This report describes the introduction of the Chief Resident for Psychotherapy at the residency training program at Vanderbilt University. We created a role for a chief resident specifically dedicated to psychotherapy training in response to several challenges perceived in our psychotherapy training program and in response to the specific interests of a senior resident in the area of adult learning theory and psychotherapy training.
Psychiatric residency programs are currently faced with many challenges in providing adequate psychotherapy training. Many factors have been implicated, including inadequate reimbursement schedules in the managed care paradigm, a shift in emphasis in the field to a biological characterization and treatment of mental illness, and increasingly limited availability of faculty members who are qualified to provide this teaching (1). Unlike trainees in other medical specialties, new residents in psychiatry may have little or no prior exposure to an essential diagnostic and training skill set of their specialty before beginning specialty training. Current challenges in residency psychotherapy training appear to parallel, and may be directly related to, the broader shift away from the provision of psychotherapy by psychiatrists in general (2). While some have questioned whether psychotherapy should remain a part of the psychiatrist’s training and repertoire, many have cogently argued that psychotherapy is indeed an essential skill, both diagnostic and therapeutic, for psychiatrists now and in the future (3).
The Accreditation Council for Graduate Medical Education (ACGME) Psychiatry Program Requirements (revised April 2008) require that psychiatric residents develop competence in “applying supportive, psychodynamic, and cognitive behavior psychotherapies to both brief and long-term individual practice” (4). In keeping with the ACGME focus on demonstrating outcomes, programs are required to demonstrate that residents achieve competency in these core psychotherapy skills, a requirement which has generated considerable debate (5–9).
At Vanderbilt we have identified many of the commonly cited challenges in our own psychotherapy training program. Residents’ clinical experience in psychotherapy begins in the third postgraduate year (PGY-3). Based on survey responses obtained by the psychotherapy chief from the rising PGY-4s, we identified additional challenges. Recruitment and retention of patients for psychotherapy was often very difficult for residents. Despite their previous year of lecture-based training, residents reported high levels of anxiety and poor self-confidence when treating psychotherapy patients. They found it difficult to engage patients in therapy and saw very few patients on a regular and long-term basis. We hypothesized that some of the difficulties that the residents were having keeping patients in psychotherapy were due to the following factors:
lack of confidence in their psychotherapy skills
trouble identifying themselves as psychotherapists
inadequate knowledge base of psychotherapy skills and theory
an undeveloped sense of what psychotherapy is “really like” in practice
We began to wonder if having a senior (chief) resident who was identified as a “psychotherapy point person” might help our junior residents overcome some of these issues.
There is a small but informative literature on the various roles of a chief resident in psychiatry programs. The majority of programs have more than one chief resident, utilizing them in administrative and organizational roles (10). Most chief residents perform some education functions such as orienting junior residents and medical students. More recently, one psychiatry program has developed a role for a “Chief Resident for Education” (11). This model encouraged us to think creatively about our chief residents and to create the role of “Chief Resident for Psychotherapy” for a PGY-4 resident. We are unaware of other programs that have a similar position.
While our program employs a faculty member to direct the psychotherapy training, we felt there were considerable advantages to using a senior resident to complement the role of the faculty director. The chief resident is uniquely positioned to understand firsthand the stage-specific needs of junior residents and medical students, and can function as a model to junior residents. The designation of this PGY-4 position is also a means to promote the career of a senior resident interested in an academic appointment and to allow protected time to enhance teaching and learning knowledge and skills.
Our goals for the psychotherapy chief reflect our idea that a senior resident was uniquely positioned to achieve the following:
Recruitment and Retention of Psychotherapy Patients
The psychotherapy chief resident actively recruits patients into the Resident Psychotherapy Clinic. This has involved advertising within the department and the medical center at large as well as working closely with psychotherapists in the community. Our psychotherapy chief has already had early success with this, generating more than 30 new referrals in the first 2 months of the academic year. The psychotherapy chief screens new referrals by telephone to confirm their interest and determine their suitability for the psychotherapy clinic. He or she can then frame the initial evaluation for the patient as a series of two to three appointments with a resident physician during which both the patient and the therapist can make a determination about beginning treatment.
The psychotherapy chief resident takes an active role in monitoring the residents’ therapy caseloads to ensure that each resident is able to retain patients in therapy. Residents who are having difficulty retaining patients can be quickly provided with more patients from the referral list. The psychotherapy chief can then engage them in an ongoing discussion to help identify particular difficulties they may be having with the therapy process.
A key part of the psychotherapy chief resident’s raison d’etre is to make a contribution to the education of residents and medical students in the area of psychotherapy. The psychotherapy chief is involved in the ongoing development of a 4-year curriculum for psychotherapy training. This year the psychotherapy chief will work closely with the Teichner Award Visiting Scholar to consult on psychotherapy training improvement. (The Victor J. Teichner Award, which is administered jointly by the American Academy of Psychoanalysis and Dynamic Psychiatry [AAPDP] and the American Association of Directors of Psychiatric Residency Training [AADPRT], supports a Visiting Scholar to visit a residency training program that wishes to supplement its training of psychodynamic psychotherapy.) Formalizing the psychotherapy chief resident position also allows resident participation and representation in the restructuring of the psychotherapy teaching, which promotes well-rounded and “intergenerational” discussion.
Residents who teach are often very responsive to the needs of the junior residents, and the role of psychotherapy chief offers this to our psychotherapy curriculum. This year the psychotherapy chief developed a course called “Orientation to Psychotherapy” based on survey feedback identifying high anxiety and self-doubt as potential causes for poor attitudes toward training in therapy. Given this feedback, and recognizing that therapeutic alliance in the very early sessions of therapy is an important predictor of outcome (12), the goal of the seminar series was to reduce resident anxiety, improve confidence, and indirectly to help residents improve their ability to build a therapeutic alliance. Course evaluations and feedback from these seminars were overwhelmingly positive and encouraging.
In addition to making a contribution to the program, the psychotherapy chief’s own career development and education is fostered by the designation of this role, through advanced psychotherapy training, additional supervision, participation in a self-awareness elective, and key psychotherapy readings.
It goes without saying that these results are preliminary and that it is hard to extrapolate from a new role at a single site. However, several months after implementing the Chief Resident for Psychotherapy position in our program, we are already seeing some early measures of success. As evidenced by the numbers of junior residents who have consulted the psychotherapy chief about therapy issues, resident interest in and enthusiasm for psychotherapy training appears to be improving. Residents are seeing more psychotherapy patients at this point in the year than the previous year. Faculty and supervisors find the renewed interest invigorating, which appears to be building momentum for the program at large.
Perhaps the psychotherapy chief, who is still a resident, is uniquely able to understand what the new resident/therapist is experiencing and is well-positioned to model confidence and tolerance of anxiety for fellow residents. Further observation will be necessary to properly assess its helpfulness and sustainability. In particular, it remains to be seen if there is a significant impact on residents’ ability to establish rapport with patients and whether retention of therapy patients improves. The effect of this role on the chief resident should also be followed, particularly as it relates to a future career in academic psychiatry.
Our initial success with this innovation is encouraging. We recognize that this is a pilot project in the early phase of implementation and we anticipate reporting more robust outcome data after a few years of follow-up. We would welcome dialogue with other programs that are interested in creating similar positions in order to compare our experiences and study outcomes across multiple sites.
At the time of submission, the authors reported no competing interests.