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 psychiatry.

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 field."

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 residents do."

Bringing the teaching alive is also critical, Goldberg noted. That means integrating good case histories into the material. FIG1

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 University.

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 it?'"

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 lifetime."

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 skills."

But along with the many hurdles of imparting psychotherapy skills to a new generation of psychiatrists comes recompense, psychotherapy educators agreed.

"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 progress."

"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." ▪