A growing literature documents how psychotherapy competencies should be taught in residency training (1–8). Yet the literature on implementing new models of psychotherapy in a residency training program is spare. Ravitz and Silver (8) review the programmatic objectives and infrastructure developed over the last decade for postgraduate, evidence-based psychotherapy training. Alternatively, this article focuses on the learning culture in a university department of psychiatry and the role of faculty and leadership in expanding the armamentarium of treatment to include evidence-based psychotherapies as part of a larger effort to provide disease-specific modalities of treatment to our patients. We review the key ingredients and practical challenges of implementing interpersonal psychotherapy in a psychiatry residency training program as part of an evidence-based system of care for patients with depression. Our experience may be applicable to other psychiatry training programs that wish to integrate evidence-based practice into clinical training.
In 1998, a multidisciplinary depression task force was convened in our department to systematize the outpatient treatment of major depression using evidence-based approaches, in order to improve the quality of care for our patients. Change in a system of care can be difficult to effect. This is particularly evident in clinical medicine, where leadership initiatives and reform from “the bottom up” are often required (9).
Previously, the treatment of depression in our clinic depended upon the theoretical orientation of a particular psychiatric attending or resident (10). Diagnosis and psychodynamic formulation commonly led to weekly open-ended psychotherapy, either individually or in a group. The depression task force conducted a literature review of psychotherapy for depression and identified interpersonal psychotherapy (IPT) and cognitive behavior therapy (CBT) as well supported, evidence-based psychotherapies for the treatment of nonbipolar, nonpsychotic, acute major depression (10, 11). CBT was already offered in our department as a treatment for depression and anxiety disorders, primarily delivered by psychologists and psychology fellows. Participants in developing a depression treatment program and implementing IPT in our clinical and training programs included leadership from residency training, other clinical and research faculty, and outside consultants.
One way of describing our implementation process is with a developmental model of change, such as the transtheoretical model outlined by Prochaska and DiClemente (12). The contemplation stage is akin to the work of the depression task force. The preparation stage consists of faculty taking courses in IPT, pre-testing the model clinically, and presenting the model to residents and faculty in formal talks, such as team meetings and a junior faculty development lecture series. The action phase established an educational model that would enable residents to deliver IPT to clinic patients with close supervision. To effect lasting change, IPT and CBT became our first-line psychotherapy treatments for major depression. Meanwhile, our maintenance phase has included resident surveys of the experience with training in evidence-based treatments, regular supervisor meetings, ongoing literature reviews and further education in IPT for faculty. An ongoing challenge in relapse prevention is continually monitoring cases so that they do not default to open-ended therapy as first-line treatment, and orienting PGY-3 residents every July (Appendix 1).
As in many academic departments, our psychotherapy training has a strong psychoanalytical tradition. Efforts to effect change were motivated by several factors. First, state-of-the-art clinical training required evidence-based approaches to treatment with clear goals and outcome measures. Second, young clinical faculty were interested in investigating new concepts in patient care and in opportunities to develop new clinical programs in the service of meeting departmental goals. Third, managed care demanded time-efficient treatments (Appendix 2).
For change to occur, leadership needs to give permission and the impetus for a cultural shift to create an environment ripe for the introduction of new treatments. Out of the depression task force process, a decision was made to apply evidence-based psychotherapies in a systematic way to the outpatient treatment of nonbipolar, nonpsychotic major depression. Since nearly all of the treatment in the adult outpatient department is delivered by PGY-3 and PGY-4 residents, the clinical and teaching leadership made a commitment to change how residents are trained and how depression treatment is delivered. This multi-pronged effort included implementation of depression-specific psychotherapies and medication guidelines, diagnostic measures for depression at the clinical intake, outcome measures, and the expectation that treatment planning be driven by diagnosis. IPT was a core component of the clinical and teaching leadership’s commitment to practice evidence-based psychiatry.
Peters and Waterman (13) discuss the importance of “champions” in effecting institutional change. At the outset of our planning process, though no faculty had direct experience with IPT, two faculty members were eager to learn about IPT and lead the implementation process. Both faculty clinicians were experienced psychotherapists and supervisors, trained primarily in psychodynamic and supportive models of psychotherapy. The department strongly supported and encouraged faculty interest in IPT. The opportunity to introduce a new psychotherapy and develop a large-scale training program was both of academic interest and in the service of the goals of the department. In 1999, our “change champions” attended an IPT training workshop that utilized videotapes of patient interviews (14). They were impressed by the power of IPT to effect change and also grasped the compelling nature of videotaped clinical material for student learning. Using the original manual as a guide, faculty developed proficiency in the model through additional workshops and peer-supervised clinical practice (15).
To launch our effort, we began the 1999 academic year with the first annual workshop on IPT for new PGY-3 residents and interested faculty. In this workshop, we relay basic concepts (Appendix 3) and distribute a review article on IPT to serve as a reference for ongoing learning (16). In addition, we provide the IPT manual to supervisors and residents and frequently refer residents to specific portions of the manual that are relevant to the particular patient in treatment (17).
Supervision occurs in small groups of three residents and two faculty members; each group meets weekly for 1 hour using a videotape of the trainees’ sessions to provide close supervision of IPT cases for all of the 16 PGY-3 residents. The two-faculty model provides differing expertise and a richer experience for trainees and faculty.
We implemented videotaping to provide closely monitored supervision. We utilize several small video cameras that residents can sign out and bring to their offices. Supervisors have videotape players and monitors in their offices. In IPT supervision, residents are instructed to bring to the hour 5-minute clips demonstrating challenging or otherwise significant moments in the therapy. Each resident is supervised in turn during the hour. All three residents see one another’s videotape segments and actively participate in peer supervision.
The department’s intake clinic was launched 1 year prior to the depression task force. It provides a 90-minute initial evaluation and treatment planning session with “real time supervision,” in which a faculty member is present continuously and participates in the interview with a PGY-3. Treatment decisions are finalized in a case conference immediately after the appointment. As of 1999, every new patient in the clinic completes a Beck Depression Inventory-II (BDI-II) at the first appointment. Those diagnosed with depression complete the BDI-II every 12 weeks thereafter to allow tracking of treatment response, and clinicians receive quarterly reports charting the patients’ progress. As the treatments progress, we continually evaluate the fit of the brief model to the patient’s clinical state. Patients who do not improve are reviewed in a weekly depression case conference in which the depression task force faculty actively participate. In 2004, we added the Mini-International Neuropsychiatric Interview (MINI) to systematically apply DSM-IV diagnostic criteria in our evaluation clinic (18). Exclusion criteria for IPT are bipolar depression, active psychosis, active substance abuse, and acute suicidal ideation, requiring a higher level of care.
Competition for Training Time
We faced the challenge of bringing IPT into an established program of training in other psychotherapy models. This change required reallocating direct clinical hours for IPT and expanding supervision time. In collaboration with residency training, and in an effort to bring IPT into the mainstream of residency education, we initially decided to pilot supervise IPT and CBT treatments together. We adapted the two-faculty/three-resident weekly supervision groups to include one faculty member with an IPT orientation and another with a CBT orientation. This provided an opportunity to compare and contrast CBT with IPT. After a year, we split CBT supervision into a separate small group program, as we found that CBT was too challenging to teach in a meaningful way with limited time but could be more effectively taught with experts co-leading CBT groups with residents. Thereafter, IPT supervision groups were co-led by two IPT supervisors. In recent years, more faculty have integrated several different psychotherapy perspectives into their teaching, including IPT, CBT, mindfulness-based cognitive therapy, and psychodynamic and supportive psychotherapy. Residents have the challenge of training in these different models simultaneously in the PGY-3 and integrating differing, sometimes contrasting, messages about the role of the therapist. The question of how best to integrate diverse training experiences is an open one that has led to rich discussions in our department (Appendix 4).
Psychological Barriers to Change
Both residents and faculty expressed several psychological barriers to the introduction of IPT into the curriculum, either explicitly or through the work of therapy. These included a preference by many residents early in training toward an open-ended psychoanalytical/supportive model, anxiety about applying a brief treatment to a complex patient, and videotaping sessions.
In our intake clinic, residents frequently referred depressed patients for an open-ended, exploratory psychotherapy rather than specifically addressing the depression. The following vignette is an example of a resident who was attracted by the opportunity to explore dynamic conflicts, irrespective of the patient’s acute symptomatology.
A 29-year-old middle school teacher presented with major depression with episodic panic in the context of feeling pressured by his long-standing girlfriend to get married. The resident felt that the patient’s issues were suggestive of a conflict about attachments and that a brief treatment focused on depression would be insufficient. The resident’s resistance to considering IPT was largely due to her belief that there was a hierarchy of treatment models, with a psychoanalytic approach as the gold standard. Nonetheless, at the urging of her supervisor, the resident tried IPT with this patient. The resident saw the patient rapidly learn to address his role dispute with his girlfriend and even appreciate its antecedents in earlier relationships, thereby resolving his depression. In addition, the patient was able to make a role transition into feeling fully adult; he was no longer as affectively attached to his beliefs about his obligations to his primary family.
The focus on current significant relationships in IPT can feel unnatural to new therapists who may be concerned about being too directive with the patient. In the following vignette, a resident felt compelled to focus treatment on a patient’s childhood trauma and not on its current manifestations.
A 36-year-old divorced female financial analyst with acute major depression wanted to work on her relationships after a breaking up with her boyfriend. Her history was notable for repeated childhood sexual abuse by an uncle. The resident believed that the patient’s trauma should be the focus of the treatment. However, the supervisor suggested that the resident refocus the patient on how these early experiences affected the patient’s current relationships, as a way to help the patient master the interpersonal stressors associated with her depression. Using the new focus, the resident was able to help the patient clarify her recurring role dispute and learn strategies to effectively assert herself in relationships. Depression resolved, and at 8-week follow-up, the patient remained in remission.
The IPT manual gives residents evidence-based and theoretical rationales for IPT as well as clear guidelines (17). At the same time, residents may be overly focused on the dos and don’ts in the manual out of concern that they will make a grievous mistake. Frequently, residents appropriately focusing the patient on relationships outside the therapy can be conflicted over how to manage negative transference. The following vignette shows how a resident’s instincts and personal style with a patient are important to good care, regardless of the theoretical frame. It demonstrates that although IPT is an empirically supported manualized treatment, it is also practical and flexible (19).
A medical student in treatment for depression regularly came to appointments a few minutes late. She repeatedly worried that the attending on her clinical rotation thought poorly of her, despite her descriptions of very conscientious work. The medical student had previously discussed her mother as highly critical and emotionally remote. The resident therapist asked the medical student whether she was concerned that the therapist also harbored critical thoughts of her. The medical student relaxed and acknowledged a pattern of anticipating criticism in her relationships and being very self-critical. Despite a therapeutically effective comment, the resident was concerned that she had committed a technical error, because of the “rule” in IPT to discuss only relationships outside of the therapy (a “rule” that has clear exceptions in actual clinical practice). The video clip demonstrated her therapeutic empathy and psychological mindedness that were appropriate responses to negative transference and were entirely consistent with IPT. The resident acknowledged the negative transference and made it a topic for discussion. She then used this insight to help the patient understand current relationships where perceived criticism was an issue.
Our own departmental culture, deeply rooted in psychoanalytic psychotherapy, had an impact on our implementation of IPT. Initially, we developed a program of a tapered frequency of visits without a clear break after the acute treatment (i.e., 12 weekly acute phase visits, followed by 4 every-other-week visits of continuous treatment, followed by a monthly maintenance treatment). The result for residents was predictable—a blurred boundary between an acute intervention for depression and open-ended treatment. In the end, certain residents simply avoided doing IPT in the service of an open-ended model. Subsequently, the model was changed to 16 weekly visits followed by a follow-up visit 8 weeks later.
Concerns About Brief Treatment
Residents’ uncertainty about their ability to treat a depressed patient in a brief treatment may underlie a preference for an open-ended model. Wanting to cure the patient can create significant internal pressure on a resident to solve all of a patient’s problems or risk feeling like a failure or aggressor. In a brief treatment, residents may feel increased pressure to know what to do moment to moment to maximize the efficacy of each session. A recurring intervention in the IPT supervision groups is simply refocusing the resident on the diagnosis-specific goals of IPT—remission from depression and mastery of an interpersonal issue associated with the depression. As in all brief treatments, we remind residents that they are doing a piece of work that can have measurable success and move the patient forward. Resident exhilaration at witnessing even small improvements in very complex patients becomes part of the learning experience.
In the following vignette, a supervisor was not particularly vigilant in keeping an IPT therapy on track. Without careful supervision, residents who feel ambivalent about the ending of a brief treatment may forget that the termination date is a catalyst for change.
A 21-year-old bisexual patient in IPT for recurrent depression was exploring the role of conflicts with her lesbian partner about her sexual orientation in precipitating her depression. She continually felt marginalized by her partner in social situations and was confused about her own needs. A year before, her mother had died of breast cancer. In the therapy, she developed a sense of agency in the relationship and greater comfort with her bisexual orientation. As she achieved remission from the depression, she began to grieve the loss of her mother in the termination phase of treatment. The resident was ambivalent about the brevity of the treatment and avoided discussion of the termination until the last session. The supervisor colluded with the resident’s silence. As a result, opportunities for reinforcing the patient’s sense of autonomy and underscoring her successes in the brief treatment were lost. Still the patient’s symptoms of depression improved.
Anxiety About Videotaping
Finally, residents often colluded with patients in IPT who did not want to be videotaped, failing to explore the meaning of the videotaping with the patient. Anxiety about videotaping the psychotherapy hour may reflect fears of exploiting the patient and shame about exposing work publicly. The following vignettes demonstrate that the experience of videotaping psychotherapy is often a positive one for residents.
A year and a half after his wife’s death, a 54-year-old man presented with looking very depressed and paranoid, wearing dark glasses in the session and having difficulty answering questions directly. Toward the end of IPT treatment, the patient was well on his way to grieving the loss of his wife and returning emotional stability and hopefulness to his life. In contrasting a first and thirteenth session, the resident and his supervision group were able to appreciate the physical transformation of a patient from disorganized to affectively engaged.
On careful questioning, a patient who was initially against being videotaped revealed that she thought that the supervision group viewing the tape would decide she was not depressed, but a fraud. This allowed the resident to understand a key factor in the patient’s interpersonal experiences that contributed to her depression. The therapist discussed this issue with the patient, who then agreed to videotape sessions.
A resident decided to train the camera on himself after a patient emphatically declined to be videotaped but agreed to be audiotaped. In this case, the resident, who felt uncomfortable in an active role as a therapist, visually appreciated how he conveyed authenticity to the patient.
Overcoming Psychological Barriers
After our first year of experience, we asked better questions of the model and received clarifying answers at workshops on IPT at the APA annual meeting (20, 21). The new academic year in 2000 provided an opportunity to implement the following changes, which are more consistent with the standard of practice: the therapy has a clear ending at 16 sessions—the completion of a treatment contract. Missed sessions are lost, unless planned for at the outset of treatment. Patients return to the resident in 8 weeks for reevaluation and then may participate in a range of treatments, if indicated. Patients are made aware that an open-ended treatment in follow-up may occur with the same or a different therapist and that it is a fundamentally different treatment contract. Since depression is often chronic, it is expected that patients may need to continue in some capacity. At the same time, a clear ending of the acute phase promotes autonomy and provides an opportunity for patients to utilize newly acquired skills on their own (16, 17, 22). In our experience, residents and patients need a firm boundary to take a brief treatment to its conclusion.
The workshop given during orientation for PGY-3 residents has been modified to directly address the psychological barriers in performing IPT. We use a patient example (with videotape) to illustrate the utility of the treatment. An experienced PGY-4 resident presents the case and discusses his or her own transformation as an IPT therapist during the PGY-3. We underscore the goals of treatment (i.e., remission of depression) and the therapeutic importance of the termination to support a patient’s sense of mastery and autonomy. We discuss different ways of utilizing transference, depending on the therapeutic model. We explicitly compare and contrast a cookbook to a psychotherapy manual to preempt any concerns that manual treatments are merely pre-measured recipes.
Six years after beginning to develop a systematic treatment program for major depression, IPT is now an integral part of residency training. Though residents learn and integrate many models of therapy and theoretical orientations during the third and fourth years of training, IPT provides an option for treatment that is evidence-based and depression-specific. All PGY-3 residents (16 residents/year) complete two to four supervised IPT cases each year. In addition, learning IPT has transformed videotaping into a common practice throughout the clinic. Residents feel more comfortable exposing their work to supervisors and colleagues. They even videotape non-IPT cases frequently. Requiring specific diagnostic screening for depression in the intake clinic using the MINI and measuring symptom severity using the BDI-II have shifted the culture toward diagnosis-based decision-making. Further, although the evidence-based depression treatment program is a key component of psychotherapy training in the clinic, we continue to teach a variety of psychotherapy orientations to residents. All residents have open-ended individual cases as well as the opportunity to lead open-ended dynamic psychotherapy groups. Two annual surveys of the residents’ attitudes toward learning evidence-based approaches to depression, before and after IPT training, were of such limited statistical power that we do not feel it is worth presenting the data here. However, the trend showed residents became more comfortable with using evidence-based treatments as first-line interventions and considered diagnosis to be more important in choosing treatments after the training.
Our experience is that IPT is eminently teachable to psychiatry residents (23). Though IPT is a specific therapy, it teaches core psychotherapy skills, such as using interpersonal/relational issues as a way to help people heal. Obviously, these skills have utility in other psychotherapies as well. For example, interpersonal analysis has significance for CBT. At the same time, IPT can be adapted to a therapist’s particular style while staying within the therapeutic frame. Implementation of the treatment is consistent with the intuition of most psychologically minded trainees. As a teaching tool, IPT models informed choice of therapy, an opportunity to clarify mutual goals, and generalizable therapeutic techniques.
Culture change occurred in a training-based large outpatient clinic and was facilitated by essential ingredients for change being present. Implementation of IPT in psychiatry residency training was a cornerstone for learning evidence-based approaches to care, as well as for conveying core psychotherapy concepts.