Learning Psychotherapy: A Time-Efficient, Research-Based, and Outcome-Measured Psychotherapy Training Program

Abstract

Although the authors of this important and timely work don't quite succeed in reaching the lofty goals implied in their title, their book is nonetheless a major contribution to the literature. I found it refreshing, exciting, and highly thought-provoking. Beitman and Yue outline three approaches to the teaching of psychotherapy. First, there is the usual “disorganized” approach of exposing residents to a variety of lecturers, seminar leaders, and supervisors, each presenting his or her own approach. Second, there is the school- based, or in its most oversimplified form, the manual-based approach (usually derived from “experimentally validated treatments”), which has yet to be clearly demonstrated as useful in naturalistic, clinical settings. The authors opt for a third approach that teaches the research-based “common factors” shown by many well-executed studies to be the essential elements in all successful psychotherapies. The one-year training program is based on a four-stage conceptualization of the psychotherapeutic process: Engagement, Pattern Search, Change, and Termination. The series of 90-minute seminars consists of very brief lectures, a good deal of discussion (much of it based on brief homework assignments), and the watching, rating, and discussion of videotapes. The program is divided into a pre-training period, six training modules, and post-training. In the pre- training period, the residents receive an overview of the course, rate themselves on a therapeutic “self-estimate” inventory, and are given a number of forms to be filled out by them and their patients before the first therapy session and after the third. The self-estimate inventory, along with a measure of what the residents feel they have learned and where they feel they need additional help, are repeated after each module and at post-training. These self-ratings, along with independent and patient ratings, appear potentially very useful for statistical measurement of the effectiveness of the training program. The six modules, varying in length and complexity, are devoted to 1) verbal response modes and intentions, 2) working alliance, 3) inductive reasoning to determine patterns, 4) strategies for change, 5) resistance, and 6) transference and countertransference. The emphasis placed on the psychoanalytic concepts in modules 5 and 6 belies the authors' stated attempt to base the program on “research-based” common factors and not on schools. Furthermore, the module on transference and countertransference is the longest, the most highly conceptual, and by far the most complex. It is also not very clearly written and contains a few outright mistakes. On the positive side, this module does contain some quite helpful material, including practical suggestions contained in the sections on managing transference and managing countertransference. Beitman and Yue state in their module on the working alliance that therapists' personal characteristics are “beyond the influence of training.” However, research-based variables such as therapists' accurate empathic understanding, warmth, and affirmation can be taught as important elements in the development of a good working alliance. If the authors would omit the school-based modules and include the most elementary of those concepts within the other modules, additional, more research-based common factors could be included or elaborated on. For example, it would be helpful to add more details about the nature and relative importance of the various patient factors, external factors, and placebo and expectation factors significantly related to positive outcome, and how best to address or capitalize on these during treatment. Adding a number of elements to the pre-training section of the program might be useful for residents with relatively little prior psychological training. First, some discussion of the meaning of the biopsychosocial model might be helpful. I have found that many residents grapple with a lack of understanding of the concept of scientific reductionism and therefore have trouble understanding how a mental disorder with demonstrated hereditary predisposition that can be responsive to chemical intervention can also have psychological, interpersonal, familial, social, and cultural components, any or all of which may be crucial to address in treatment. Second, psychiatry residents might benefit from some brief exposure to the literature on effective doctor–patient relationships across various fields of medicine. Third, the training program, and Beitman and Yue's four-stage conceptualization of the psychotherapy process, lend themselves most readily to the treatment of patients who are relatively high- functioning. I would suggest more attention during pre-training to the application of a differential diagnosis to psychosocial treatment planning, along with some measure of ego functioning, to determine whether Stage Four (successful termination) is a reasonable goal for the particular patient being evaluated. One research-based approach to this kind of initial evaluation and planning is that described by Prochaska and his colleagues.1,2 In sum, despite some flaws and some areas where there is potential for improvement (including the quality of the editing), this book is an extremely important and timely contribution to the literature, in that it presents the efforts of educators sincerely interested in tailoring a research-based, outcome-measured, and interesting psychotherapy training program to the needs of psychiatry residents. In my opinion, it ought to be read by all directors of psychiatry training programs interested in teaching from a biopsychosocial perspective.