The state of psychotherapy supervision: recommendations for future training

Teaching Psychotherapy

Although there is debate about the importance of a strong foundation in psychotherapy for psychiatrists, the literature provides ample evidence of the positive impact on patient care outcomes when psychiatrists are competent to provide this important form of treatment. Despite financial pressures and increases in managed care posing a threat to the maintenance of psychotherapy as a core skillset for psychiatrists, psychotherapy training should not only be maintained within psychiatry residency training but should in fact be given a renewed focus and priority within training programs.

The future of psychiatric education

Mental health disorders cause a large burden on global public health, with many patients living years with the disability. However, many doctors are ill-equipped to treat mental health disorders given inadequate training during their undergraduate years. In some countries, psychiatry is even considered an elective course rather than a core module. There is, therefore, a pressing need to improve the training of medical students in managing mental health disorders. Measures need to be implemented to attract students to choose psychiatry as their career. Given the developments in the fields and the challenges currently faced by trainees and early career psychiatrists, changes may also be made to the training programme in the postgraduate stage to unify the variations across the world in terms of the training duration and format. This paper will describe the ways that undergraduate and postgraduate psychiatry training may be ameliorated to improve the delivery of mental healthcare around the world and to equip doctors to face challenges in the future.

Características de la supervisión clínica en las terapias conductuales: un análisis del proceso de supervisión clínica

Se presentan las características de la supervisión clínica conductual abstraídas de un análisis de tipo etnográfico de entrevistas realizadas a 18 supervisores de la primera, segunda y tercera generación de terapias conductuales. Los entrevistados contaban con experiencia de 17 años en promedio (DE = 9.85) como clínicos y 16 años en promedio (DE =10.51) como supervisores. Se utilizó el software Altlas.ti 6.2 para analizar y relacionar las características centrales de la supervisión. Los resultados mostraron la supervisión conductual como categoría central con dos subcategorías axiales: factores que afectan la supervisión y proceso de supervisión. Los procedimientos de enseñanza con mayor fundamentación fueron: la formulación de caso, la discusión teórica, la retroalimentación, el modelamiento y el moldeamiento. Se concluye que la supervisión clínica se conceptualiza como un proceso y no como un resultado, y se discuten las implicaciones para los programas psicología clínica en la formación de futuros terapeutas. 

From Learning Psychiatry to Becoming Psychiatrists: A Qualitative Study of Co-constructive Patient Simulation

Objectives: Co-constructive patient simulation (CCPS) is a novel medical education approach that provides a participatory and emotionally supportive alternative to traditional supervision and training. CCPS can adapt iteratively and in real time to emergent vicissitudes and challenges faced by clinicians. We describe the first implementation of CCPS in psychiatry. Methods: We co-developed clinical scripts together with child and adolescent psychiatry senior fellows and professional actors with experience performing as simulated patients (SPs). We conducted the simulation sessions with interviewers blind to the content of case scenarios enacted by the SPs. Each hour-long simulation was followed by an hour-long debriefing session with all participants. We recorded and transcribed case preparation, simulation interactions, and debriefing sessions, and analyzed anonymized transcripts through qualitative analysis within a constructivist framework, aided by NVivo software. Results: Each of six CCPS sessions was attended by a median of 13 participants (range, 11-14). The first three sessions were conducted in person; the last three, which took place during the COVID-19 pandemic, via synchronized videoconferencing. Each of the sessions centered on clinically challenging and affectively charged situations informed by trainees' prior experiences. Through iterative thematic analysis we derived an alliterating "9R" model centered on three types of Reflection: (a) in action/"while doing" (Regulate, Relate, and Reason); (b) on action/"having done" (Realities, Restraints, and Relationships); and (c) for action/"will be doing" (with opportunities for Repair and Reaffirmation). Conclusions: CCPS is an experiential approach that fosters autonomous, meaningful, and individually tailored learning opportunities. CCPS and the 9R model for reflective practice can be effectively applied to psychiatry and have the potential to contribute uniquely to the educational needs of its trainees and practitioners.

Web-Based Therapist Training in Interpersonal Psychotherapy for Depression: Pilot Study

BACKGROUND

Training mental health professionals to deliver evidence-based therapy (EBT) is now required by most academic accreditation bodies, and evaluating the effectiveness of such training is imperative. However, shortages of time, money, and trained EBT clinician teachers make these challenges daunting. New technologies may help. The authors have developed the first empirically evaluated comprehensive Internet therapist training program for interpersonal psychotherapy (IPT).

OBJECTIVE

The aim of this study was to examine whether (1) the training protocol would increase clinicians' knowledge of IPT concepts and skills and (2) clinicians would deem the training feasible as measured by satisfaction and utility ratings.

METHODS

A total of 26 clinicians enrolled in the training, consisting of (1) a Web-based tutorial on IPT concepts and techniques; (2) live remote training via videoconference, with trainees practicing IPT techniques in a role-play using a case vignette; and (3) a Web-based portal for therapists posttraining use to help facilitate implementation of IPT and maintain adherence over time.

RESULTS

Trainees' knowledge of IPT concepts and skills improved significantly (P<.001). The standardized effect size for the change was large: d=2.53, 95% CI 2.23-2.92. Users found the technical features easy to use, the content useful for helping them treat depressed clients, and felt the applied training component enhanced their professional expertise. Mean rating of applied learning was 3.9 (scale range from 1=very little to 5=a great deal). Overall satisfaction rating was 3.5 (range from 1=very dissatisfied to 4=very satisfied).

CONCLUSIONS

Results support the efficacy and feasibility of this technology in training clinicians in EBTs and warrant further empirical evaluation.

Training Psychiatry Residents in Psychotherapy: The Role of Manualized Treatments

Evidence-based treatment and manualized psychotherapy have a recent but rich history. As interest and research have progressed, defining the role of treatment manuals in resident training and clinical practice has become more important. Although there is not a universal definition of treatment manual, most clinicians and researchers agree that treatment manuals are an essential piece of evidence-based therapy, and that despite several limitations, they offer advantages in training residents in psychotherapy. Requirements for resident training in psychotherapy have changed over the years, and treatment manuals offer a simple and straightforward way to meet training requirements. In a search limited to only depression, two treatment manuals emerged with the support of research regarding both clinical practice and resident training. In looking toward the future, it will be important for clinicians to remain updated on further advances in evidence based manualized treatment as a tool for training residents in psychotherapy, including recent developments in online and smartphone based treatments.

Psychiatry resident outpatient clinic supervision: how training directors are balancing patient care, education, and reimbursement

OBJECTIVE

Recent literature on psychiatry resident outpatient clinic supervision is sparse. In designing outpatient supervision, training directors must balance optimization of patient care, education, and reimbursement. The authors sought to describe current practices for supervision within psychiatry resident outpatient clinics.

METHODS

Directors of US psychiatric residency training programs were surveyed to examine methods used for supervision and billing in psychiatry resident outpatient clinics.

RESULTS

Seventy of 183 (38%) training directors responded. Most programs utilize live supervision for medication management visits, but psychotherapy supervision is more varied. Billing practices are variable among programs.

CONCLUSIONS

This report is intended to help training directors consider options for optimizing patient care and resident education in their outpatient clinics, while maintaining financial solvency. Ultimately, programs should have a way of ensuring all patient cases have some form of ongoing supervision, with possible modification based on training level, resident ability, patient acuity, and appointment type.