Psychiatric Residency Training Programs Research Articles

Teaching Psychotherapy to Psychiatric/Mental Health Nurse Practitioner Students in the Virtual Classroom

The aim of this quality improvement project was to evaluate student satisfaction and achievement of select core competencies in psychotherapy by Psychiatric Mental Health Nurse Practitioner (PMHNP) students enrolled in a newly developed, and virtually delivered psychotherapy course. Both qualitative and quantitative data were collected to assess students’ competencies in five domains (i.e. professionalism, cultural diversity, ethical/legal standards of care, reflective practices, and application of knowledge and skills) and satisfaction with content and delivery using simulation and virtual sessions. Using pre- and post-training surveys, we found that competencies in the five domains increased from an average score of 3.1 to 4.5. Integrating a virtual psychotherapy course in advanced nursing education, bringing PMHNP students together to learn about interviewing clients, applying various psychotherapeutic modalities and techniques across diverse cultures, and maintaining ethical and legal standards of care is a challenging but achievable endeavor. We found that using a version of an APA self-assessment tool that was used in psychiatric residency training programs was an effective way to assess PMHNP students’ knowledge, skills, and attitudes on these core competencies. Although this training course proved to be effective in imparting appropriate skills, there is a need to develop sophisticated methods to evaluate how students use complex psychotherapy skills in the clinical setting.

Unnecessarily prolonged suffering: a case of missed diagnosis of post-traumatic stress disorder in a teaching hospital

ABSTRACT We described a case in which a heavily-traumatized patient had been under psychiatric treatment for seven years (five of them in a university mental health clinic) but was never diagnosed with PTSD and, therefore, did not receive the proper treatment for a very long period. After the correct diagnosis was made and personalized treatment instituted, the patient has shown marked improvement in functionality and wellbeing. The key element in this case, was the adequacy of psychiatric training. Our report suggests that psychiatrists are not being adequately trained to identify traumatic events and to diagnose atypical cases of PTSD. With that in mind, we emphasize that theoretical modules on trauma and trauma-related disorders and practical training in specialized PTSD clinics should be incorporated into the psychiatric residency training programs wherever they may be missing, particularly in countries most impacted by violence. Furthermore, continuing medical education on trauma and PTSD should be provided by medical associations and journals to keep physicians updated on recent progress in the field.

Innovations in Psychopharmacology Education in U.S. Psychiatric Residency Programs.

Medications available to treat psychiatric illnesses continue to increase, in conjunction with a shifting of outpatient psychiatric practice from psychotherapy toward medication management. To be successful in this climate, a psychiatrist needs to select the appropriate pharmacologic option(s) for their patient, drawing from old and new psychotropics while accounting for variables such as a patient's comorbid medical conditions and potential drug-drug interactions. In the absence of any national psychopharmacology training guidelines, these skills are taught to varying degrees in American psychiatric residency training programs. The past 20 years have seen an increase in innovations in the areas of psychopharmacology curricula topics, teaching strategies, and assessments of psychopharmacology knowledge and skills. Psychiatric training programs can benefit from and build on these innovations, ensuring that all physicians graduating from a psychiatric residency program meet psychopharmacology-based learning objectives and that their learning can be measured in a valid and reliable way.

Descriptions and Reflections on the Cognitive Apprenticeship Model of Psychotherapy Training & Supervision.

This paper offers a detailed description of a Cognitive Apprenticeship Model for psychotherapy training and supervision. This form of training has been utilized in a novel psychotherapy training program developed for psychiatric trainees, enrolled in a specialized psychotherapy scholars track, embedded in an adult psychiatric residency training program. The paper offers new elaborations of the model, reflections on the apprenticeship supervision and implementation, and clinical lessons learned. The four dimensions of this model include: (1) acquisition of psychotherapy content knowledge; (2) an application of the Cognitive Apprenticeship Model of Supervision, utilizing modeling, coaching, scaffolding, articulation, reflection and exploration as essential aids in structuring a live, real-time supervisory experience; (3) sequencing of clinical psychotherapy training activities; and (4) use of situated learning and communities of practice, as important components of psychotherapy training. The article also discusses an apprentice method of psychotherapy supervision including the intake, working through, and termination phases, Barriers impeding apprenticeship supervision and implementation, and reflections on participant experiences are discussed. This approach may be valuable to others considering the development or evolution of psychotherapy training programs for psychiatrists, psychologists, social workers, or other mental health professionals.

Developing an Advocacy Curriculum: Lessons Learned from a National Survey of Psychiatric Residency Programs.

Advocacy by physicians, defined as a physician's public support for causes, policies, or actions that advance patient health, is increasingly recognized as a professional responsibility as well as a core competency in medical training. The authors describe a survey they conducted on advocacy curricula in psychiatric residency training programs across the USA, from their vantage point as members of an advocacy council within a medical professional organization. Between Fall 2016 and Winter 2018, psychiatry residency programs with advocacy curricula were identified through personal communications with stakeholders as well as a blast email to the American Association of Directors of Psychiatric Residency Training. Semi-structured interviews were conducted with program leaders at residencies with an advocacy curriculum to collect detailed information on these curricula. Seven psychiatry residency programs with advocacy curricula were identified. All seven programs agreed to be interviewed and are included in the survey results. Lessons learned from this survey include how to approach the development of an advocacy curriculum; the components, attributes, and supports of an effective curriculum; and the challenges commonly encountered by medical educators trying to implement such a curriculum. The authors hope that these observations will contribute to the development of a best practice guideline for advocacy teaching within psychiatry and perhaps for other medical disciplines.

Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists.

Regardless of their area of specialization, adult psychiatrists are likely to encounter gender-variant patients; however, medical school curricula and psychiatric residency training programs devote little attention to their care. This article aims to assist adult psychiatrists who are not gender specialists in the delivery of respectful, clinically competent, and culturally attuned care to gender-variant patients, including those who identify as transgender or transsexual or meet criteria for the diagnosis of Gender Dysphoria (GD) as defined by The Diagnostic and Statistical Manual of Mental Disorders (5th edition). The article will also be helpful for other mental health professionals. The following areas are addressed: evolution of diagnostic nosology, epidemiology, gender development, and mental health assessment, differential diagnosis, treatment, and referral for gender-affirming somatic treatments of adults with GD.

Response to Joshi and Langley-Degroot

Response to Joshi and Langley-Degroot

On Family Therapy Training in Psychiatric Education: A Recent Trainee's Perspective

Family therapy has been labelled a neglected core competency of psychiatric residency training programs. Several models of effective integration into training in both general and child and adolescent psychiatry have been proposed, yet the restraint exhibited in educational guidelines to guide developed family therapy programming results in varied trainee experiences. This perspective piece offers the narrative of a trainee's progression through one educational program that offered a generous elective engagement with family therapy. This piece intends to complement in an original manner the existing literature supporting family therapy training for psychiatric trainees that are usually authored by senior clinicians and/or established proponents of family therapy. The program described in this piece is an American model that entailed mandatory seminar didactics with elective active case involvement and clinical supervision. The author's three‐year engagement with a family consisting of a young man diagnosed with schizophrenia and his mother, who comprised the active case component, is presented with a description of how both the family and the clinician developed through the process. The conclusion comments upon how this work facilitated ongoing work with severely disturbed children and their families upon the trainee's graduation to serve as a unit attending on a child and adolescent psychiatry acute inpatient service. This piece illustrates in a personal narrative the importance of family therapy training to the contemporary graduate and recommends greater immersion for psychiatric trainees in this modality.

FOOD FOR THOUGHT: CHALLENGES AND TRAINING RECOMMENDATIONS FOR PSYCHIATRIC RESIDENTS CARING FOR COLLEGE-AGE PATIENTS WITH EATING DISORDERS

Eating disorders (EDs) are on the rise in college students, who are particularly at risk due to biological and lifestyle changes.1,2 However, a conspicuous lack of training curricula for psychiatric residents to manage EDs in a college-age population accompanies these trends. Therefore, practicing psychiatrists enter the field often illequipped to deal with these clinical challenges. This manuscript discusses the impact of EDs, identifies training challenges, and provides pedagogical recommendations for psychiatric residency training programs.

General and Child and Adolescent Psychiatry Resident Training in Integrated Care: a Survey of Program Directors.

Integrated care models are an evidence-based approach for integrating physical and behavioral health services. The American Association of Directors of Psychiatric Residency Training Integrated Care Task Force sought to describe current practices for providing training in integrated care to general and child and adolescent psychiatry residents. Directors of US general and child and adolescent psychiatric residency training programs were anonymously surveyed to examine current practices in educating their residents in integrated care. Based on themes that emerged from the survey, the authors make recommendations for integrated care education of general and child and adolescent psychiatry residents. Fifty-two of 197 (26%) general and 36 of 111 (32%) child and adolescent program directors responded. Results demonstrate that a majority of responding general psychiatry (78%) and child and adolescent psychiatry (CAP) (72%) training programs offer integrated care rotations, many of which are electives for senior residents. The Veterans Health Administration (VA) and Federally Qualified Health Centers are common venues for such rotations. Sustainable funding of these rotations is a concern. Fewer than half of programs offer integrated care didactics. This report is intended to help program directors consider options for starting or optimizing their own integrated care curricula. Future research should examine the educational value, and the overall value to health care systems, of training in the integrated care model.

Applied public mental health: bridging the gap between evidence and clinical practice.

Applied public mental health: bridging the gap between evidence and clinical practice.

APA Hosts Meeting to Build Bridges Between Faith, Mental Health Communities

APA Hosts Meeting to Build Bridges Between Faith, Mental Health Communities

Psychiatry Resident Outpatient Clinic Supervision: How Training Directors Are Balancing Patient Care, Education, and Reimbursement

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

Dialectical Behavior Therapy for Psychiatric Residency Training Programs

CME Educational Objectives 1. Contrast the clinical need for clinicians trained in the treatment of borderline personality disorder with the relative lack of residency training programs providing curricula in dialectical behavior therapy (DBT). 2. List the components of the curriculum developed and implemented at Columbia University for clinical training for residents in DBT. 3. Describe challenges associated with implementing a DBT curricula for psychiatry residents in the current graduate medical education structure. Suicide is the 10th-leading cause of death in the US. More than 38,000 individuals died by suicide in the US in 2010. 1 This figure, although high, reflects only a fraction of those who engage in nonlethal suicide attempts; there are estimated to be 25 suicide attempts for every completed suicide in the US. 2 The incidence of nonsuicidal self-injury (NSSI), distinguished from suicidal behavior as deliberate self-harm without the intent to die, is unknown because no large-scale epidemiologic study of this behavior has been conducted. However, in studies of psychiatric inpatients, estimates of NSSI range from 4.3% to 6.5%. 3 In studies of psychiatric inpatients with borderline personality disorder (BPD), the estimates of the prevalence of NSSI are considerably higher and NSSI is a risk factor for later suicidal behavior. 4 Suicidal risk is one of the most frequent causes of visits to the emergency department, and of psychiatric hospitalization. 5

Teaching Psychodynamic Psychotherapy to Psychiatric Residents: An Integrated Approach

There is enduring controversy in our field regarding the place for supportive interventions in psychodynamic psychotherapy. This controversy is reflected in the differing ways in which psychodynamic psychotherapy has been conceptualized and taught in psychiatric residency training programs. The authors propose an "integrated" approach for teaching psychodynamic psychotherapy to trainees. In the integrated model, psychodynamic psychotherapy is conceptualized as a form of therapy designed to (a) uncover unconscious elements that influence thoughts, feelings, and behavior, and (b) support weakened psychological function. Using this model, residents learning psychodynamic psychotherapy are taught both uncovering and supporting techniques side by side in one course with specific guidelines for assessing when to use one set of interventions or the other. Teaching psychodynamic psychotherapy to residents in this integrated way prepares them to become skilled clinicians who are able to move fluidly from supporting to uncovering in a pragmatic and flexible manner, matched to the particular moment-to-moment needs of the individual patient.

The Role of Therapist Activity in Psychodynamic Psychotherapy

The teaching of psychodynamic psychotherapy is a critical component of psychiatric residency training programs. The authors argue that encouraging our residents to become active while providing psychodynamic psychotherapy is a skill that can be taught. By helping residents to understand how to actively help patients focus on their internal world, identify and work with the defenses, and develop and maintain a treatment alliance, psychodynamic educators can enable psychiatric residents to feel far more competent when working in this paradigm. Such a stance inevitably leads to greater excitement and enjoyment for trainees, as well as better outcomes for patients.

Psychiatry in Korea

This paper reports the current status of Korean psychiatry. In 2011, there were 3005 psychiatrists and 75,000 psychiatric beds. There were 84 psychiatric residency-training hospitals in 2011, which produced about 150 psychiatry board-certified doctors annually. As for academic activity, there is the Korean Neuropsychiatric Association, a main association for neuropsychiatry, and 21 other research societies. Psychiatric residency is a 4-year training program, with different objectives for each grade. The Korean health system accepts National Health Insurance. When severely mentally ill patients register as having a mental disorder, they pay only 10% of their total medical costs. Private clinics usually see patients with less severe conditions such as anxiety, mood and eating disorders; general and university hospitals and special mental hospitals often deal with severe conditions such as schizophrenia and bipolar disorder. One great concern is an increasing trend to depend upon pharmacotherapy and neglect the role of psychotherapy. Additionally, conflicts among medical sectors are becoming fierce as other doctors request abolition of the current law that restricts them from prescribing anti-depressants for more than 60 days. The average hospitalization period of all mental care institutions was 166 days in 2010, substantially longer compared with developed countries. To win the heart of the general public, cutting edge research to improve the quality of treatment for mental diseases, reformation of psychiatric residency training programs, public campaigns to increase awareness of mental health value, and timely reflection on policy decisions should be pursued persistently.

A Biopsychosocial Approach to HIV/AIDS Education for Psychiatry Residents

AIDS psychiatry has been described as a paradigm for teaching psychosomatic medicine with a biopsychosocial approach (1–7). The need for HIV/AIDS education has been emphasized in descriptions, studies, and surveys of psychiatric residency training programs (3–6). HIV/AIDS psychiatry provides opportunities for psychiatry residents to learn about preventing illness and managing chronic and acute illness in persons with psychiatric disorders. It magnifies the significance of assessing acute mental status changes in medically ill persons, discussing sexual and drug-use behaviors, and integrating a cognitive assessment into every psychiatric consultation. The complexities of AIDS and its treatments also magnify the complicated interactions of medications as influenced by mechanisms of drug metabolism and the necessity for building rapport to facilitate the recognition and management of psychiatric symptoms and disorders that affect adherence to medication and participation in treatment. HIV/AIDS complexities also substantiate the value of integrating palliative approaches to care throughout the course of illness, not only at the end of life. AIDS is similar to most other complex and severe medical illnesses, such as cancer, cardiovascular illnesses diabetes mellitus, emphysema, and systemic lupus erythematosis. Severe, complex illnesses have a profound impact on the lives of individuals, their loved ones, and families. Nonadherence tomedical care heightens suffering,morbidity, andmortality. Most persons with severe, complex illnesses can benefit from a comprehensive, compassionate, biopsychosocial approach to care. Integrating medical and psychiatric care for persons with HIV and AIDS can improve adherence, ameliorate suffering, and decrease morbidity and mortality. AIDS differs from many other complex and severe illnesses because it leads to other multi-morbid and debilitating medical illnesses, such as endocrine, hematologic, renal, pulmonary, neoplastic, and cardiac illness, as well as concomitant illnesses, such as hepatitis C (HCV). AIDS is also associated with specific psychiatric disorders, such as mood disorders, anxiety disorders, psychosis, and HIV-associated neurocognitive disorders (HAND). AIDS differs from many complex and severe illnesses in two ways that are very relevant to HIV/AIDS education. The first is that it is an unusual illness because it is almost entirely preventable, and adherence to risk-reduction behaviors has public health implications. The second is that HIV and AIDS are associated with sex, drug use, and AIDS-associated stigma and discrimination, or AIDSism (8). Whereas nonadherence to prevention and treatment of all illnesses has tragic consequences to patients, families, and loved ones, nonadherence to prevention and treatment of HIV and AIDS also results in HIV transmission and has significant public health implications. The most significant challenges to AIDS education in psychiatric residency training include illness-related and training-related factors. Illness-related challenges include an illness with rapidlychanging prevalence, incidence, and treatments, as well as stigma and AIDSism. Training-related factors include pressures of time and productivity, as well as complacency and denial regarding HIV and AIDS. During 4 years of training, psychiatry residents rotate through the inpatient and outpatient units of psychiatry and general care, the emergency room, and intensive care units. Each of these settings provides an opportunity for HIV training. In this article, we document the relevance of AIDS education for psychiatry residents and describe an HIV and AIDS curriculum Received February 11, 2012; accepted April 19, 2012. From the Dept. of Psychiatry, Mount Sinai Medical School, New York, NY, Dept. of Psychiatry, Harvard Medical School, Boston, MA. Send correspondence to Mary Ann Cohen, M.D., e-mail: macohen@nyc.rr.com Copyright © 2012 Academic Psychiatry

Psychodynamic Psychotherapy Training as Acculturative Experience for International Medical Graduates: A Commentary

“Preparing International Medical Graduates (IMGs) for Psychiatry Residency: AMulti-Site NeedsAssessment” (1) addresses the needs of IMGs entering psychiatry residency training in Canada. On the basis of a survey of five psychiatric residency training programs, the authors report that respondents ranked (in order of importance) understanding the Canadian healthcare system, learning medical documentation, practicing evidence-based medicine, and providing mental health care among the greatest challenges they face in successfully adapting to postgraduate medical training. Language barriers and social isolation were particularly difficult for those residents who did not speak English as their first language. Furthermore, residents who had lived in Canada for 12 months or less reported greater perceived knowledge gaps in psychotherapy. This commentary will focus on acculturation issues that underlie the survey’s findings, including language difficulties causing social isolation that may affect the psychotherapeutic competence of IMGs. Among the cultural challenges, we will examine how differences between the collectivistic cultures of origin (for the majority of IMGs originating in non-Western countries) and the host country’s individualistic culture (2) can affect an IMG’s performance in psychiatry. After assessing various approaches to acculturation of IMGs, we will explore how training in psychodynamic psychotherapy can serve as an acculturation tool, offering IMGs unique opportunities for letting go of their old cultures and adapting to the new culture in a phase-appropriate manner. In this commentary, we use the term psychotherapy to refer to psychodynamic psychotherapy.

Neurology Didactic Curricula for Psychiatry Residents: A Review of the Literature and a Survey of Program Directors

Minimal literature exists on neurology didactic instruction offered to psychiatry residents, and there is no model neurology didactic curriculum offered for psychiatry residency programs. The authors sought to describe the current state of neurology didactic training in psychiatry residencies. The authors electronically surveyed 172 directors of U.S. psychiatric residency training programs to examine the types and extent of neurology didactic instruction offered to their residents. Fifty-seven program directors (33%) responded. The majority of these psychiatry residency programs offer neurology didactic instruction to their residents, as provided by both neurology and psychiatry faculty, in a number of different settings and covering many topics. However, room for improvement likely remains. The authors hope this report will guide psychiatry residencies in optimizing their neurology didactic curricula. Further research should explore tools for assessing resident knowledge in neurology and measure the effectiveness of neurology curricula in increasing knowledge and improving clinical outcomes.