The Accreditation Council of Graduate Medical Education (ACGME) and the Royal College of Physicians and Surgeons of Canada (RCPSC) recently mandated that training programs must demonstrate resident competence and proficiency in several forms of evidence-based psychotherapies (1, 2). In the United States, residents must attain competence in supportive, psychodynamic, and cognitive therapies, with exposure to couple, family, and group therapies (1). In Canada, residents must have proficiency (be prime therapist with ongoing supervision) in supportive, psychodynamic, cognitive, family, or group therapy; have working knowledge (be a co-therapist or observe) in behavioral, dialectical-behavioral, interpersonal, and family or group therapies; and possess introductory knowledge in brief psychodynamic, mindfulness, relaxation, and motivational interviewing (2). Psychotherapy requirements in both countries pose significant challenges for training programs, given the lack of resources to train residents in a variety of evidence-based psychotherapies and the on-going confusion over the definition of competence (3). Although the literature offers some guidance in this area (4, 5), programs continue to struggle to meet these demands.

E-learning, or web-based learning (WBL), has been used extensively in undergraduate medical education and other specialties to provide trainees with access to resources and methods to assess competence in knowledge-base and clinical skills through the use of simulations (6). Simulations provide an interactive on-line presentation of an enacted case scenario with opportunities to assess decision-making skills regarding different aspects of treatment. In psychiatry, simulations have been found to improve resident performance and confidence in prescribing medications (7, 8). Regardless of specialty, designing optimal websites requires paying attention to findings from cognitive science (9, 10) and models of information-processing (11).

With respect to e-learning and psychotherapy education, there does not appear to be a comprehensive, evidence-based, on-line learning resource in psychotherapy that incorporates multimedia to demonstrate multiple therapies, knowledge assessment questions to assess competence, and simulations to assess clinical skills. This article introduces a web-based psychotherapy program developed at McMaster University that contains these specific components, and we present details regarding design and development of this website. E-learning tools should not be incorporated into training programs without a good understanding of the pedagogic principles behind their use; therefore, a discussion of on-line learning issues in psychotherapy precedes the presentation of the website.

In most training programs, learning in psychotherapy occurs on-site in seminars, in clinical supervision, and in patient sessions. When integrated with these existing methods of learning, web-based learning (WBL) can provide additional benefits. First, websites can house an extensive collection of rich resources, such as power-point seminars and reference material that is easily accessible. Second, WBL allows one to assess competence with multiple-choice questions and simulations. And, finally, WBL allows the learner to view numerous clinical vignettes demonstrating the unique components of different types of psychotherapy.

From a cognitive-science perspective, on-line learning utilizes several effective methods of learning: the capacity for continuous and repeated exposure to the same material; utilization of learning material on an as-needed basis; the opportunity for pretesting, posttesting, and retesting; and the ability to use problem-based or case-based learning (12, 13). These methods have been demonstrated to enhance memory and improve generalization to real cases (14). More importantly, the ability to view a large series of clinical vignettes that demonstrate specific therapies is crucial in the first step of learning psychotherapy, as it provides the modeling of specific components of each intervention (15). Research has demonstrated that WBL is equivalent to on-site learning, and can be integrated with on-site learning to enhance knowledge acquisition, and even clinical skills in some cases, through simulations (6). On-line learning does not replace existing teaching methods in psychotherapy, but can augment learning, facilitate the assessment of competence, and assist with resource issues.

Given the potential benefits of WBL the postgraduate psychotherapy program at McMaster University designed and developed a web-based psychotherapy program to supplement its existing program. The ADDIE model of web design guided all phases of development: the acronym stands for assessment, design, development, implementation, and evaluation. This well-known model of web design emphasizes the following steps in web development: a needs-assessment to determine whether WBL will be helpful, careful measures to ensure proper design, a well-planned development phase, implementation of the initial product, evaluation or beta-testing, and a reassessment to determine modifications (16).

The ADDIE Model of Web Design

An assessment of the McMaster University psychotherapy program revealed that although program satisfaction and resident competence had been demonstrated (17, 18), many issues deserved attention: resident exposure to modeling of clinical skills in psychotherapy was limited; knowledge-base was not evaluated; and a wide range of resource material was not easily accessible. Therefore, it appeared essential to provide residents with opportunities to view many psychotherapy video clips, access seminars and other resource materials on a 24/7 as-needed basis, and carry out self-assessments through testing with multiple-choice questions (MCQs) and simulations. As a result of this assessment, a decision was made to develop a web-based resource to supplement the existing program. Funding was procured through a department educational grant for 3 consecutive years, to purchase the necessary audio-visual equipment and software, and to hire a part-time multimedia consultant and obtain computer technical services.

In designing the website, we adhered to principles derived from cognitive-science research (10). First, an effort was made to minimize cognitive overload by decreasing the usage of text. Second, graphics were kept simple. Third, conversational, rather than formal, language was utilized throughout the site. Fourth, multimedia clips demonstrating different psychotherapies were kept to 10–12 minutes, so that attention would be maintained. The simulations contained even shorter clips, so as not to overload the information-processing system. And, finally, immediate feedback was provided whenever competence was assessed. After 3 years of development, the original website was housed on WebCT and integrated with our existing psychotherapy program. WebCT (now known as Blackboard), is an on-line virtual learning environment used by many institutions for e-learning purposes (http://www.blackboard.com/).

The PTeR

The Psychotherapy Training e-Resources, or PTeR (http://pter.mcmaster.ca) model, was developed 3 years later, on a MOODLE platform (http://moodle.org/: an alternate learning content management system), in order to permit universal access to the site. Two additional years were necessary to transform PTeR to Moodle, obtain copyright and university approval for licensing, and to beta-test the site. Therefore, 5 years in total were required to create PTeR and make it available to other institutions. Participants in PTeR include over 85 faculty, residents, and staff of the department, and other creative consultants (see contributors, below). In addition to initial development cost, considerable time is expended to create and maintain the site. All participants volunteered their time to be “patients” and virtual therapists in clinical vignettes. Consent was obtained from all participants for their contribution on the website. The contributors spent additional time creating power-point seminars and designing video materials. Module coordinators for each e-module spent additional time ensuring that the content of the e-module was cohesive and current. The main author also expended 2 days per week to create the site for the entire production period.

PTeR is a web-based psychotherapy program containing resources in 11 organized psychotherapy e-modules (see Table 1). PTeR houses over 70 video clips demonstrating at least 12 different types of psychotherapy for patients with psychiatric disorders. All sessions present role-play enacted scenarios carried out by faculty, residents, and staff in the department.

Additional resources provide guidelines for teaching the therapeutic alliance, mindfulness-based cognitive therapy (MBCT), mindfulness for anxiety disorders, teaching International Medical Graduates basic interviewing skills, schema therapy, and relaxation.

In working through PteR, it is recommended that users first review the “How to Use PTeR” and “Evidence-Based Teaching Methods in Psychotherapy” sections before exploring other modules on the site. This will provide the user with a good outline on how to use the website and how to incorporate empirically-based methods for teaching and learning psychotherapy. After this, it is recommended that the learner start with the Introduction to Psychotherapy module. This module defines the most common psychotherapies and reviews the evidence-based psychotherapy literature. It also discusses the therapeutic alliance and explores the evidence for individual patient variables that predict differential outcome to treatment. After this introduction, learners can pursue each psychotherapy e-module at their own pace, or consider a more systematic approach to learning.

If following a more systematic approach, it is recommended that the learner first complete Quiz 1 in all modules, so that a baseline knowledge assessment is obtained across all therapies. Then the Objectives should be reviewed for the specific therapy being studied, as this will give an overview of the module. The next step is to review the seminars sequentially with the accompanying reading material and clinical vignettes. For a comprehensive understanding of each therapy, all vignettes should be viewed before supervision begins, or, alternatively, vignettes can be viewed during supervision. The latter approach allows supervisors to use this resource to highlight specific therapeutic issues. Details regarding the supervision process, manuals to be used, readings, and therapist competence scales are available for learners and supervisors in the Supervision section.

Once learners have worked through the seminars, reading materials, and vignettes, they should move to the assessment section and complete Quiz 2 and The Virtual Therapists. The Virtual Therapists (VTs) are simulations that attempt to assess “clinical skills.” These simulations provide a safe platform to test decision-making skills or therapy specific response skills before learners engage with a live patient. PTeR provides at least 10 VTs in each module. In each VT, learners are presented with a patient scenario specific to each therapy, and are then asked to select from one of two responses that they would give to the patient. After the response is submitted, feedback is provided regarding the accuracy of the response, with an explanation as to why one response is more appropriate than another. With these simulations, learners become familiar with therapist specific interventions, and are therefore being assessed on both therapy competence and adherence. After completion of all the modules, the learner can print a “Log Summary” of all activity on PTeR, which includes log hours, quiz scores, and VT scores.

Implementing PTeR into the pre-existing McMaster Psychotherapy Program required faculty to be creative, while still maintaining close attention to cognitive-science research. At the present time, before each therapy module, residents take a pretest and view power-point presentations and video clips on-line on PTeR before the first live seminar. These “priming” tasks enhance learning and memory by providing a skeleton or schema for the material that follows (19). The power-point seminars and additional clips are then reviewed in the live-seminars, so that this material can be re-examined, reviewed, and discussed. Repeated exposure to the same material permits consolidation of memory and enhances learning (20). The ability to review these seminars and clips during supervision further promotes learning. The posttest and Virtual Therapist exercises provide feedback regarding knowledge gained, and point to areas requiring additional attention.

This article presented a comprehensive, evidence-based, competency-focused, web-based psychotherapy program known as PTeR, or Psychotherapy Training e-Resources. WBL encourages efficient, effective ways of learning and assessing competence, while simultaneously providing a medium to house extensive educational materials in areas that are resource-poor or virtually nonexistent. Websites also permit one to archive the skills of talented faculty, residents, and staff, which can be utilized for years to come. Websites can also present up-to-date information, which can help learners stay current with the psychotherapy literature—crucial for all mental health professionals if they are to practice in an evidence-based manner. PTeR also provides on-line resources to help training programs meet ACGME and RCPSC requirements, augment clinical supervision, assist with seminar preparations, and assess competence. PTeR helps learners see many different forms of psychotherapy, thereby expanding their knowledge-base in this area.

The empirical literature to-date provides support for several psychotherapies for patients with psychiatric disorders. Even though one may not practice these therapies, it is important to be aware of this information, as it has relevance for patient-management. Other specialists, such as family practitioners, psychologists, social workers, occupational therapists, psychiatric nurses, and physiotherapists can also benefit from having access to PteR, as these professionals work with psychiatric patients in some capacity and can benefit from knowledge of the psychotherapy literature. Psychotherapy is a growing field with an established research base. Access to on-line resources that can deliver this information in a continuous, as-needed basis should help our trainees, our professionals, and, most of all, our patients.

We thank the following individuals for their contributions: Mr. Tom Alexander, Dr. Martin Antony, Ms. Jennifer Aquino, Ms. Debbie Bang, Dr. Peter Bieling, Dr. Michele Boivin, Dr. Leslie Born, Dr. James Bourgeois, Dr. Lisa Bourque, Ms. Julie Buffett, Dr. Lisa Burckell, Ms. Maria Campagnolo, Mr. Chris Cardey, Dr. Nick Carlton, Dr. Michelle Carroll, Ms. Sabreena Chohan (nee Bola), Dr. Susan Chudzik, Ms. Colleen Clairmont, Ms. Angela Clause, Dr. Jacquie Cohen, Mr. David Cooper, Ms. Linda Cox, Ms. Lisa DiNardo, Ms. Nancy Dobson, Mary Lou Doxdator, Ms. Karen Durocher, Dr. Alan Eppel, Dr. Rachel Erstling, Mr. Peter Evans, Dr. Anita Federici, Ms. Katie Fracalanza, Dr. Lindsay George, Ms. Shannon Gifford, Dr. Joel Goldberg, Ms. Donna Gorle, Dr. Les Greenberg, Ms. Erika Haber, Dr. Sheila Harms, Ms. Jennifer Harrington, Ms. Ruth Harris, Ms. Tiffany Higson, Ms. Lori Hoar, Dr. Andrew Jacobs, Ms. Rupa Jani, Ms. Kristy Keeber, Dr. Sean Kidd, Dr. Andrew Kolchak, Dr. Marilyn Korzekwa, Ms. Jennifer Kraul, Ms. Aarti Kumar, Mr. Kyle Kuchmey, Ms. Claire Lawlor, Dr. Craig Livermore, Dr. Lawrence Martin, Dr. Randi McCabe, Ms. Jennifer Miller, Ms. Heather Moulden, Ms. Joanne Mueller, Dr. Eric Mulder, Ms. Sheila Murphy, Ms. Lisa Nancekivell, Mr. Tom Newman, Ms. Diana Orem, Dr. Cintia Padoin, Ms. Andrea Peterman, Dr. Mark Rhyno, Dr. Karen Rowa, Dr. Andreia Scalco, Dr. Zindel Segal, Dr. Steven Selchen, Dr. Anjali Sharma, Dr. Ian Smith, Mr. David Smith, Ms. Sarah Stassen, Ms. Emily Stein, Dr. Richard Swinson, Ms. Marlene Traficante, Dr. Tanya Tuliplan, Dr. Ryan VanLieshout, Dr. Steve Webb, Dr. Pri Weerasekera, Dr. Ron Whyte, Ms. Adele Wolpert-Zur McMaster, and the Computer Services Unit.