Physicians across a variety of medical specialties screen and refer patients for psychiatric treatment. Primary care doctors are expected to understand and start first-line medication treatments for depressive illness and anxiety disorders. Psychotherapy is also an effective, well-proven intervention for many mental illnesses. More patients may have the opportunity to benefit from psychotherapy when their physicians are aware of the concepts of and indications for psychotherapy.
Medical school provides a key opportunity for students to be exposed to psychotherapy as a treatment option. The Association of Directors of Medical Student Education in Psychiatry (ADMSEP) (1) wrote the following in its 2007 Clinical Learning Objectives with regard to the medical school psychiatry curriculum:
Regardless of medical specialty, an effective practitioner should have a basic understanding of psychotherapy, recognize the relevance of psychotherapy principles to the doctor-patient relationship, be aware of those psychotherapies with evidence-based efficacy for particular disorders, and be able to refer patients for psychotherapy.
At Baylor College of Medicine, the 2-month psychiatry core clerkship devotes 1 hour to an overview of psychotherapy, in contrast to the 6 hours devoted to psychotropic medications. This brief didactic time is insufficient for most students to appreciate the range of psychotherapies, their indications, techniques, and evidence for use. At medical school, no core rotation opportunities provide any substantial exposure to psychotherapeutic interventions.
As future physicians, medical students can benefit from exposure to different treatments for mental illnesses. A student’s experience and understanding of the practice of psychiatry may influence whether he or she pursues a career in the field. On reflecting on her own medical school education, the resident author (FA) believed that she would have been more confident in her career choice of psychiatry if, as a student, she had had a better understanding of psychotherapy. Psychotherapy is an exciting and integral part of psychiatric practice that can be attractive to medical students who are interested in pursuing a career in psychiatry. She felt that her student peers were underexposed to therapy during their psychiatry didactics and rotations. This personal experience inspired her to examine how other programs approach teaching students about psychotherapy.
We searched PubMed, PsycINFO, Med Ed Portal, and the EMBASE databases for the period between 1950 to June 2009 for a psychotherapy curriculum for medical students using the medical subject heading terms medical students and psychotherapy. Two articles focused on psychotherapeutic concepts within all doctor-patient relationships, while another two argued for the importance of teaching medical students about these concepts (2–5) without including a recommended curriculum. In 1961, Ornstein (6) described a medical student course that introduced psychotherapeutic concepts, analyzed a 3-hour therapy session, and discussed the role of hypnosis in treatment. One article (7) discussed teaching French medical students to perform behavioral therapy. In 1999, Cabaniss (8) wrote about introducing medical students to psychoanalysis over five 1-hour seminars, with 1 hour dedicated to the introduction of concepts and types of psychotherapy and the remaining 4 hours reading process notes. Among these articles, only one resident-taught course was found (9); it introduced medical students to personality disorders in four 1.5-hour weekly sessions using movie clips and role plays. Although principles of transference and countertransference were introduced in this context, no other emphasis on psychotherapy appeared.
Although there is literature on teaching medical students about a certain aspect of psychotherapy, we did not find a curriculum that gives students an overview of basic concepts and applications of multiple types of psychotherapy. This article describes the creation and implementation of a curriculum aimed at educating medical students about psychotherapy by a third-year psychiatric resident (FA) who is a member of the Clinician Educator Track in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. The Clinician Educator Track is a specialized training track designed to prepare residents for careers as clinician-educators and is described in another article in this issue (10). The program requires that participants develop a scholarly project that focuses on an educational activity.
Through mentorship with a faculty member of the Clinician Educator Track (AA) and discussion with leaders in medical education and psychotherapy at Baylor, “Therapy 101: An Introduction to Psychotherapy” was developed as six 1-hour lectures using electronic presentation software, case examples, and video clips to cover the concepts and applications of psychotherapy. The course was integrated into an elective longitudinal mental health experience at Baylor College of Medicine.
The resident physician (FA) and faculty mentor (AA) met regularly prior to initiating the course to discuss the resident’s goals for the project, which included using slides, developing and teaching a curriculum, and learning how to solicit and use student feedback. “Therapy 101” was then constructed with four main goals for its students: to give students basic theoretical and practical knowledge of major psychotherapies, to interest students in therapy and deepen their appreciation of the value of psychotherapy, to give students a broader appreciation for mental health treatments and thus expose them to a different side of psychiatry, and to provide a model of student education in psychotherapy (Table 1).
The course introduced the theoretical constructs and application of the most commonly practiced types of psychotherapy. The integration of media and examples of therapy cases prompted students to examine their impressions of therapy and engaged them in learning how a patient may be “prescribed” a certain type of psychotherapy. Finally, the instructor used her recent transition from medical student to resident therapist to relate to students the personal experience of a therapy session.
We planned each session together to ensure that the goals and the course objectives were being met. Special attention was paid to using different teaching techniques to keep the students engaged. Each workshop incorporated video clips from TV shows, role play, case examples, and electronic slides.
Eight third-year medical students in the Longitudinal Ambulatory Clinical Experience–Mental Health and Behavioral Sciences Pathway at the Baylor College of Medicine participated in this pilot project. At Baylor, students choose from several longitudinal pathway experiences and are selected to a particular pathway on the basis of essays expressing their interest. The mental health pathway spans the academic year and involves weekly meetings with an ambulatory preceptor and community site visits. It teaches students to take an in-depth approach to the psychosocial issues associated with mental and physical wellness.
Through collaboration with the faculty directors of the mental health pathway, 1 hour per month was assigned to “Therapy 101.” Institutional review board approval was received to collect data on this project and the medical students were provided cover letters explaining the purpose for collecting data. Attendance was not recorded, and students were informed that attendance and participation in the series would not influence their grades for the mental health pathway. The first session introduced the lecture series and assessed students’ knowledge and attitudes about psychotherapy with a multiple-choice test and a discussion. Media portrayals of psychotherapy were discussed with two video clips. One clip from the TV show ER (11) demonstrated a physician using supportive techniques with a grieving patient, exemplifying psychotherapeutic concepts being implemented outside of a therapy session. The other clip from the HBO series In Treatment (12) showed a therapist’s first meeting with his patient and began a discussion on what brings a patient to therapy and the challenges of the first session. These two videos were used to ignite dialogue about media portrayals of the physician-patient relationship and psychotherapists in particular.
The second session explored transference, mentalizing, and therapeutic alliance, which were considered to be core concepts in a range of psychotherapies. In addition to case examples, the In Treatment video from the first session was reexamined.
The next three sessions presented cognitive and dialectical behavioral therapies, psychodynamic psychotherapy, and interpersonal and supportive therapies. Each hour began with a brief overview of the theoretical basis of the therapy and included basic techniques of the psychotherapy and indications and evidence for its use. A case example and discussion concluded the hour.
The last lecture discussed a therapy session with the intention of demystifying and normalizing psychotherapy. Students watched a video of a therapy session of the resident-instructor with a patient. (The patient gave written consent for the video recording to be used for educational purposes.) The instructor discussed her thoughts and feelings during the session while reviewing concepts from the previous workshops.
Students’ attitudes and knowledge were assessed at sessions 1 and 6 through discussion and written feedback. Fifteen multiple-choice questions were developed and administered as a pre/postcourse test (available from the authors upon request).
At the beginning and end of the series, students also answered the question “On a scale of 1–10 (1=no knowledge, 10=extremely knowledgeable), how would you rate your current knowledge about psychotherapy?”
Students rated the resident-instructor at the conclusion of each session from 1 to 5 (1=poor, 5=excellent) in 15 categories. These evaluations were reviewed weekly with the faculty mentor (AA) as part of regular reflective exercises. The faculty mentor, who was present during one session, also gave the resident (FA) feedback on items such as the pace of the session, body language, use of jargon, and the engagement of the audience.
The mean number of questions answered correctly was 11.3/15 on the multiple-choice precourse test and 11.6/15 on the postcourse test. The mean for the students’ rating of their current knowledge of psychotherapy at the onset of the course was 3.4 (1=no knowledge, 10=extremely knowledgeable). By the last session, this rating had increased to 6.
On the instructor evaluation form, the resident was rated as very good (4) to excellent (5) in all categories. A few students noted that the pace of the sessions was too fast and that the interactive teaching exercises were the most beneficial aspect of the course.
“Therapy 101: An Introduction to Psychotherapy” introduces medical students to the concepts and uses of psychotherapy to increase their theoretical and practical knowledge about psychotherapy. Case examples, video clips, and role play were used to give students a feel for psychotherapy.
Student scores from the pre/postcourse tests show little change. It is possible that the higher than expected precourse test scores resulted from superior student knowledge at the outset. Students in the mental health pathway had already identified a greater interest in psychiatry than their peers and may have had a higher baseline level of knowledge than expected, making any gains difficult to detect with this test. Also, the questions were formulated before the course was fully designed. The most emphasized concepts in the course were only partially reflected in the multiple-choice questions. Two of the most commonly missed questions on the precourse test were also missed on the postcourse test. On further review, these questions did not reflect the main teaching objectives of the course. Now that the curriculum is fully developed, future test questions will be extracted directly from the slide presentations to accurately reflect the most emphasized concepts in the curriculum. It is also possible that the once-a-month lecture frequency impaired retention of knowledge over the course. To aid in continuity and retention of knowledge, future lectures will be scheduled weekly rather than monthly.
Students’ self-rating of their knowledge of psychotherapy greatly increased. We hypothesize that the course provided an increased appreciation for psychotherapeutic interventions that were not reflected in the knowledge-based, multiple-choice test. On the basis of student feedback and reflection with the faculty mentor, the resident-instructor adjusted the pace of the course and increased interactive exercises, which could also have led to students feeling more confident in the material.
Students felt that the course was useful as an exposure to psychotherapy, and for some it confirmed an interest in psychiatry. Students who planned to enter a specialty other than psychiatry said that the concepts and information learned would be useful in other fields of medicine.
Residents are uniquely positioned to contribute to medical student curriculum development because of their recent transition from the student role. The resident-teacher (FA) clearly remembered never having observed psychotherapy; learning theory was immensely difficult in the absence of a real-life context. She identified with the students’ needs to hear about theory and practice together. Her recent experience helped her create a course that emphasized the basic concepts of psychotherapy and relied heavily on examples to illustrate those ideas. The resident-teacher is also a student of psychotherapy, a dual role with which most lifelong learners are familiar. During the academic year, the resident’s psychotherapy skills improved as her experience with the different modalities increased. The growing experience allowed for the use of more personal examples as the class progressed and greater confidence in the resident’s perceived skills in teaching. It must be noted that because the resident is still a trainee, a faculty mentor provides additional experience and expertise in course content and development.
The combination of mentorship and initiative at the resident level spurred the resident’s professional growth in the direction of academic psychiatry and demonstrated the effect a resident can have in the syllabus of a medical student education program. Through coordination with her mentor, this course has been successfully integrated as a permanent piece of the mental health pathway curriculum. One of the goals of the Clinician Educator Track at Baylor is to support and develop resident educators. This course met that goal and resulted in an enduring curriculum for medical students.
By increasing an understanding of psychotherapy, the lecture series served the pathway’s objective of expanding students’ perceptions of physician roles in the community. From the feedback, students had a clearer understanding of psychotherapy and the value of referring to psychotherapeutic treatment. Our hope is that the student who values psychotherapy will be able to take a more in-depth psychosocial approach, which the mental health pathway promotes as its primary goal.
We anticipate that this course will continue to change in response to students’ needs for education in psychotherapy. Our long-term goal is for the curriculum to be integrated as an elective at Baylor College of Medicine and to be replicated at other medical schools.
At the time of submission, the authors reported no competing interests.