International Medical Graduates (IMGs) have assumed significant leadership roles in North America in research, education, clinical, and professional organizations (1–3). Although patterns have changed, IMGs represent 25% of the physician workforce in the U.S., playing a key role in the delivery of health care, especially to underserviced populations (3, 4). Close to 30% of psychiatry residents in the United States are International Medical Graduates (IMGs), with the majority arriving from India, Pakistan, the Middle East, and Eastern European countries (3). A review of the literature over the past 10 years, using the search engines PubMed and PsychInfo with the mesh term “International Medical Graduate” yields close to 150 articles and letters on various topics concerning IMGs. Original papers limited to educational issues include acculturation, social adjustment, language proficiency, communication skills-training, attaining competencies, and professionalism (4–11).
Searight and colleagues (12) found family-medicine IMGs to have little previous exposure to the “behavioral sciences,” clinical psychiatry, interviewing skills-training, the biopsychosocial model, and an understanding of the “doctor–patient” relationship. One must be cautious, however, in generalizing these findings to all IMGs, given that the data were obtained from only 10 residents in a qualitative manner. In a more recent review, Pilotto and colleagues (13) identified 18 evidence-based papers meeting clearly-defined empirical criteria, which addressed issues pertinent to the training of IMGs. On the basis of this review, good communication skills were identified as one of the most important areas for success in training IMGs in all specialties. The specific communication components found most likely to create difficulties for IMGs included reading patient’s nonverbal cues, responding to patient’s emotions, expressing empathy, and carrying out reflective listening, all essential skills for the development of a positive therapeutic alliance found to predict a good outcome in psychotherapy and pharmacotherapy (14–16).
The practice of psychotherapy demands sophisticated communication skills and proficiency with the English language, a challenge for many IMGs. A more refined search of the literature with the same search engines, using the terms “psychotherapy training,” “psychotherapy,” and “International Medical Graduates” yielded only two papers. The first reported an increase in IMGs’ confidence level after completing a course on boundary issues (17), and the second found IMG psychotherapy session evaluations to predict success in residency, a finding that has implications for training (18). Missing from the literature, however, are guidelines for psychotherapy training tailored specifically for IMGs.
The purpose of this article is to provide guidelines that attend to the specific issues for psychotherapy training for IMGs identified in the literature: communication-skills difficulties and lack of previous exposure to the behavioral sciences. Some of the content discussed here has been presented at four consecutive meetings of the American Psychiatric Association’s IMG Institute (19). This paper will focus on empirically-based guidelines, including effective methods of teaching psychotherapy, the therapeutic alliance, issues common to all therapies, and the teaching of specific psychotherapies as they pertain to IMGs. The guidelines presented are meant to supplement already-existing comprehensive psychotherapy training programs.
Use Effective Teaching Methods
In their review, Pilotto and colleagues (13) found that IMGs had not received adequate training or been given feedback in communication-skills training. In the Searight et al. study (12), IMGs were quoted as saying, “We had no formal training. Nobody taught me how to talk to patients” (p 167). Using effective teaching methods is by far the most important component to consider in designing training programs for IMGs (and for all residents, for that matter). The topic of incorporating effective teaching methods in psychotherapy training has been discussed elsewhere (20); the application to IMGs, however, has not. Specific teaching methods, such as microcounseling, modeling, rehearsal, feedback, and coaching, have been demonstrated to enhance general and specific psychotherapeutic skills (20). Microcounseling provides moment-to-moment feedback to trainees, based on their actual performance heard or seen on audiotapes or videotapes, respectively, or in role-play scenarios. This is an excellent method for teaching communication skills as attention is paid to therapist’s delivery of empathy, warmth, respect, positive regard, reflection of content and feeling, vocal quality, intonation, and tone. Initially developed by Carl Rogers, subsequent research has demonstrated its effectiveness in teaching empathic skills, necessary for the development of a positive therapeutic alliance (21).
The teaching triad of modeling, rehearsal, and feedback have also been found to enhance learning in psychotherapy (20). Modeling requires expert demonstration of specific therapy skills; rehearsal allows practice; and feedback provides an opportunity for new learning. Feedback must focus on specific behaviors (heard or seen on session audio/videotapes or viewed live), so that new learning occurs. It is especially important to provide feedback early in training, when behaviors closely approximate the specific therapy. For these reasons, systematic feedback and reinforced practice are well-known, empirically-grounded principles of learning that can be utilized to improve therapist competence across all therapies. Using these teaching methods with IMGs is crucial, as they have been shown to improve the very specific behaviors referred to as “communication skills” in the IMG literature. Although not formally investigated, informal feedback from IMG participants at four consecutive APA workshops (2008–2011) (19) revealed that almost none had received any training in psychotherapy where these techniques were utilized. This finding must be interpreted with caution, given the possibility that IMGs receiving more structured training may not have attended the workshop.
Build Therapeutic-Alliance Skills First
A good doctor–patient relationship is considered essential for the practice of medicine. In the Searight et al study (12), family-medicine IMGs reported different experiences with respect to attention given to this variable in their previous training, “There is no doctor–patient relationship. You have multiple patients in the same room. You do not have any kind of relationship with them … (p 167).” Although the term “doctor–patient relationship” is used in medicine generally, the “therapeutic alliance” is used in the practice of psychiatry and psychotherapy. The therapeutic alliance, defined as the relationship between the therapist and the patient contains three components: 1) a bond (relational component); 2) mutually agreed-upon goals; and 3) tasks (means to attain goals) (15). Certain therapist attributes (warmth, genuineness, respectfulness, and being empathic) and techniques (empathic reflection, affective exploration, supportiveness, facilitation of the expression of affect, and attention to the patient’s experience) are related to a positive therapeutic alliance, and are therefore important skills to learn (14). Interviewing-skills modules following evidence-based teaching methods can ensure that IMGs learn specific alliance-building skills. During these sessions, fundamental skills, such as attending, listening, and reflection of feeling can be taught by use of specific methods described by Hill and colleagues (23). These resources are valuable in that they can help IMGs with the specific words to use when reflecting feelings or providing empathic responses. This was identified as one of the most difficult areas by IMGs when conducting role-plays (19) and by family-medicine IMGs learning communication skills (12). Specific therapies that pay more attention to these skills can also be learned (24). Assessing the alliance early in treatment with the Working Alliance Inventory (WAI) (20, 22) may also be beneficial. This instrument can be given to the patient to complete early in therapy (because it predicts outcome), with results being discussed with the IMG for formative feedback. The WAI can also track the IMGs’ performance across all years of training in all the psychotherapies and in core rotations. Empathic skills can be more specifically assessed by other instruments (25, 26).
Patient problems can be understood according to various conflictual themes, specific cognitive distortions, reinforcement schedules, interpersonal events, emotional dysregulation, family and couple dynamics, and many other psychological constructs. These constructs are complex and even more difficult to understand when English proficiency is poor. Once language skills are developed, attention must focus on the comprehension of these constructs. The best method of operationalizing these constructs is to demonstrate them either through role-playing or videotapes. After this, repeated exposure to the construct, accompanied by repeated testing, is important in order to ensure comprehension before therapy begins.
“Medical” Versus “Psychosocial” Model in Psychiatry
The biopsychosocial approach is advocated in both American and Canadian psychiatric training programs (27, 28). Many IMGs may not have had any exposure to psychiatry or the biopsychosocial model (12). “Medicine was the focus…you really didn’t study psychiatry unless you were planning to study it as a specialty (p 166).” For many IMGs, learning a psychosocial model may prove difficult, and, in some cases, considered “a waste of time.” This opinion is likely attributable to lack of previous exposure to the behavioral science literature, psychiatry, and a lack of knowledge of the empirical psychotherapy literature. It is therefore critical that all residents be exposed to the major readings in psychotherapy, and especially to the evidence-based literature. Well carried-out randomized, controlled trials (RCTs) and over 60 metaanalyses (Level-1 evidence) support the use of psychotherapies for patients with psychiatric disorders (29). Informal feedback from IMGs at the APA workshops revealed that very few were aware of this literature (19). Once exposed, IMGs gained a new-found respect for psychotherapy and the psychosocial model, and they appreciated receiving training in this area.
Self-Disclosure in Supervision
Self-disclosure of therapist feelings in psychotherapy is important if learning is to take place. Although audio- or videotapes more readily permit self-disclosure with effective feedback, many issues are not easily discussed. Effective psychotherapy occurs in the context of a trusting relationship between the therapist and the patient, and it is expected that a parallel process between resident and supervisor will facilitate learning and a better treatment outcome. IMGs may be less likely to disclose difficulties in therapy because of cultural norms that inhibit them and a heightened sense of vulnerability they feel in a new culture (12). “I am so scared, I do not feel secure. I feel like I might get kicked out (p 169).” Alliance issues and, specifically, boundary issues need to be addressed skillfully and efficiently. When the need to succeed is great and the fear of failure high, self-disclosure decreases, as does the opportunity for learning.
Some feelings, such as attraction to patients, are even harder to disclose. Many residents may feel more comfortable discussing these feelings with a therapist than with a supervisor. Although there is a significant literature on the topic of boundary issues, there has been little focus on IMGs. One study reported an increase in IMGs’ confidence level after participating in a structured curriculum on boundary issues; however, whether or not participation in the course actually changed self-disclosure or professional behavior is unknown (17). An open discussion of the different types of feelings therapists can develop toward patients, with an understanding of why these feelings develop and what they represent is important. More importantly, a clear plan should be laid out to assist residents developing sexual feelings toward patients. Opportunities to meet with the supervisor privately or seek therapy should be made readily available. These issues should be discussed before therapy begins. Supervisors need to remind residents that these feelings do develop, but that psychotherapy is to be practiced in an ethical manner, with clear professional boundaries being maintained at all times. It is important to note that a recent study by a state disciplinary board examining boundary violations did not find differences between IMGs and non-IMGs (30), underscoring the importance of not treating IMGs as if they are more likely to behave in an unprofessional manner.
Although most training programs in North America will be guided by requirements set by the Accreditation Council of Graduate Medical Education (ACGME) or the Royal College of Physicians and Surgeons of Canada (RCPSC), it is prudent to consider the evidence-based literature when selecting therapies for training. Current research supports the use of cognitive-behavioral (CBT), emotion-focused (EFT), interpersonal (IPT), behavioral activation (BA), psychodynamic, dialectical-behavioral (DBT), motivational interviewing (MI), couple, family, group, and many other therapies in the treatment of patients with psychiatric disorders (29). Since the purpose of this article is to highlight psychotherapy training issues for IMGs, it will not present a general discussion on psychotherapy training for each therapy with references and resources, which can be found elsewhere (20, 31). Each program is left to its own discretion to determine the content of readings, seminal papers for inclusion, and general psychotherapy focus.
The teaching of supportive therapy is recommended by both the RCPSC and the ACGME, and can be learned through interviewing-skills modules or specific therapies (23, 24). Cognitive-behavioral therapy, the most investigated psychotherapy for depression and anxiety disorders, is an important therapy for IMGs to learn. In conducting CBT, the IMG must be able to assign and review weekly homework, deal with homework noncompliance, and deliver a structured, goal-directed therapy. Dealing with homework noncompliance may be difficult for the IMG if the therapeutic relationship is authoritative rather than collaborative in nature.
Learning psychodynamic therapy may prove to be particularly difficult for IMGs because of the language difficulties inherent in understanding this area. It is important that IMGs first attain a level of competence at a conceptual level by providing a psychodynamic case-formulation and treatment plan. As therapists, IMGs must be able to understand and interpret the transference when it is appropriate to do so, be capable of examining their countertransference reactions, be able to provide a corrective emotional experience, and provide interpretations to the patient when this is considered to be helpful. Supervision, accompanied by carefully-selected readings, will help IMGs focus on these areas.
Family interventions integrated with medication or other therapies have been found to be helpful for patients suffering from a variety of psychiatric disorders. To attain competence, IMGs should be able to assess, formulate a plan, and treat a family with ongoing supervision in the context of a child or adult case. Given the complexity of family therapy, IMGs may find this approach challenging to learn. Families follow culturally-bound rules and adhere to society’s norms.
IMGs will need to understand North American family culture and how this influences family functioning. Specific family-therapy skills need to be actively taught (ability to join a family, assessment skills, formulation skills, and treatment skills), with special attention given to the IMGs’ cultural issues and how this interplays with the specific family (12). Therapist competence scales will help operationalize specific therapist behaviors that are difficult to understand (20).
Group therapy can be delivered to a wide range of patients suffering from a variety of psychiatric problems across the lifespan, with much fewer resources. In group therapy, the therapist needs to attend to the delivery of interventions and group process. This may be difficult for IMGs new to dealing with group process. Live supervision and or videotaping are important methods to use in such cases. Several individual therapies can be delivered in a group format: CBT, psychodynamic, IPT, and DBT, to name a few.
In a recent comparative metaanalysis, Cuijpers et al. (32) found that although most therapies were helpful for depression, IPT demonstrated a slight advantage, with CBT showing more dropouts. IPT assumes that the onset and maintenance of, and recovery from depression are determined by four key interpersonal events: losses, role-transitions, interpersonal conflicts, and interpersonal deficits. IMGs may find this therapy easier to learn, as it integrates the medical model with other therapeutic ingredients found in other therapies, yet relies less on homework compliance.
It is to be encouraged that IMGs have exposure to behavioral activation, motivational interviewing, and mindfulness. Behavioral activation incorporates activity-scheduling in the treatment of depression; it is highly effective and much easier to learn. Motivational interviewing (MI) incorporates an empathic, nonjudgmental, open dialogue with patients to explore readiness for change or commitment to engage in treatment. IMGs will benefit from learning this approach, as it lends itself to the development of a collaborative, non-authoritarian doctor–patient relationship, with competence scales available (20). And, finally, IMGs should be aware of the mindfulness literature and its importance in CBT, DBT, and other therapies. Although other therapies have been found to help patients with psychiatric disorders, the ones selected above have the best supportive evidence for treating patients with psychiatric disorders, making them important to consider when selecting specific therapies for IMGs to learn.
Many IMGs train in resource-poor programs that may not have adequate resources to teach all of these therapies. Members from other departments, such as Counseling, Psychology, and Social Work can help train psychiatry faculty and residents in these areas. Videos, DVDs, and on-line resources demonstrating these therapies, and distance-supervision using web-based techniques can also help.
This article presented empirically-oriented guidelines for teaching psychotherapy to International Medical Graduates on the basis of the concerns identified in the literature. Although attention was paid to enhancing IMGs training in psychotherapy, it is important to note that many IMGs arrive highly skilled in one or many forms of psychotherapy, have extensive analytic training, and experience in psychotherapy research. Therefore, IMGs are an important resource in assisting faculty in teaching psychotherapy to other IMGs, non-IMGs, and medical students.