Chief Resident for Psychotherapy Tries to Allay Anxiety

Designating one individual—such as a chief resident—to oversee psychotherapy training of psychiatry residents can enhance trainees' experience of learning therapy and improve patient recruitment and retention in programs that train residents, says Michael Ferri, M.D., of the Department of Psychiatry at Vanderbilt University.

Ferri addressed residents' experience of learning psychotherapy at the APA annual meeting in Honolulu in May. His remarks were part of a symposium on "Teaching Psychodynamic Psychotherapy in an Era of Neuroscience."

Ferri described his experience as chief resident for psychotherapy, a position created by Vanderbilt in an effort to address residents' concerns about learning psychotherapy and to enhance and improve their training. His experience is also described in a report, "The Chief Resident for Psychotherapy: A Novel Teaching Role for Senior Residents," in the July-August 2010, Academic Psychiatry.

Ferri said that medical students entering psychiatry training programs typically have little or no acquaintance with psychotherapy. While most medical students observe and participate in a wide variety of clinical experiences as part of their four-year schooling, students considering going into psychiatry are unlikely to observe a psychotherapy session.

"When it comes to making an informed decision about entering psychiatry, most students know little about this important treatment option, because there is inadequate exposure to psychotherapy prior to training," he said.

And by the third year of training, most residents have had didactic teaching about psychodynamic psychotherapy, but many have not had experiential clinical exposure to it.

Anxiety Levels Start High

Consequently, they are liable to bring to the experience a dearth of knowledge and an extraordinary amount of anxiety.

To address these and other issues, Vanderbilt established the position of chief resident for psychotherapy. As the chief resident for psychotherapy Ferri focused on residents' experience of outpatient psychotherapy of all kinds—psychodynamic, interpersonal, and cognitive-behavioral therapy—and also assisted in patient recruitment. "Once we had one person with dedicated time for recruiting patients, through advertising and contacts in the community, we instantly had a waiting list of 30 or 40 patients," Ferri said.

He also established a series of psychotherapy orientation sessions around all manner of practical, work-a-day matters associated with conducting psychotherapy, such as how to approach and speak to the patient in the waiting room and how to conduct an initial interview. The sessions also used role playing and other techniques to "demystify" the psychodynamic psychotherapy session, with a focus on learning to listen to the patient, he explained.

"We try to impress on residents that they will use the first sessions to listen to the patient, that they don't have to do a lot of talking, and that they don't have to get a complete history in the first 45 minutes," he said.

Ferri emphasized the crucial importance of one-on-one supervision to help residents cope with feelings of inadequacy in their early efforts at psychotherapy. "The positive encouragement of a supervisor assuring residents that they won't kill the patient but are helping the patient and doing it well, is profoundly important in the trainees' experience," he noted.

That point was amplified by Norman Clemens, M.D., a past APA Assembly speaker and a past chair of the APA Committee on Psychotherapy by Psychiatrists. Clemens and Malkah Notman, M.D., presented qualitative data from an informal survey of residency training programs about psychotherapy training (see What Works and What Doesn't in Teaching Psychotherapy to Residents).

Psychotherapy Research Should Inform Training

Also participating in the symposium was Glen Gabbard, M.D., who presented research data on the relevancy of psychotherapy to psychiatric practice. Gabbard also outlined approaches that training programs should actively avoid when exposing residents to psychotherapy (see What Works and What Doesn't in Teaching Psychotherapy to Residents).

Gabbard echoed Ferri and Clemens in emphasizing that psychodynamic principles were crucial to all aspects of psychiatric practice, including inpatient care and psychopharmacology.

"When a patient comes for a med check and starts to tell you how awful his or her mother was the night before, you don't say 'shut up, I don't want to hear about those problems, I just want to hear about side effects.' You act like a doctor and deal with whatever the patient brings to the encounter," Gabbard said. "I encounter residents who say they don't want to do psychotherapy, and I tell them you are going to have to do a lot of it when you are doing med checks."

"The Chief Resident for Psychotherapy: A Novel Teaching Role for Senior Residents" is posted at <http://ap.psychiatryonline.org/cgi/reprint/34/4/302>.