A Look at Current Psychotherapy Education during Psychiatry Residency Training in Canada

The decrease in use of psychotherapy by psychiatrists [1], shorter psychiatric appointment durations [2], and the erosion of psychotherapy as a core component of psychiatric training [3] have led many to debate, and even question, the value of psychotherapy in psychiatric education and practice. Despite these realities, many psychiatrists and psychiatrist educators see psychotherapy as an integral component of the role and identity of psychiatrists [4]. As a result, renewed excitement and interest have been occurring in this field in Canada around psychotherapy education in psychiatry residency training. This editorial provides a brief description of the Canadian training context for psychiatric residency training, the new Canadian objectives for training in psychotherapy, and presents key experiences, and lessons learned, from developing a psychotherapy program at Memorial University in St. John’s, Newfoundland, Canada.

The collaboration between the Canadian Psychiatric Association, the professional organization which promotes excellence in clinical practice, and the Royal College of Physicians and Surgeons, which oversees medical education of specialists in Canada, has resulted in a review of specialty training requirements in psychiatry including a demand for increased competencies in a broader range of psychotherapies. The review of training requirements was in response to the increasing appreciation that psychotherapy is an integral part of best practice standards and a foundational component of psychiatry.The mandated changes were, in part, based on the results of a national survey of Canadian psychiatrists regarding necessary training experiences for best clinical practice [5] and reflected the expanding scientific literature validating psychotherapy as an effective treatment [6,7].

There are currently seventeen accredited, university integrated programs which prepare medical school graduates for certification in general psychiatry by the Royal College of Physicians and Surgeons in Canada. The programs are five year training models which aim at graduating a ‘sophisticated generalist in contemporary psychiatric practice’ who is able, and qualified, to provide integrated biological and psychological treatments in collaboration with others [8].

The new training requirements and objectives came into effect in 2008. According to the new standards, psychotherapy education must be longitudinal, and must involve structured didactics and regular supervision of encounters with suitable patients, throughout the specialty training in psychiatry. Psychiatry residents are expected to achieve varying degrees of competence in several psychotherapies [9].

The highest level of competence is defined as ‘proficiency’ and it requires the resident to be the primary therapist to assigned patients with weekly supervision from an expert in the respective psychotherapeutic modality. Attainment of proficiency is required in supportive therapy, crisis intervention, cognitive behavioral therapy and long term psychodynamic psychotherapy. Residents must also demonstrate proficiency in either family therapy or group therapy and ‘working knowledge’ in the other. Working knowledge is defined as participating as an observer or co-therapist and residents must demonstrate such competence in interpersonal therapy, behavioral therapy, dialectical behavior therapy and family or group therapy. The most basic competence, ‘introductory knowledge’, is required in brief dynamic therapy, mindfulness training, motivational interviewing and relaxation. Introductory knowledge should be accomplished through teaching sessions, seminars, workshops or tutorials [10].

Recognizing the disparities in resources and training opportunities across different Canadian programs and the difficulty faced by education coordinators to develop new psychotherapy training models, a group of master educators developed a book aimed at assisting faculty and residents with the implementation of the changes. ‘Approaches to Postgraduate Education in Canada: What Educators and Residents Need to Know’ was published by the Canadian Psychiatric Association in 2009 and has been receiving great attention and appreciation ever since. The chapter on psychotherapies does an excellent job elaborating on the new psychotherapy training goals and targets and also suggests objectives and strategies for the mandated changes.

They offer a number of options to address the limited resources for psychotherapy training such as: the didactic integration of therapies requiring different levels of competence, the pursuit of inter professional education and supervision opportunities with other mental health disciplines, the creation of alliances with other departments within the same university or with other institutions and the use of distance learning or on–line training resources [10].

Lessons learned at Memorial University suggested that the most optimal way to implement the new requirements, and provide new and sustainable psychotherapy training, was to engage in a collaborative and collegial consultation process with faculty and residents in the respective program areas. As the task of developing a new curriculum, which spans over five years of training, is a complex, dynamic and in flow process, organizational and practical challenges are to be expected. It is important that both faculty and residents develop a good understanding of the proposed goals, and consensus is built, before formal changes take effect. A significant process of curricular and organizational change was needed to accommodate the new structured learning activities and supervision. The change could not have been possible without negotiation and coordination with residents, lecturers, supervisors and clinical site education coordinators.

The more informal approach to psychotherapy training, which was variable and dependent on several factors such as residents’ readiness and motivation and faculty’ availability to provide teaching and supervision, was replaced with a formally organized and predictable program of modality specific didactic sessions and small group supervision. Modules were developed in the required psychotherapies by collaborating with academic and community–based experts in the field who included several psychologists, a social worker and a family physician. This process facilitated several other inter professional training and scholarly opportunities and the perception is that it has been very beneficial. Memorial’s psychotherapy training model starts in the first year and allows residents to build a psychotherapeutic understanding of their patients and develop useful skills in their practice early in their training.

Despite protected psychotherapy time for the residents, more dedicated time is needed, along with an optimization of the integration of psychotherapy education with the remainder of the residents’ clinical service duties and the other components of general psychiatry curricula. While residents have been given enhanced access to regular and accessible group supervision, patients suitable for psychodynamic psychotherapy and videotaping in supervision, work still needs to be done on recording psychotherapy training by keeping logs, making available adequate secretarial support to residents and dealing with the frequent interruptions in training due to residents’ various leaves and on–call duties.

In conclusion, psychotherapy remains an important component of the identity and role of a psychiatrist. The Canadian psychiatrist is trained to employ a range of diagnostic and therapeutic modalities and to bring specific psychopharmacological and psychotherapeutic expertise to individuals with a combination of medical and psychological issues and to multidisciplinary teams. Psychotherapy is an effective intervention which is frequently used in combination with medications for patients dealing with a host of psychiatric conditions. Importantly though, for such an intervention to be optimally effective its prescribers and providers must be properly trained in its theory and use. Psychiatry residency training in Canada has significantly expanded its scope of psychotherapy preparation. As seen in this current editorial, despite various systemic and institutional challenges, it is possible to produce high quality psychotherapy training in Canada even where time and other resources are seemingly limited.

References

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