The role of the academic psychiatrist is changing. Previously, psychiatric educators were distributors of content [1]. Lectures and didactics were the norm in the psychotherapy curricula of the past, and little emphasis was placed on the development of the skills-based clinician [2]. Increasingly, the academic psychiatrist is becoming a facilitator of learning and an evaluator of competency. In the past, information was imparted passively by means of lectures. Little was done to pursue active, videotaped supervision of skills. As a result, psychiatry residents complained of not learning how to “do” psychotherapy [3]. Many educators have argued that psychiatry residents need to take a more active stance in their psychotherapy learning. Educators must also strive to encourage adult learning consistent with a constructivist approach to learning [4].

The Royal College of Physicians and Surgeons of Canada [5] has greatly enhanced the psychotherapy expectations for residents training in psychiatry. Psychiatry residency programs must now graduate residents with varying degrees of competence in several modalities (or types) of psychotherapy. Within this framework, residents must demonstrate proficiency in some psychotherapeutic models (cognitive-behavioural, for example) and working knowledge in others (interpersonal, for example). Residents are expected to demonstrate only introductory knowledge (gained in didactic seminars, no supervision of an actual patient case) in other modalities such as brief psychodynamic psychotherapy. While slightly different, enhanced expectations have also been outlined by the Accreditation Council of Graduate Medical Education [6] in the United States.

Educators are finding it difficult to ensure that a resident achieves summative competence in any psychotherapeutic modality, let alone multiple modalities. This is due to many factors including a lack of an accepted definition of resident competence [7]. There are faculty related factors as well. Many faculty members complain that they lack expertise in any one modality. Many are pressed for adequate time and are either unwilling or unable to directly observe residents in the actual practice of psychotherapy [8]. Many residents begin their own practice of psychotherapy without ever having witnessed a faculty member engaged in an actual psychotherapy session, let alone an entire course of psychotherapy in any given modality [9]. Given the advances in video-technology and the large group of patients who would consent to videotaping for educational purposes [10], there is little excuse for this. There is the traditional, albeit reductionist, dictum in medical education of “See one, do one, teach one” [11]. In psychotherapy education, residents are expected to “do” without seeing [7].

It is clear that new, competency based curricula must be designed and developed to meet these enhanced expectations. The first step in any curriculum design is a well designed needs analysis. This is needed to ensure that new curricula reflect not only the goals and objectives of the educator but the learner as well. While previous contributions have focused mostly on the needs of the psychotherapy educator, few studies have focused on the needs of the psychotherapy learner. The purpose of this study, then, was to examine the experiences, goals and objectives of a resident group learning psychotherapy in a training program in North America. It should be noted this study was intended to provide an important “first step” in the process of considering psychotherapy training on a larger scale. As such, it provides only preliminary evidence intended to inform future research in the area.

The psychotherapy program at the author’s institution had undergone major changes in the previous four years under a new director. These changes included the addition of 36 weeks of didactic sessions. Each session consisted of a two hour block of lectures. To date, the resident body had not been surveyed about their experience with the changes in psychotherapy education. Formal needs assessment procedures had not been implemented prior to the curriculum change four years ago and until now had not been completed.Learner satisfaction with the current curriculum had not been assessed at any point in the past four years.

In order to assess learners’ needs and the teaching environment more generally, a ten-item survey was distributed to all potential participants. This included nineteen residents who had experience with the psychotherapy teaching in the program for at least one year. The target population was drawn from the psychiatry resident group at the author’s institution. This is an eclectic group of individuals-many of whom are International Medical Graduates. Individual exposure to psychotherapy varies tremendously and depends on each resident’s previous education and interest level.

Since the first year (PGY1) residents had completed only a rotating internship year, they had limited access to the psychotherapy teaching which was offered during the Academic Half-Day. As such, only second through fifth (PGY2-PGY5) year residents were targeted. Out of 24 possible residents, 5 were first year residents and excluded from the sample. The survey was circulated via email to the remaining 19 residents. Ethics approval from the local Health Research Ethics Board was obtained prior to the initiation of the study.

The survey questions were compiled by the researcher as no similar tool was available in the literature. Questions specifically related to the residents’ interest level in psychotherapy, as well as their perception of the current curriculum. Questions were selected based on the informal feedback the residents had provided the author during previous teaching experiences.

The previous curriculum consisted of didactic lectures on cognitive-behavioral, interpersonal, supportive and psychodynamic psychotherapies. Each of these four modalities had approximately equal time in the didactic curriculum.

Residents were asked about their views on the amount of didactics, group discussion/interaction, and DVD review of actual sessions. A Likert-type scale as well as opened ended questions were used. Survey Monkey (available online) was used for this survey.

Table 1: Resident Perception of the Current Psychotherapy Curriculum.

Descriptive statistics were used for items 1-5 and 9. The remaining open-ended questions (6-8) produced qualitative data. A conventional content approach [12] was used to analyse the data. One coder verified the coding categories as representative of the participant responses. This was reviewed by two additional individuals who provided feedback accordingly.

Respondents provided either one-word or 1-3 sentence responses to the open-ended questions. Coding for the content analysis was based on the entire open-ended response from the participant (rather than line by line).

Nine out of nineteen residents responded for a response rate of 47%. Nine residents responded to question 1. Eight residents responded to questions 2-4. All nine responded to question 5.

The resident responses were divided on the actual amount of psychotherapy teaching. However, Eighty-seven point five percent of residents stated that there were too many didactic sessions in the curriculum. Seventy-five percent of the residents said that there was not enough group interaction/discussion with the teacher. Seventy- eight percent of the residents stated that there was not enough DVD review of actual patient sessions (Table 1).

Eighty- nine percent of the respondents expressed interest in engaging in an online learning module in psychotherapy. There was a reasonably strong interest in psychotherapy (66% of the residents were at least moderately or extremely interested in this topic) (Table 2).

It should be noted that psychiatry residents can have a broad range of specific interests in the field. It is the author’s experience that residents are either innately interested or disinterested in psychotherapy. It is also the author’s experience that teaching can nurture interest if it is appropriately timed and of high quality.

The strengths of the program’s psychotherapy teaching

When asked about the positive aspects of the teaching, several important themes emerged (Table 3). These themes included the amount of teaching as well as the variety of teachers and modalities. One comment was made about the use of multimedia in past teaching, specifically the author’s past use of video cases. Finally, one comment was made about the curriculum’s attempt to meet the Royal College’s Objectives of Training.

Table 2: Resident Interest in Psychotherapy, n=9.

Table 3: Strengths of the Program's Psychotherapy Teaching.

To summarize, residents appreciated the variety of teachers and modalities. As well, multimedia was seen as a strength. This would support the findings of Averbuch,and Garvan [13] who reported that the use of video clips in psychiatric lectures improved learner satisfaction. Learners also appreciated the attempt to align the objectives of the curriculum with the Royal College’s Objectives of Training [5] which indicated their awareness of these objectives and their importance in a training program.

Perceived deficiencies of the program’s psychotherapy teaching

Residents were asked to list the deficiencies of the psychotherapy teaching they had been exposed to. Again, a number of important themes were discussed including lack of skills-based training, a lack of integration with the clinical rotations, and not enough use of multimedia - such as the use of actual patient videotaped sessions as part of the curriculum (Table 4).

Once again, the lack of multimedia - in this case the use of videotaped sessions to demonstrate important theories—was highlighted. In addition, the residents were clear about their need to not only learn about the principles of psychotherapy but to be able to practice (with supervision) the techniques of psychotherapy. In the dictum of “See one, do one, teach one” [11], residents in this program were not “seeing one”. In addition, residents felt that they were expected to “do” psychotherapy to meet Royal College requirements. But in keeping with Yager and Bienenfeld’s [7] findings, they were expected to “do” without “seeing”.

Recommendations for change

Residents were asked to provide general comments about their recommendations for change in the psychotherapy curriculum. Many of these comments called for action to correct the deficiencies that were highlighted in Table 5.

Clearly, the residents were aware of the Royal College’s expectations for the Objectives of Training [5]. They expressed a desire for teaching that reflected these requirements. In addition, they were aware of the available online resource PTeR [14] and found it useful.

This study was a preliminary (or exploratory) needs assessment. The purpose of such an exploratory needs assessment was to heighten awareness for the need to explore/evaluate curricula related to psychotherapy training within psychiatric residencies. Residents in this university program presented with mixed reviews on the actual amount of psychotherapy teaching. However, there was a clear sentiment that the teaching, while generous in amount and covering many modalities, was composed of too much didactics. Group discussion and interaction are easy for faculty to facilitate. However, both were lacking in the curriculum.

Patient DVD review is not as easy for faculty to facilitate-- as it requires the production of videotapes/DVDs of actual or simulated patients. Simulated patients need to be trained and actual patients need to give their informed, written consent for the videotaping process. Training simulated patients and videotaping scripted psychotherapy sessions had not been done in this program. Videotaping actual psychotherapy sessions is the practice of only the author in this program—but it is commonplace in other universities and institutions. As such, the residents were aware of this valuable resource and recognised it as missing in their training.

Residents were aware of the Royal College’s Objectives of Training [5]. They expressed a desire for a curriculum that reflected these. There was one comment that suggested that the training program should try to change the psychotherapy curriculum to reflect these objectives. This may have been the comment of a pragmatic learner, possibly because teaching that is based on Royal College objectives may better prepare residents for the final summative examination associated with the end of residency. However, there was some accountability on behalf of the residents. One comment reflected a desire for the program to make the residents aware of the requirements throughout residency and to assist them in meeting these requirements by the end of training.

Table 4: Deficiencies in the Program's Psychotherapy Teaching.

Table 5: Recommendations for Change.

Several comments were focused on the specific need for less didactics and more “hands on” or skills-based training. This was related to individual supervision. While didactics in psychotherapy can be easily arranged and delivered by one or two faculty experts, hands-on skills-based training requires more thoughtful, planning and scheduling - potentially with many faculty supervisors. Residents, however, seemed flexible in the approach to the delivery of this skillsbased training, and suggested options ranging from simulated patients to individual supervision.

Multimedia was also of key importance to the residents. Residents pointed out that psychotherapy involves learning knowledge, and the application of knowledge through skills. Seeing videotaped examples of faculty performing the skill of psychotherapy was highly valued, as it is otherwise difficult to understand how various theories are applied. In this sense, residents were clear that they wanted to see actual patients in actual therapy with actual therapists. The absence of such an experience (by means of DVDs or live, closed circuit therapy sessions) was seen as a weakness. The use of multimedia to demonstrate psychotherapeutic techniques carries certain practical and ethical considerations (getting patients’ informed, written consent, for example). However, it is not insurmountable and can be achieved in an academic program if there is the will of faculty to prioritize it.

Finally, there was an understanding and expression of the need to integrate psychotherapy teaching. The psychotherapy teaching had historically been offered during the Academic Half-Day teaching. In recent years, there had been 3 blocks of 12 weeks of psychotherapy teaching. This teaching was delivered in “siloes” and not integrated with any other didactic teaching. However, the residents expressed a desire to not only learn psychotherapy during Academic Half-day didactics, but to integrate the didactics with the rest of the teaching and within the clinical rotations themselves. Rather than having isolated teaching on “Mood Disorders”, for example, residents expressed a preference for integrated teaching including medication management and psychotherapy for a given psychiatric disorder. They also preferred to integrate this teaching with actual clinical encounters during their mandatory rotations. Without this integration, the residents perceived the teaching as “disjointed”.

Despite the limitations of the training program, most residents were inherently interested in psychotherapy and the majority were interested in engaging in an online training module in psychotherapy.

Taken together, these preliminary results suggest the need for a new psychotherapy curriculum - one that is integrated, interactive and based on the Royal College’s Objectives of Training (or ACGME expectations). Innovative delivery methods, including multimedia and review of actual and simulated patients, were preferred. These results suggest that a blended course might be an ideal way to combine an appropriate balance of didactic content with hands on viewing and discussion of previously recorded, actual patient sessions.