Supportive psychotherapy is a key foundation for informed interactions between medical professionals and psychiatric patients. During their education, medical students learn how to create a patient-physician relationship, an experience that can be particularly complex during their psychiatry clerkship. We have observed that medical students often struggle to interact empathically with their patients; students express that they are concerned about making patients’ symptoms worse through their interactions and about not knowing specifically what to do during difficult interactions. Perhaps reflecting their discomfort, students also report frustration with a lack of therapy training during their psychiatry clerkship. This may be because medical students often do not have backgrounds in psychotherapeutic theory or technique, and the clerkship may be their first formal exposure to significant psychiatric illness. However, the psychiatry clerkship provides an excellent opportunity to address medical students’ anxiety, teach key therapeutic techniques, and provide hands-on experience in developing the ability to form a patient-physician relationship. Therapy training during the clerkship also has the potential to inform students’ future interactions with patients outside of the psychiatry clerkship and to satisfy requirements of the Liaison Committee on Medical Education (LCME) (1).
To assess available tools for addressing these issues, we reviewed the literature for previous methodologies of teaching therapeutic techniques to medical students. One poster from McMaster University (2) focused on teaching problem-focused therapy using experiential teaching methods, including role-plays and simulated patients. A series on motivational interviewing for smoking cessation from the University of Virginia (3) utilized small group learning, didactics, and role playing, and suggested that role-plays with peers were comparable to standardized patient encounters for motivational interviewing (4). There was some limited literature on teaching exposure therapy (5), which primarily focused on computer-based teaching but noted that teaching therapeutic techniques to students is feasible. Several articles detailed how role playing is an effective way to teach students communication skills and discussed how to use role playing in teaching, but these articles did not focus on teaching the techniques (6, 7). There is also more literature on teaching supportive psychotherapy to residents, but this literature focuses more on teaching specific competencies (8–10). The limited available data on teaching medical students may reflect that individual medical schools teach psychotherapy, and anecdotal discussion with other medical schools suggests that some programs believe that there is not sufficient time during a 6-week clerkship to teach psychotherapy.
To our knowledge, there are no published reports of teaching supportive psychotherapy to medical students. As such, we created a preliminary education module for residents to teach medical students key techniques of supportive psychotherapy. Our goal is to give students basic tools they can apply during and beyond their psychiatry clerkship and to foster a greater understanding of the use of therapy in psychiatry. The module focuses on the fundamental tenets of supportive psychotherapeutic technique, provides basic but specific guidelines for patient interactions, and provides an overview of general therapeutic modalities. This module focuses primarily on interactions with psychiatric patients, which differentiates it from a more general course on patient-physician communication.
The purpose of this educational column is to demonstrate how a basic teaching module can begin to address a specific training gap in medical student education that has ramifications within and beyond psychiatry, and that a brief module taught by residents may be an effective tool to promote further training of psychotherapeutic technique.
We developed the supportive psychotherapy module for third- and fourth-year medical students completing a 6-week psychiatry core clerkship within the Warren Alpert Medical School at Brown University. During this rotation, medical students participate in weekly didactics with a wide range of topics taught by residents and faculty.
The module was developed by one of the authors (NP) while training as a resident in psychiatry at the institution. The 50-minute module consists of a combination of didactic instruction, discussion, and role-playing activity and is conducted by a resident throughout the year. The module explores core elements of supportive psychotherapeutic technique: empathizing and normalizing, being nonjudgmental, developing a shared formulation, and mobilizing hope. The approach is atheoretical—the module emphasizes practical skills and suggests what to say and what not to say in specific situations.
The module begins with a slideshow presentation of approximately 20 slides to introduce the basic tenets of supportive techniques, which are subsequently reinforced with interactive role play. The resident instructor recruits volunteers to read three scripted scenarios representing typical patient-physician interactions in psychiatry for approximately 20 minutes (Table 1). We developed these scenarios from the American Psychiatric Publishing series on supportive psychotherapy (11) and in consultation with expert faculty at Brown University.
The resident leads a discussion after each scenario to examine the patient-physician interaction and focuses on examples of core elements of supportive techniques. The resident then facilitates a discussion of the importance of these elements as well as how they can be generalized to clinical experience beyond psychiatry. Medical students are encouraged to bring up difficult or interesting interactions with patients for discussion. Following the discussion, there is another brief didactic session to review the core elements detailed earlier, and the module ends with an overview of other psychotherapeutic techniques.
At the end of the module, medical students are able to identify key elements of supportive psychotherapeutic technique. Students also use the time to examine and discuss their patient interactions during the clerkship. Medical students voice a desire to learn more about the psychotherapeutic process, explore their own feelings, and understand the motivations behind their patients’ behaviors. We have also found that the module can be completed in the time allotted.
Residents enjoy teaching the module and have been consistently impressed with the level of insight, thoughtfulness, and introspection demonstrated by the students. The module has been given to five clerkship rotations (N=45), and three different residents have given the lecture.
We evaluated the module using a Likert scale ranging from 0 (poor) to 5 (excellent); graded items included pace and organization of lecture, clarity of content, and enhancement of understanding of the subject matter. Evaluation scores have been consistently between 4 and 5 (Table 2). Informal feedback from the students included statements about how they wished they had received the module earlier in their clinical years and how the module provided tools to use beyond their psychiatry clerkship. Additionally, through their discussion of the role play and their patient interactions, students showed how the module is applicable to clinical practice.
This experience suggests that not only are medical students able to process the basic tenets of supportive psychotherapeutic technique, but that they consistently demonstrate a thirst for knowledge about psychotherapy in general. Students are able to discuss the relevant concepts of how to be appropriately empathic with psychiatric patients by relying on key tenets of supportive psychotherapy and the impact of their own actions on the therapeutic relationship. Given their ability to accomplish these goals, students may be better poised to use these techniques during patient interactions in other clinical rotations. The positive student feedback also indicates that they appreciated the exposure to discussion of therapeutic interactions.
Because basic supportive techniques likely complement the components of good patient-physician communication (12), one area of future development would be to include education in supportive techniques more explicitly during preclinical training, perhaps as part of education on patient-physician communication. This would allow a basic focus on supportive techniques earlier in the learning process and enable more advanced discussions of psychotherapeutic technique during the psychiatry clerkship.
The primary limitations of this project are its narrow scope and evaluation. The module has been performed with a relatively small number of students at a single institution. Furthermore, the only outcome measure is that of student satisfaction with the session; although satisfaction may be important in demonstrating the feasibility of the module, we cannot know what the students actually retained or subsequently incorporated into their clinical encounters.
Despite these limitations, this educational column is intended as a proof of concept: medical students find basic training in supportive techniques to be useful, and they willingly participate in the interactive learning required for the module. Furthermore, the module can be successfully used by different instructors with presumably different teaching styles.
Clearly, a next step would be to collect more data. For example, outcome measures from faculty on student interactions would be of significant benefit. Specific measures could include before and after evaluations of student-patient interactions and feedback from the patients themselves. These measures could be compared with a control group not receiving the module. Clinical evaluations could be either “real world” or standardized encounters. Such steps would help to establish this preliminary module as an evidence-based teaching technique. Future development of the project would include investigating the optimal number of sessions for incorporation of these skills outside of the classroom and, ultimately, investigating the module at different institutions.
Finally, the disappointment voiced by medical students regarding the lack of psychotherapy teaching is significant. Most medical students form their opinions of the medical specialties during their clerkships. To avoid even the most basic training in psychotherapeutic technique during the psychiatry clerkship may represent a missed opportunity to introduce students to one of the more interesting and unique aspects of psychiatry and, as such, may affect recruitment into the field.
In summary, this column proposes the need for teaching core elements of supportive psychotherapy during medical school and then provides preliminary evidence for the feasibility of a simple teaching module. Regardless of the students’ eventual specialty choice, basic training in therapeutic techniques provides an invaluable opportunity to introduce future physicians to an important aspect of the field of psychiatry. Such training may improve students’ interactions with patients while nurturing those who wish to pursue specialty training in psychiatry.
At the time of submission, the authors reported no competing interests.