazing training experiences. Are you being trained by PhD’s or MD’s? Do most of you do therapy post training?

 

[meringue]

It sounds like some of you have had amazing training experiences. Are you being trained by PhD’s or MD’s? Do most of you do therapy post training?

There are many that graduate from my program are full time therapists and do not prescribe medications that pursued full psychoanalytic training afterwards. I received training by both MDs and PhDs in my program, which is fairly therapy heavy. Some of our best teachers are experts/book authors in both CBT therapy and psychodynamic therapy. It's super cool and inspiring!

 

[clozareal]

Do most residency programs today offer basic training in CBT, etc or for those of you who practice therapy did you have to secure training on the side? Did you have to pay for the training/supervision?

In my program, we had training on CBT, psychodynamic, IPT, couples therapy (EFT). We got additional training in whatever we wanted to. I got additional training in ERP, PE, CPT, psychoanalytic psychotherapy, DBT, ACT, motivational interviewing, real CBT-I (not just sleep hygiene nonsense), and group therapy, all of which had supervision and case discussions. Sessions were recorded via webcam in person, seen live during session via webcam, during the pandemic on Zoom. All of these were a few cases though, perhaps 3 months up to 2 years for each modality. 1-3 patients per modality.

In fellowship CBT for kids including those with autism, play therapy, family therapy, parent management training, PCIT, SPACE, hypnotherapy (basics) and HRT/CBIT. Therapy is about 50% of my private practice. I had to pay for psychoanalytic training on the side. I'm interested in getting MBT training now that I'm out in practice or doing the full analytic training. I'm paying for biweekly therapy supervision. I've also done some training in schema therapy that I paid for. Some residents are just not interested in it though.

It sounds like some of you have had amazing training experiences. Are you being trained by PhD’s or MD’s? Do most of you do therapy post training?

I got trained by PhDs, MDs, LCSWs, and LMFTs. I'm in my own analysis and provide therapy.

 

[surfguy84]

There's "workshop CBT" and then there is real CBT. Unfortunately, many people "doing CBT" are "workshop CBT" people. This is why I think there are so many people out there who dislike CBT from a patient side, they've just had really bad CBT from people who were not properly trained or supervised in anything but the most surface level techniques of CBT.

What's the difference?

 

[Stagg737]

It sounds like some of you have had amazing training experiences. Are you being trained by PhD’s or MD’s? Do most of you do therapy post training?

My supervisors were almost exclusively PhDs. I had intermittent supervision from some of our physicians, but not on a regular basis and had to seek out further experiences other than our basic supervision. I regularly do brief therapeutic interventions with my patients, but don't do ongoing therapy as my outpatient role is in a consultation clinic. I have a small handful of people who I've taken on longer term, mainly for therapy, as the care they need doesn't exist in their locales.

 

[tr]

What's the difference?

I'm not sure but when I hear people describe CBT as rote or boring it just makes me think they aren't doing it right. Maybe they are applying prefab worksheets in a cut and dried manner without attending to the patient's specific concern?

I'm not totally sure but my experience with CBT is that for most patients it works too fast for me to get bored. I usually see significant progress towards goal in 4-5 sessions and lots of people are done and dusted after fewer than ten. I have had a few long haulers but they are not as common.

Endless sessions of unstructured, meandering navel-gazing with no therapeutic goal, on the other hand? I had a couple of supervisors who encouraged that sort of thing early on, and I definitely found that boring.

 

[calvnandhobbs68]

There's "workshop CBT" and then there is real CBT. Unfortunately, many people "doing CBT" are "workshop CBT" people. This is why I think there are so many people out there who dislike CBT from a patient side, they've just had really bad CBT from people who were not properly trained or supervised in anything but the most surface level techniques of CBT.

Eh I'd go the other direction and say that many people who say they're doing CBT aren't even doing "workshop CBT"...they're barely even discussing core CBT principles or adhering to core CBT program concepts consistently. It's not uncommon that someone tells me they've been in therapy with a therapist who does "CBT" and act like the 3 component model is completely new information....

 

[Celexa]

It sounds like some of you have had amazing training experiences. Are you being trained by PhD’s or MD’s? Do most of you do therapy post training?

In my program most (but not all) of our psychodynamic supervisors were MDs, and most of our supervision for CBT, couples, and families were Phds with a few LCSWs thrown in.

Our clinical work was also structured so that we could be, depending on context, the patient's med person, therapist, or both. It was common to have patients for which one resident was the therapist and another seeing them in med clinic, and yet another to have the pt in group or couples therapy. It was an very effective way to teach collaboration.

I do not do any work anymore (and don't plan to) where I would be considered someone's therapist. I do not see any patients weekly. In fact doing so would be a misuse of my subspecialized psychiatric skill set. But I use my therapy skills every day. I draw on them continually in every setting. Therapy approaches inform my prescribing, ie as discussed in the current thread about treatment resistant depression. I also supervise resident therapy cases although I am careful to stay within my limits and would turn down supervising therapy cases that require a specialized skill set I do not have.

 

[Celexa]

I'm not sure but when I hear people describe CBT as rote or boring it just makes me think they aren't doing it right. Maybe they are applying prefab worksheets in a cut and dried manner without attending to the patient's specific concern?

I'm not totally sure but my experience with CBT is that for most patients it works too fast for me to get bored. I usually see significant progress towards goal in 4-5 sessions and lots of people are done and dusted after fewer than ten. I have had a few long haulers but they are not as common.

Endless sessions of unstructured, meandering navel-gazing with no therapeutic goal, on the other hand? I had a couple of supervisors who encouraged that sort of thing early on, and I definitely found that boring.

It's probably more accurate to say CBT didn't suit me. I can do the basics and you're right, there's a lot of people it gets better quickly. It's also easy to bundle some basic interventions effectively into a 30 med follow up and I do. It's more that with only a limited use of my time to study things, the work of learning more advanced CBT techniques for more complex cases didn't interest me. I found myself drifting off reading it and avoiding planning my sessions. This seemed to be a common feeling among those of us who favored dynamic approaches.

Psychodynamic therapy can look meandering and unstructured at first but it should ALWAYS have a therapeutic goal. Always. We sometimes sit back more and wait longer than in CBT for that goal to identify itself, but even in that stance, the act of investigation and curiosity supplies the energy. I literally teach my residents if you start feeling bored in the session then our job is to interrogate that feeling and understand why because we have probably run into an important defense. An endless meandering navel gazing session falls into the same 'rent a friend' nonsense as most ineffective therapy. But certainly if someone has an affinity for CBT, I'm sure they feel the way I described above about dynamic work....

 

[tr]

It's probably more accurate to say CBT didn't suit me. I can do the basics and you're right, there's a lot of people it gets better quickly. It's also easy to bundle some basic interventions effectively into a 30 med follow up and I do. It's more that with only a limited use of my time to study things, the work of learning more advanced CBT techniques for more complex cases didn't interest me. I found myself drifting off reading it and avoiding planning my sessions. This seemed to be a common feeling among those of us who favored dynamic approaches.

That's fair. I don't think I learned anything about CBT from a book. I learned it all from hands-on supervision with observation and modeling in small group settings. I agree that psychotherapy manuals make for pretty boring reading and I don't think I've ever gotten through one cover to cover.

I also do not do any 'session planning' or between-session work. Homework is for the patient IMO.

Psychodynamic therapy can look meandering and unstructured at first but it should ALWAYS have a therapeutic goal. Always.

That's very interesting because you are the first person I have ever heard say this. In my mind one of the main differentiators of CBT based approaches from other types of therapeutic interventions is the explicit, up-front delineation of a therapeutic goal.

Globally I would say if a therapeutic approach includes a clear therapy goal, introduction of some concrete method to achieve the goal, and any type of explicit between-session practice or implementation, then it's a CBT-type intervention.

I feel like most psychodynamicists I have met raise their eyebrows at the very idea of an explicitly delineated goal. Have you met others besides yourself who include a goal-delineation or agenda-setting component?

We sometimes sit back more and wait longer than in CBT for that goal to identify itself, but even in that stance, the act of investigation and curiosity supplies the energy. I literally teach my residents if you start feeling bored in the session then our job is to interrogate that feeling and understand why because we have probably run into an important defense.

Totally agree that attending to one's own reactions to the therapy and using that information to inform the approach is important. I think this is trans-modality though. I wouldn't consider that it 'belongs' to one modality or another.

 

[Celexa]

That's fair. I don't think I learned anything about CBT from a book. I learned it all from hands-on supervision with observation and modeling in small group settings. I agree that psychotherapy manuals make for pretty boring reading and I don't think I've ever gotten through one cover to cover.

I also do not do any 'session planning' or between-session work. Homework is for the patient IMO.


That's very interesting because you are the first person I have ever heard say this. In my mind one of the main differentiators of CBT based approaches from other types of therapeutic interventions is the explicit, up-front delineation of a therapeutic goal.

Globally I would say if a therapeutic approach includes a clear therapy goal, introduction of some concrete method to achieve the goal, and any type of explicit between-session practice or implementation, then it's a CBT-type intervention.

I feel like most psychodynamicists I have met raise their eyebrows at the very idea of an explicitly delineated goal. Have you met others besides yourself who include a goal-delineation or agenda-setting component?


Totally agree that attending to one's own reactions to the therapy and using that information to inform the approach is important. I think this is trans-modality though. I wouldn't consider that it 'belongs' to one modality or another.

I think we conceptualize goals and agendas differently and that's where the lost in translation aspects happen. Our goals ARE less explicit and we don't agenda-set the way you do in a cbt sessions; those cards are played closer to the vest and not discussed with the patient in quite a nuts and bolts way, and we don't enter the session with 'today we are going to talk about x thing'.

Maybe it's better to say a psychodynamic therapist should always have a sense of direction. I tell my resident, we are looking for threads and patterns. As more information becomes available to you, you will have more and more of an idea where to steer and ideally you are providing an environment for the patients own self-realization. In supervision, I talk through with my resident different directions he could go as well as ways to approach certain topics. For example, I am supervising a case where the patient presents as very abnormally mature, from a self-suffiency standpoint, than is developmentally typical. In supervision I discussed this aspect of the presentation with my resident and how we will need to understand why this relatively young person became someone who presents atypically mature. We talked about ways the resident could start exploring the patients relationships with their parents, siblings, financial situation, questions he could ask to take a session in that direction naturally based on what the patient generally wants to talk about (which are not generally those topics). That opening might not come in the next session. Maybe it's two or three sessions later where it makes sense to get to it. But eventually it does. Done well, the sessions flow. The patient should feel they are in secure, purposeful hands but not that the therapist has an agenda.

I don't know if I'm making sense lol. I am competent but far from a master. But I was taught that a good psychodynamic therapist always must have a sense of direction--they don't always know where they're going to end up, or the exact route they'll take to get there, but if you aren't moving through the sessions with purpose you aren't going to get anywhere.

What we DON'T do is give explicit homework or between session practice.

You're right that transference and countertransference are not in any way unique to psychodynamic work but we do directly operationalize them more than in other modalities.

I'm a psychodynamic partisan so I see applicability everywhere, but it does frequently take longer. Some patients resist the CBT framing and psychodynamic fits better. Others benefit from CBT initially but then would benefit from a psychodynamic approach for other issues. Unfortunately good psychodynamic therapy has become a real niche market, limited almost exclusively to therapy trained MDs who only take cash. Interestingly, it was far and away the dominant modality of choice for residents in my program when we chose our own therapists. I picked a dynamic therapist myself. I found that I was able to apply a lot of CBT principles to my own life in learning them and that was helpful, but a dynamic therapist offered something I couldnt give myself.

 

[Celexa]

That's fair. I don't think I learned anything about CBT from a book. I learned it all from hands-on supervision with observation and modeling in small group settings. I agree that psychotherapy manuals make for pretty boring reading and I don't think I've ever gotten through one cover to cover.

I also do not do any 'session planning' or between-session work. Homework is for the patient IMO.


That's very interesting because you are the first person I have ever heard say this. In my mind one of the main differentiators of CBT based approaches from other types of therapeutic interventions is the explicit, up-front delineation of a therapeutic goal.

Globally I would say if a therapeutic approach includes a clear therapy goal, introduction of some concrete method to achieve the goal, and any type of explicit between-session practice or implementation, then it's a CBT-type intervention.

I feel like most psychodynamicists I have met raise their eyebrows at the very idea of an explicitly delineated goal. Have you met others besides yourself who include a goal-delineation or agenda-setting component?


Totally agree that attending to one's own reactions to the therapy and using that information to inform the approach is important. I think this is trans-modality though. I wouldn't consider that it 'belongs' to one modality or another.

Also re: session planning, you're a psychologist? I imagine in your training you were focusing on one thing. When I was learning CBT I had been dumped into my third year of residency, handed multiple therapy patients, multiple med clinics at multiple hospitals, was still taking call, and expected to simultaneously be learning psychodynamic and CBT. I had didactic lectures and 1 hour of shared CBT supervision a week, our patient acuity was through the roof, and we were encouraged to do use protocolized approaches. I absolutely hated doing therapy for the first six months and was expected to do a significant amount of additional reading/prep on my own time. Psychodynamic sessions at least I could get away with a) showing up to the session and b) talking about it with my psychodynamic supervisor afterward without having to feel TOO guilty about choosing between trying to learn what my patient needed me to do and, well, sleeping or eating .

 

[Geraltofrivia]

I'm extremely biased but I recommend getting as much free Psychodynamic Psychotherapy supervision during residency as you can. I also recommend reading a few books on it too (Glenn Gabbard: Psychodynamic Psychiatry in Clinical Practice, Nancy McWilliams: Psychoanalytic Diagnoses, few more that I forget)

This forum is seriously an invaluable resource. I wish I used it more when I was in residency

 

[WisNeuro]

I think we conceptualize goals and agendas differently and that's where the lost in translation aspects happen. Our goals ARE less explicit and we don't agenda-set the way you do in a cbt sessions; those cards are played closer to the vest and not discussed with the patient in quite a nuts and bolts way, and we don't enter the session with 'today we are going to talk about x thing'.

Maybe it's better to say a psychodynamic therapist should always have a sense of direction. I tell my resident, we are looking for threads and patterns. As more information becomes available to you, you will have more and more of an idea where to steer and ideally you are providing an environment for the patients own self-realization. In supervision, I talk through with my resident different directions he could go as well as ways to approach certain topics. For example, I am supervising a case where the patient presents as very abnormally mature, from a self-suffiency standpoint, than is developmentally typical. In supervision I discussed this aspect of the presentation with my resident and how we will need to understand why this relatively young person became someone who presents atypically mature. We talked about ways the resident could start exploring the patients relationships with their parents, siblings, financial situation, questions he could ask to take a session in that direction naturally based on what the patient generally wants to talk about (which are not generally those topics). That opening might not come in the next session. Maybe it's two or three sessions later where it makes sense to get to it. But eventually it does. Done well, the sessions flow. The patient should feel they are in secure, purposeful hands but not that the therapist has an agenda.

I don't know if I'm making sense lol. I am competent but far from a master. But I was taught that a good psychodynamic therapist always must have a sense of direction--they don't always know where they're going to end up, or the exact route they'll take to get there, but if you aren't moving through the sessions with purpose you aren't going to get anywhere.

What we DON'T do is give explicit homework or between session practice.

You're right that transference and countertransference are not in any way unique to psychodynamic work but we do directly operationalize them more than in other modalities.

I'm a psychodynamic partisan so I see applicability everywhere, but it does frequently take longer. Some patients resist the CBT framing and psychodynamic fits better. Others benefit from CBT initially but then would benefit from a psychodynamic approach for other issues. Unfortunately good psychodynamic therapy has become a real niche market, limited almost exclusively to therapy trained MDs who only take cash. Interestingly, it was far and away the dominant modality of choice for residents in my program when we chose our own therapists. I picked a dynamic therapist myself. I found that I was able to apply a lot of CBT principles to my own life in learning them and that was helpful, but a dynamic therapist offered something I couldnt give myself.

I don't think this is true in many places. I'm not even in a dynamic hot bed and I can refer out to about 20 doctoral level psychologists from good programs well trained in this, who also take insurance.

 

[Celexa]

I don't think this is true in many places. I'm not even in a dynamic hot bed and I can refer out to about 20 doctoral level psychologists from good programs well trained in this, who also take insurance.

Maybe it's a matter of geography then. It's entirely possible that the psychology training programs where I was just lean very heavily towards CBT. Where I am now I'm jealous that you have 20 people of any type to refer people to who have openings. We have months long waiting lists everywhere.

 

[WisNeuro]

Maybe it's a matter of geography then. It's entirely possible that the psychology training programs where I was just lean very heavily towards CBT. Where I am now I'm jealous that you have 20 people of any type to refer people to who have openings. We have months long waiting lists everywhere.

I'd get in contact with your state psych association. I have psychiatrists and neurologists say that to me here, and then I give them a list of 10 names to get their patients in within a couple weeks. Now, there are some insurances that many private practice people won't touch, so that could drag things out due to access issues, but the main insurers and cash pay can usually get in pretty quickly.

 

[tr]

Also re: session planning, you're a psychologist? I imagine in your training you were focusing on one thing.

No I'm a psychiatrist. My PhD was in basic laboratory science (developmental neurobiology), and predated my psychotherapy training.
It's possible the basic science training was relevant in that it primed me to appreciate a data-driven approach to clinical work as well.

When I was learning CBT I had been dumped into my third year of residency, handed multiple therapy patients, multiple med clinics at multiple hospitals, was still taking call, and expected to simultaneously be learning psychodynamic and CBT. I had didactic lectures and 1 hour of shared CBT supervision a week, our patient acuity was through the roof, and we were encouraged to do use protocolized approaches. I absolutely hated doing therapy for the first six months and was expected to do a significant amount of additional reading/prep on my own time. Psychodynamic sessions at least I could get away with a) showing up to the session and b) talking about it with my psychodynamic supervisor afterward without having to feel TOO guilty about choosing between trying to learn what my patient needed me to do and, well, sleeping or eating

.

That sounds terrible

We did have psychotherapeutic training starting in second year of residency. We just had one or two longer-term psychotherapy patients to start with. My official individual supervisor for that year was of the beard-stroking variety. I was less than impressed with that approach. I met with my first therapy patient for many months and don't think she benefited much. I still feel bad when I think about how much time we both wasted.

However there was an extracurricular evening CBT training group going on that someone told me would be a good idea to attend. I had dropped in a few times in first year and had my mind blown. PGY1 was unpredictable enough that I wasn't able to go that often, but I got to attend more regularly in PGY2. I also happened to get an inpatient attending who was really good at motivational interviewing that second year, and I learned a ton from him. I took what I had learned there and in the CBT group and implemented it in other rotations. A lot of what I learned in the CBT group and from the MI attending proved really priceless for managing difficult patients in the inpatient, ED, and C/L settings. (Not to mention crabby overworked residents from other services! The applicability was endless!)

By the time I got to PGY3 when we were 'officially' introduced to CBT I already had a pretty good idea of what sorts of interpersonal interactions were likely to be efficacious, across treatment settings. In PGY4 I finagled my way into getting the leader of the evening CBT group assigned as my official individual therapy supervisor. By that time I had already had plenty of exposure to the basic approach so I was able to do a lot of refining and optimizing.

Psychodynamic sessions at least I could get away with a) showing up to the session and b) talking about it with my psychodynamic supervisor afterward without having to feel TOO guilty about choosing between trying to learn what my patient needed me to do and, well, sleeping or eating

I hear you about the sleeping and eating. But I have to say this type of 'supervision' is one of the things that really turned me off about at least the variety of psychodynamic I was exposed to. I was like, OK, I should just show up and talk with the patient in some unstructured, unsupervised way, and then later go describe what I did to the supervisor? How am I supposed to learn to be effective if the supervisor doesn't actually see anything I do, and just hears my selective post hoc report? Would you try to learn how to dance ballet by showing up cold in front of an audience, doing whatever you thought seemed correct, and then going and meeting with your ballet teacher afterwards and describing to them how you danced so they could give you 'feedback'?

 

[Celexa]

No I'm a psychiatrist. My PhD was in basic laboratory science (developmental neurobiology), and predated my psychotherapy training.
It's possible the basic science training was relevant in that it primed me to appreciate a data-driven approach to clinical work as well.



That sounds terrible

We did have psychotherapeutic training starting in second year of residency. We just had one or two longer-term psychotherapy patients to start with. My official individual supervisor for that year was of the beard-stroking variety. I was less than impressed with that approach. I met with my first therapy patient for many months and don't think she benefited much. I still feel bad when I think about how much time we both wasted.

However there was an extracurricular evening CBT training group going on that someone told me would be a good idea to attend. I had dropped in a few times in first year and had my mind blown. PGY1 was unpredictable enough that I wasn't able to go that often, but I got to attend more regularly in PGY2. I also happened to get an inpatient attending who was really good at motivational interviewing that second year, and I learned a ton from him. I took what I had learned there and in the CBT group and implemented it in other rotations. A lot of what I learned in the CBT group and from the MI attending proved really priceless for managing difficult patients in the inpatient, ED, and C/L settings. (Not to mention crabby overworked residents from other services! The applicability was endless!)

By the time I got to PGY3 when we were 'officially' introduced to CBT I already had a pretty good idea of what sorts of interpersonal interactions were likely to be efficacious, across treatment settings. In PGY4 I finagled my way into getting the leader of the evening CBT group assigned as my official individual therapy supervisor. By that time I had already had plenty of exposure to the basic approach so I was able to do a lot of refining and optimizing.



I hear you about the sleeping and eating. But I have to say this type of 'supervision' is one of the things that really turned me off about at least the variety of psychodynamic I was exposed to. I was like, OK, I should just show up and talk with the patient in some unstructured, unsupervised way, and then later go describe what I did to the supervisor? How am I supposed to learn to be effective if the supervisor doesn't actually see anything I do, and just hears my selective post hoc report? Would you try to learn how to dance ballet by showing up cold in front of an audience, doing whatever you thought seemed correct, and then going and meeting with your ballet teacher afterwards and describing to them how you danced so they could give you 'feedback'?

It's funny bc I would say exactly what you did about the applicability of cbt to working with patients and consulting teams in the day to day just substituting in the word psychodynamic in place of CBT! There is certainly something about therapy modalities that is not unlike languages--they grew from each other and follow certain rules that are universal, and once you're fluent in one or two the patterns of the others start coming faster. But there's always going to be the one you're most fluent in.

I had such a hard time with MI early in residency and to this day don't understand why its held up as a 'starter' modality. Came back to it after I was grounded in psychodynamic and cbt and realized it made sense now.

I also had a bad experience with CBT early where I had an EXTREMELY character disordered patient and tried to do CBT with a supervisor who was good at their particular favorite patient population but it was just a bad match of modality, supervisor, and patient. I switched that patient to psychodynamic and it was a much better fit for the case.

For good psychodynamic supervision you can't go just from memory. Bare minimum you need process notes made during/immediately after the visit. We also use video. You also can't provide a 'selective' post op report. If you can't cough up the moments when you were uncertain/confused/embarassed or moments you felt you made a mistake well.... That's either on you or on your supervisor for not creating an environment where you feel safe bringing those moments up.

I got particularly lucky with one of my pgy4 psychodynamic advisors and really felt my skills grow leaps and bounds working with them. But I definitely know what you're talking about in terms of ineffective supervision. There were definitely those in the mix who would say useless things like "just be curious" endlessly. I'm sure there's some degree to which our modality preferences end up dictated as much but our early supervision experiences as anything else.

 

[tr]

It's funny bc I would say exactly what you did about the applicability of cbt to working with patients and consulting teams in the day to day just substituting in the word psychodynamic in place of CBT! There is certainly something about therapy modalities that is not unlike languages--they grew from each other and follow certain rules that are universal, and once you're fluent in one or two the patterns of the others start coming faster. But there's always going to be the one you're most fluent in.

Yes I think for sure there are universal basics of effective therapy that transcend modalities, and to some extent it's trainee luck whether and when you get a supervisor who is good at them and can help you develop them.

I had such a hard time with MI early in residency and to this day don't understand why its held up as a 'starter' modality. Came back to it after I was grounded in psychodynamic and cbt and realized it made sense now.

I don't think MI is a 'starter' modality in the sense that it is any easier than other approaches, but I do think the applicability is nearly universal (including non-psych services).

It's also the most important piece to know for effective functioning in acute settings like the inpatient unit, which in most residencies comprise the first two years of the training period.

So those are arguments for introducing it very early in training - I would say in med school actually. (Can you imagine how much more effective a lot of EM docs would be if they had basic MI training?).

I think of MI principles as one of the bedrock, trans-modality skills of effective therapy.

I also had a bad experience with CBT early where I had an EXTREMELY character disordered patient and tried to do CBT with a supervisor who was good at their particular favorite patient population but it was just a bad match of modality, supervisor, and patient. I switched that patient to psychodynamic and it was a much better fit for the case.

For good psychodynamic supervision you can't go just from memory. Bare minimum you need process notes made during/immediately after the visit. We also use video. You also can't provide a 'selective' post op report. If you can't cough up the moments when you were uncertain/confused/embarassed or moments you felt you made a mistake well.... That's either on you or on your supervisor for not creating an environment where you feel safe bringing those moments up.

I'm going to say that expecting a new trainee to correctly identify the critical moments in a 45+ minute therapy session and then effectively communicate them to a supervisor after the fact is pretty unrealistic, regardless if they kept notes or not.

How does the trainee know what is 'selective'?
Regardless of whether they feel 'safe,' can they identify which bits were important? That's a big ask.

Video is slightly better but since you can't watch the full 50 minute video in a 50 minute supervision session, you're still stuck with the trainee's assessment of which bits are important.

I felt that the most effective training approaches I experienced were

1) role play based introduction to the therapy techniques *prior* to any patient contact

2) direct observation of a skilled attending in action - that was the inpatient attending with the MI expertise.

(Edit to add: also the converse, compare and contrast with unskilled attendings who would get into power struggles with patients and then just fall back on their position of authority. The contrast was powerfully educational. One of these attendings actually was attacked by an inpatient and ended up with a long hospital stay. Having observed her in action I was in no way surprised.)

3) one-way mirror supervision for actual patient encounters.

4) written feedback from therapy patients

Post hoc discussion of a therapy session with a supervisor is of very marginal utility, notes or no.

I really don't know why we still dump psychotherapy trainees directly into patient contact settings with no prep (or didactics only), and then expect them to get better by talking about what they did after the fact, with someone who wasn't even in the room. You can't learn any other complex skill with such indirect feedback.

I got particularly lucky with one of my pgy4 psychodynamic advisors and really felt my skills grow leaps and bounds working with them. But I definitely know what you're talking about in terms of ineffective supervision. There were definitely those in the mix who would say useless things like "just be curious" endlessly. I'm sure there's some degree to which our modality preferences end up dictated as much but our early supervision experiences as anything else.

Definitely agree on this

 

[psychma]

Yes I think for sure there are universal basics of effective therapy that transcend modalities, and to some extent it's trainee luck whether and when you get a supervisor who is good at them and can help you develop them.


I don't think MI is a 'starter' modality in the sense that it is any easier than other approaches, but I do think the applicability is nearly universal (including non-psych services).

It's also the most important piece to know for effective functioning in acute settings like the inpatient unit, which in most residencies comprise the first two years of the training period.

So those are arguments for introducing it very early in training - I would say in med school actually. (Can you imagine how much more effective a lot of EM docs would be if they had basic MI training?).

I think of MI principles as one of the bedrock, trans-modality skills of effective therapy.


I'm going to say that expecting a new trainee to correctly identify the critical moments in a 45+ minute therapy session and then effectively communicate them to a supervisor after the fact is pretty unrealistic, regardless if they kept notes or not.

How does the trainee know what is 'selective'?
Regardless of whether they feel 'safe,' can they identify which bits were important? That's a big ask.

Video is slightly better but since you can't watch the full 50 minute video in a 50 minute supervision session, you're still stuck with the trainee's assessment of which bits are important.

I felt that the most effective training approaches I experienced were

1) role play based introduction to the therapy techniques *prior* to any patient contact

2) direct observation of a skilled attending in action - that was the inpatient attending with the MI expertise.

(Edit to add: also the converse, compare and contrast with unskilled attendings who would get into power struggles with patients and then just fall back on their position of authority. The contrast was powerfully educational. One of these attendings actually was attacked by an inpatient and ended up with a long hospital stay. Having observed her in action I was in no way surprised.)

3) one-way mirror supervision for actual patient encounters.

4) written feedback from therapy patients

Post hoc discussion of a therapy session with a supervisor is of very marginal utility, notes or no.

I really don't know why we still dump psychotherapy trainees directly into patient contact settings with no prep (or didactics only), and then expect them to get better by talking about what they did after the fact, with someone who wasn't even in the room. You can't learn any other complex skill with such indirect feedback.


Definitely agree on this

This is a lot of therapy training too both at the masters and doctoral levels (of the Universities I know of.). Trainees get a lot of didactics, minimal practice that is supervised, and are then sent off to internship for 6 months to “learn”. It is very uncomfortable and not good for patient care. I got a lot of supervision around assessment, but much less around counseling. It’s the reason that 8 years out I still meet with a collaborating psychologist. He can’t observe me but I do my best to recreate the sessions and then we talk about them. I’m skilled at assessments but still seek out collaboration. It’s good practice.

 

[Celexa]

Yes I think for sure there are universal basics of effective therapy that transcend modalities, and to some extent it's trainee luck whether and when you get a supervisor who is good at them and can help you develop them.


I don't think MI is a 'starter' modality in the sense that it is any easier than other approaches, but I do think the applicability is nearly universal (including non-psych services).

It's also the most important piece to know for effective functioning in acute settings like the inpatient unit, which in most residencies comprise the first two years of the training period.

So those are arguments for introducing it very early in training - I would say in med school actually. (Can you imagine how much more effective a lot of EM docs would be if they had basic MI training?).

I think of MI principles as one of the bedrock, trans-modality skills of effective therapy.


I'm going to say that expecting a new trainee to correctly identify the critical moments in a 45+ minute therapy session and then effectively communicate them to a supervisor after the fact is pretty unrealistic, regardless if they kept notes or not.

How does the trainee know what is 'selective'?
Regardless of whether they feel 'safe,' can they identify which bits were important? That's a big ask.

Video is slightly better but since you can't watch the full 50 minute video in a 50 minute supervision session, you're still stuck with the trainee's assessment of which bits are important.

I felt that the most effective training approaches I experienced were

1) role play based introduction to the therapy techniques *prior* to any patient contact

2) direct observation of a skilled attending in action - that was the inpatient attending with the MI expertise.

(Edit to add: also the converse, compare and contrast with unskilled attendings who would get into power struggles with patients and then just fall back on their position of authority. The contrast was powerfully educational. One of these attendings actually was attacked by an inpatient and ended up with a long hospital stay. Having observed her in action I was in no way surprised.)

3) one-way mirror supervision for actual patient encounters.

4) written feedback from therapy patients

Post hoc discussion of a therapy session with a supervisor is of very marginal utility, notes or no.

I really don't know why we still dump psychotherapy trainees directly into patient contact settings with no prep (or didactics only), and then expect them to get better by talking about what they did after the fact, with someone who wasn't even in the room. You can't learn any other complex skill with such indirect feedback.


Definitely agree on this

Re: dumping trainees into rooms, it's not just in therapy that I'm surprised how little trainees are directly observed and received feedback about patient interactions. I am particularly Disturbed by the number of residency programs that don't provide real-time Staffing in the outpatient clinics which to me is a terrible idea because outpatient is very hard and the differentials are very complicated but somehow we assume that the residents after spending time on inpatient with extremely sick people that fit into certain particular buckets usually are ready to just see outpatients which is a much wider spectrum of disease and know what to do. I'm very grateful that in my residency we got a lot of real time feedback in Med management. We also did do one-way mirror work although since it was covid it was actually Zoom and we did get to watch videos of senior therapists working with their patients which I always enjoyed a lot.

On the consult service I try and give my trainees the chance to see me do a full interview at least once and it's always received really well and it seems like something they don't get a lot.

 

[tr]

Re: dumping trainees into rooms, it's not just in therapy that I'm surprised how little trainees are directly observed and received feedback about patient interactions. I am particularly Disturbed by the number of residency programs that don't provide real-time Staffing in the outpatient clinics which to me is a terrible idea because outpatient is very hard and the differentials are very complicated but somehow we assume that the residents after spending time on inpatient with extremely sick people that fit into certain particular buckets usually are ready to just see outpatients which is a much wider spectrum of disease and know what to do. I'm very grateful that in my residency we got a lot of real time feedback in Med management. We also did do one-way mirror work although since it was covid it was actually Zoom and we did get to watch videos of senior therapists working with their patients which I always enjoyed a lot.

On the consult service I try and give my trainees the chance to see me do a full interview at least once and it's always received really well and it seems like something they don't get a lot.

Same. I'm usually in the room for the full length of the intake, and usually all or most of the follow up sessions as well. (As a result I am constantly being tapped to fill out their required observed interview assessments because apparently very few of their other attendings do this.)

Most of my outpatient training followed the last-5-minutes model. I thought it was bad then, and now being on the other side of it I find it even more horrifying. Some trainees are fantastic but some can't diagnose their way out of a paper bag, which is to be expected since they're here to learn. But leaving someone like that to manage the intake on their own and then taking their word for it on what transpired really shortchanges both the patient and the trainee.