One cold, gray day in January, the day when a U.S. Airways pilot landed a
crippled plane on the Hudson River, a less-publicized drama was playing out on
the west side of Manhattan, but one critical for the future of North American
In a warren of offices on the first floor of the New York State Psychiatric
Institute, which is part of Columbia University, psychiatry residents attended
courses on various types of psychotherapy and applied their newly learned
skills with patients. Videotapes of their sessions with patients were then
used to give them feedback.
In brief, psychotherapy educators were attempting to "pass the
psychotherapy torch" on to a new generation of psychiatrists, just as
they do nearly every day of the year, and just as psychotherapy educators in
the other 200 some psychiatry residency programs throughout the United States
and Canada do (see What Does the
Future Look Like?).
What are some of the challenges that psychotherapy educators face as they
attempt to "pass on the psychotherapy torch"?
One of the biggest challenges is designing the psychotherapy program,
according to David Goldberg, M.D., acting chair of psychiatry and the
psychiatry residency training director at California Pacific Medical Center in
San Francisco. "It is an incredibly complex field, an evolving
For example, what is the core? Should courses be selected on how much
scientific evidence underlies them? How should courses be sequenced? Should
many different psychotherapies be taught superficially or only a few
psychotherapies in depth? And of course the design of the psychotherapy
program must take into account the requirements of the Accreditation Council
for Graduate Medical Education (ACGME) regarding what psychiatry residents
must master to complete their training successfully.
Some therapies are more difficult to teach than others, Goldberg also
pointed out. "Dynamic psychotherapy is clearly the most difficult to
teach. I think most people would agree with that.... Cognitive-behavioral
therapy [CBT], in contrast, is easier to grasp. A seminar about it tends to be
a lot more logical and obvious and in the frame of a lot of other things that
Bringing the teaching alive is also critical, Goldberg noted. That means
integrating good case histories into the material.
Deborah Cabaniss, M.D.: "I think more and more synergy between
psychotherapy and neuroscience will take place."
Credit: Joan Arehart-Treichel
Yet another challenge is imparting some psychotherapeutic skills to
residents that are essential regardless of the type of psychotherapy they do,
Deborah Cabaniss, M.D., observed. She is an associate clinical professor of
psychiatry and director of psychotherapy training at Columbia
For example, she said, "Residents have to learn to listen for what is
beneath the surface of what a patient says. In other words, as you listen, you
let a lot of things wash over you, but you also start to pick up patterns in
what the patient is saying. Residents have to learn how to set boundaries, or
a very secure frame, which allows patients to feel safe. And residents have to
learn how to develop a therapeutic alliance."
Indeed, teaching residents how to form such an alliance is crucial whether
they do psychotherapy or prescribe medications, Priyanthy Weerasekera, M.D.,
stressed, because research has shown that patients will stay on medications if
they have a good alliance with their psychiatrist. Weerasekera is an associate
professor and postgraduate psychotherapy coordinator in the Department of
Psychiatry at McMaster University in Ontario.
Although some psychiatrists believe that being able to develop a
therapeutic alliance with a patient is something that comes
intuitively—that is, you either have it or you don't—it is
actually a skill that can be taught, Cabaniss and Weerasekera agreed. For
instance, after a psychiatrist has listened to a patient, the psychiatrist
might summarize the patient's narrative by asking, "Mr. Smith, is that
what you are telling me?," and then Mr. Smith thinks, "That doctor
is really listening to me."
Even with all the efforts that psychotherapy teachers make to teach
residents psychotherapy, of course, the residents have to be receptive for the
teaching to bear fruit. But what does "receptive" really mean?
"I would say that, as in any area of medicine, motivation is the
number-one requirement," Weerasekera commented. "Any resident who
is motivated to learn anything, whether psychotherapy or pharmacotherapy, I
find that those residents do well."
"Even though residents have different personalities, they can still
learn psychotherapy," Cabaniss contended. "I think what is more
important is that residents are open to new ideas."
Goldberg believes that residents' personalities "definitely"
influence how well they learn psychotherapy. "I would say their
personalities and their capacities," he said. "For instance, I
have one resident—an excellent physician, an excellent
psychiatrist—who struggled a great deal, and still does, with the
dynamic model. On the other hand, he took to CBT immediately. He is the type
of person who likes to be in charge, who likes concrete things, who wants
clear guidelines on what to do. Self-reflection and examining one's own
motivations and feelings do not come easily to him. [In contrast,] residents
who are more introspective, who take a more leisurely approach, who want to
get into deeper issues, tend to take much more to a dynamic model."
Yet two other hurdles of teaching psychotherapy to residents were cited by
Donald Rosen, M.D., an associate professor of psychiatry and psychiatry
residency training director at Oregon Health and Science University. One is to
instill in residents that they have to develop their own unique styles of
doing psychotherapy—that is, it's 'not how am I going to imitate Aaron
Beck, Otto Kernberg, or Glen Gabbard, but how am I going to do
The other is to impress on residents that while they can expect to be
skilled psychopharmacologists by the end of residency, they should not expect
to be skilled psychotherapists at that point. "Psychotherapy is harder
to learn and takes longer," said Rosen. "Mastery takes a
Julie Niedermier, M.D., who oversees the psychotherapy curriculum in the
general adult psychiatry residency program at Ohio State University, agreed:"
Realistically, the art of learning psychotherapy is truly that—an
art. When we talk about the art and science of medicine, psychotherapy is the
art of what we do.... Residents get a foundation in residency, but their years
beyond residency are also important in developing psychotherapy
But along with the many hurdles of imparting psychotherapy skills to a new
generation of psychiatrists comes recompense, psychotherapy educators
"What is especially rewarding for me," Weerasekera reported,"
is when I compare tapes from residents' early psychotherapy sessions
with patients to tapes from their later psychotherapy sessions with patients.
Early on, you can hear the struggle. Later on, you can hear the
"When residents see patients get better from psychotherapy, it is
really thrilling for them," attested Cabaniss. "And their success
makes me happy too."
"The biggest reward for me," Goldberg noted, "is seeing
residents when they are into the end of their third year or in their fourth
year really getting what all this training is about. [Also] another
compensation is to be able to work with colleagues both in my own program and
nationally. It is a wonderful community—very inspired and motivated. It
feels as if we are carrying a certain kind of flame forward." ▪