Gabbard Explains Dos and Don'ts Of Teaching Psychotherapy

Though not etched in stone like the original set, the 10 commandments of teaching psychotherapy were handed down at a meeting of psychiatry residency training directors last month by a renowned psychotherapist and educator.

“We all learn by making mistakes,” Glen O. Gabbard, M.D., told attendees at the annual meeting of the American Association of Directors of Psychiatric Residency Training in Tucson, Ariz.

Rather than telling training directors how to teach psychotherapy, he said,“ I am using the `thou shalt not' mode of teaching” that Moses used with his people after returning from Mount Sinai with the stone tablets.

“The only differences between Moses and me are that my authority is derived from personal bias rather than God,” Gabbard quipped, “and Charlton Heston has never portrayed me in a feature film.”

Gabbard is the Brown Foundation Chair of Psychoanalysis and a professor of psychiatry at Baylor College of Medicine in Houston. He is also director of the Baylor Psychiatry Clinic and a training and supervising analyst at the Houston-Galveston Psychoanalytic Institute.

Psychotherapy Integral to Psychiatry

Problems can arise when psychotherapy supervisors and instructors teach psychotherapy to trainees as though it were isolated from the field of psychiatry as a whole, Gabbard said.

It is not uncommon for him to encounter psychiatry residents who have no desire to learn about or conduct psychotherapy and who assume “there is a psychiatry that exists apart from psychotherapeutic principles,” he said. But they couldn't be more wrong, he emphasized.

“Is it possible to obtain optimal compliance with a psychopharmacology regimen without understanding psychotherapeutic principles?” he asked. “Can you manage a suicidal patient effectively without some understanding of countertransference?”

Psychotherapy supervisors and instructors may be part of the problem, he said, because “they often convey that psychotherapy operates in a vacuum apart from medication,” when in fact there is plenty of scientific evidence to the contrary.

Those who teach psychotherapy should convey to residents that“ psychotherapeutic principles are applied in all settings where psychiatric treatment is delivered,” he said. For instance, the meaning of medication or electroconvulsive therapy “may need to be explored and discussed with the patient to maximize compliance.”

Rigid Adherence Discouraged

Psychotherapy educators should not advise residents to adhere too rigidly to one theoretical model, Gabbard said. “We can sound like fanatics when we claim that one approach is far better than another and, therefore, demand strict adherence to it.”

While he acknowledged that “there is great value in teaching specific theoretical and technical models of psychotherapy that allow for a coherent understanding of the patient,” he emphasized that clinicians should not be slaves to one theoretical model and that “the patient's improvement is far more important than theoretical purity.”

A good psychotherapy teacher, Gabbard said, creates an environment of learning in which residents feel free to be flexible in their psychotherapeutic approach and borrow from several different theoretical models when conducting psychotherapy with patients.

Since the practice of psychotherapy is often “accompanied by a good deal of uncertainty,” Gabbard said, psychotherapy teachers should not pretend they have all the answers or “know how to deal with every clinical situation that arises.”

Instead, “teachers who acknowledge their own struggles and uncertainty prepare their residents for the realities of psychotherapeutic practice.”

It is also a good idea for psychotherapy teachers to use clinical examples to illustrate how they work with patients, Gabbard said. “If you have the courage to show your own work, residents will then see that you are also faced with a variety of dilemmas, as they are.”

Protecting residents from the reality of having to set and collect patient fees is another potential pitfall, according to Gabbard. “I have never seen as much anxiety in the Baylor Psychiatry Clinic as when we changed our policy so that the residents themselves were responsible for establishing the fee and collecting the patient's payment,” he recalled.

He also noted that “the resident's favorite mode of avoiding aggression, anger, and negative transference is to collude with the patient in never discussing the fee.”

Another mistake psychotherapy teachers and supervisors sometimes make is to treat “countertransference as a sign of pathology or egregious error,” Gabbard said. “Residents have all kinds of emotional reactions to patients,” including feelings of attraction. These countertransference phenomena “are a goldmine of information about what the patient may induce in others,” he said.

When the teacher or supervisor conveys to the resident that countertransference is an “aberration that reflects inexperience or therapist psychopathology, the astute trainee will shut down” and keep emotions private, he noted.

He concluded that much of psychotherapy can't be sufficiently taught in a classroom or in supervision and that “there is no substitute for the hands-on experience of rolling up one's sleeves, making occasional errors, and monitoring the consequences of one's interventions.” ▪