Academic Psychiatry 26:96-101, June 2002
© 2002 Academic Psychiatry
Readiness of Psychiatry Residency Training Programs to Meet the ACGME Requirements in Cognitive-Behavioral Therapy
Donna M. Sudak, M.D.,
Judith S. Beck, Ph.D. and
Edward J. Gracely, Ph.D.
Dr. Sudak is Associate Professor, Department of Psychiatry, MCP Hahnemann University School of Medicine, Philadelphia, PA. Dr. Beck is Clinical Associate Professor, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, and Director, Beck Institute for Cognitive Therapy and Research, Bala Cynwyd, PA. Dr. Gracely is Associate Professor, Family, Community and Preventive Medicine, MCP Hahnemann University School of Medicine, Philadelphia, PA. Address correspondence to Dr. Sudak, Eastern Pennsylvania Psychiatric Institute, 3200 Henry Avenue, Philadelphia, PA 19129.
ABSTRACT
The authors assessed the readiness of adult psychiatry residency programs to train residents in cognitive-behavioral therapy (CBT) prior to the January 2001 revision of program requirements by the Accreditation Council for Graduate Medical Education (ACGME). Adult residency training program directors were surveyed. Data analysis evaluated relationships between directors' confidence in CBT training and the program and faculty characteristics. Responses were received from 54.2% of programs. Half had no requirement for resident-performed CBT. Directors' confidence in CBT training was significantly related to didactic hours (P=0.041), psychotherapy hours (P=0.007), and ACT-certified faculty (P=0.035). A substantial lack of required training in CBT exists in least 25% of accredited programs. Assessing faculty credentials and working with specialty organizations recommended in this article could assist in developing better programs in CBT.
Key Words: Cognitive and Behavioral Therapies • ACGME Requirements
In January 2001, revised program requirements of the Accreditation Council for Graduate Medical Education (ACGME) for training in adult psychiatry went into effect (1). Among the revisions is a requirement for programs to demonstrate that residents achieve competency in five different types of psychotherapy. No specific mandate exists as to how programs are to achieve, demonstrate, and record these competencies. This article presents the results of a survey, taken prior to the effective date, that asked psychiatric residency training directors about the extent of their programs' training in cognitive-behavioral therapy (CBT), one of the mandated competencies in psychotherapy under the new ACGME requirements. The questionnaire also assessed the specialty training of faculty who are currently available to programs, as well as the training directors' perceptions of their program's readiness to meet the new requirements.
Cognitive-behavioral therapy is a relatively short-term therapy characterized by an empathic, active therapist; structured sessions; a focus on defined treatment goals and reducing symptoms; and the learning of cognitive and behavioral skills, including direct modification of dysfunctional beliefs, thoughts, and behavior. It was developed nearly 40 years ago as a treatment for depression, the theoretical basis of which has been largely supported by empirical research (2). Cognitive-behavioral therapy has been adapted for a wide range of psychiatric disorders, and its efficacy has been demonstrated in over 325 outcome trials for, among other disorders, major depression in both psychiatric inpatients and outpatients, anxiety disorders, bulimia, substance abuse, and some personality disorders. For a discussion of the meta-analyses of the effectiveness of CBT, see Butler and Beck (3). As an adjunct to medication, CBT has also been shown to be effective in treating bipolar disorder and schizophrenia. A number of studies have recently emerged that point to its effectiveness in many medical patients, such as those with chronic fatigue syndrome, hypertension, chronic pain, or fibromyalgia. CBT has been adapted and empirically validated for children, adolescents, adults, and older adults. Studies have shown it to be effective in individual, group, couples, and family therapies (4).
The discipline of cognitive-behavioral therapy has a long history of standardizing methods of training, supervision, and assessment. Treatment manuals for the use of CBT in treating various major psychiatric disorders have been developed, disseminated, and published (5–18). Methods of training therapists have been developed, as have assessment measures (19,20). These measures are currently used by organizations such as the Academy of Cognitive Therapy (ACT), the Beck Institute for Cognitive Therapy and Research, and many psychotherapy research groups to assess the competence in CBT of mental health professionals, including psychiatrists (21).
METHODS
In August 2000, we devised and mailed an eight-item survey (Appendix A) to 153 residency training directors in adult psychiatry, using the ACGME CD-ROM address list. A second mailing, with added instructions to avoid duplication of responses, was sent out two months later. The content of the survey was designed to obtain information about didactic training in cognitive-behavioral therapy, required hours of psychotherapy experience and supervision in CBT, and documentation requirements. A series of questions was included to assess faculty capabilities: the number of faculty used to train residents in cognitive-behavioral therapy, their own training/certification in CBT, and the division or department to which they were primarily assigned. Finally, we asked training directors about whether they were confident or not confident in the ability of their department's training program to meet the January 2001 requirements in achieving resident competence in CBT.
Survey data were returned by fax and inspected for fax numbers to delete any duplicate respondents. The responses were entered into a computerized database. Descriptive statistics were used (mean, median, standard deviation, frequency, and range) to summarize and evaluate the responses. Data analyses were performed with SPSS 8 software (22). Mann-Whitney U-tests were performed to evaluate the relationship between the directors' confidence in their programs' readiness to meet the requirements and each specific item. Chi-square tests were performed to evaluate the relationship between the extent to which training directors knew about their faculty's credentials in CBT and the confidence they had in their programs.
RESULTS
We received 84 valid returned surveys, for a total response rate of 54.2%. Table 1 shows some basic characteristics of the cognitive therapy didactic, patient care, and supervision requirements of the entire group. As seen there, the number of didactic hours ranges from 0 to as many as 75, with 50% of the programs providing between 8 and 20 didactic hours. The median number of required treatment hours for the whole sample is 1 because half of the programs (49.4%) had no requirement at all for residents to treat patients using cognitive-behavioral therapy; of those programs with any required hours, the number ranged from 1 to 288, with a median of 35. Nearly 70% of the residency training directors who responded to the survey indicated that their residents were required to perform only between 0 and 20 hours of CBT. About half of the programs (46.4%) had no requirements for documenting the hours of CBT actually performed by residents.
A substantial number of returned questionnaires failed to provide information about the credentialing of faculty members who were teaching cognitive-behavioral therapy. These findings are summarized in Table 2. Of the completed surveys, 17% did not provide any data regarding faculty training, 39% did not have any data regarding Academy of Cognitive Therapy certification, and 48% did not have any data regarding American Board of Professional Psychology cognitive-behavioral therapy certification (available only to psychologists). Programs that provided data about faculty indicated that they came from a number of different backgrounds. Table 2 also shows that 68% of programs used department of psychiatry faculty; almost half used department of psychology faculty; and one-third were volunteer faculty. Our survey did not specifically ask for the credentials of the volunteer faculty group. Thirty-six percent of the programs responding reported having faculty with no specific training in CBT or left this item blank.
A substantial percentage (35/83 or 42%) of the program directors responded by answering "no" to a question regarding program readiness to meet the new requirements (less confident group). A comparison of the characteristics of the less confident group with the characteristics of programs with more confident directors is presented in Table 3. There was a significant difference between these two groups in their programs' hours of didactic training, required psychotherapy hours, and faculty with ACT certification; hours of required supervision approached significance. There was no significant difference between these groups with respect to number of faculty with ABPP certification. Median hours of required resident-performed CBT in the more confident group's programs was 20, as opposed to 0 in the less confident group's programs. There was no significant association between the lack of confidence in a program and residency training directors' knowledge about specific cognitive-behavioral therapy credentials of their faculty (P=0.143).
DISCUSSION
The data demonstrate a lack of required training in cognitive-behavioral therapy, both in didactic and required psychotherapy hours, in nearly half of the residency training programs whose directors responded to the survey. Furthermore, 36% of the surveys contained written comments indicating training directors' lack of confidence about implementing the training requirements in this discipline (e.g., "We really need help in this area."). Of these comments, 20% alluded to an absence of didactic training, 50% to lack of clarity about what competency measures actually were, 37% to significant problems with recruiting or finding suitable faculty, and 27% to the problem of a lack of suitable patients. (Many respondents listed more than one problem.) The confidence that training directors have in the adequacy of resident education in cognitive-behavioral therapy is significantly correlated with the hours of didactic teaching provided, the hours of supervised CBT residents are required to perform, and the credentialing of faculty in CBT.
It is interesting that so few training directors were aware of the training or credentials in cognitive-behavioral therapy of the faculty teaching their residents. This could reflect time available to training directors to scrutinize the prior experience and training of their faculty or insufficient knowledge of training programs and certification in CBT. Overall, the data indicate that many training directors have fewer resources than they need to train residents in this empirically validated modality of psychotherapy.
The major weakness of this study is the response rate of the training directors. We cannot be certain if the programs that did not respond are significantly different from the ones that did. However, responses indicating lack of confidence in their program's readiness on nearly 50% of returned questionnaires establish that, at the very least, 25% of accredited programs within the United States have training directors who do not feel confident in their capacity to provide adequate training in cognitive-behavioral therapy to their residents at this time and are responsible for programs that do not specify an adequate number of therapy hours and didactic and supervisory hours in CBT.
Programs with limited CBT-trained faculty will need assistance in fulfilling this important psychotherapy training requirement. A number of resources exist to help develop faculty expertise in CBT. ACT, the Academy of Cognitive Therapy, is an organization that certifies psychiatrists, psychologists, social workers, and other mental health professionals in cognitive therapy. ABPP also provides specialty certification in behavioral psychology. ACT, ABPP, AABT (the Association for Advancement of Behavior Therapy), and cognitive therapy institutes such as the Beck Institute for Cognitive Therapy and Research in Philadelphia could serve as a potential source of teaching and consulting faculty for residency programs, at a time when volunteer and regular faculty available are scarce. Trained cognitive therapists could serve as consultants to programs that have little CBT expertise for program assessment and training consultation and development.
Training faculty in an extramural training program at an established cognitive therapy institute (e.g., the Beck Institute) would provide residencies with their own CBT "experts" who, in turn, could teach and supervise faculty and residents in their home department, thus increasing the amount of expertise available. The Beck Institute has a number of training programs, including an extramural program for residency training directors and other faculty.
Smaller training programs could form relationships with departments of psychology, or with graduate training programs that have expertise in CBT, and could develop mutually beneficial shared teaching programs. (Many graduate programs are interested in obtaining teaching in psychopharmacology, psychiatric diagnosis, and medical disorders with psychiatric manifestations that could be "bartered" for CBT didactic training.) Expert consultation could be used by programs to help them design, plan, and implement effective training in CBT.
Group supervision in CBT is a well established and widely used method of providing instruction that maximizes the use of trained faculty. CBT traditionally relies on taped material for supervision, which allows faculty and residents alike to compile a series of training tapes. Residents can also use peer supervision, rating their own tapes and the tapes of their peers with the Cognitive Therapy Scale (23) and thus enhancing the ability to self-critique and hone their skills.
There are several good resources for obtaining CBT educational materials. The Academy of Cognitive Therapy (www.academyofct.org) provides suggested readings, a competency rating scale and manual instructions, examples of developing CBT case formulations, and a geographical listing of trained professionals. AABT (www.aabt.org) and ABPP (www.abpp.org) provide similar geographical listings of professionals with CBT expertise. The Beck Institute web site (www.beckinstitute.org) lists CBT textbooks, worksheet packets, videotapes, and patient booklets. ACT and the Beck Institute can be contacted for guidance in developing or enhancing cognitive therapy programs.
Additional research should be conducted to further assess the readiness of residency training programs to provide adequate training in cognitive-behavioral therapy and the other four forms of psychotherapy mandated by ACGME to their residents and to identify the resources necessary to rectify identified deficiencies. Additional studies will also be needed to measure the overall effectiveness of programs in providing the required training in the various types of psychotherapy.
REFERENCES
- Accreditation Council for Graduate Medical Education: Graduate Medical Education Directory, 2001-2002. Chicago, American Medical Association, 2001
- Clark DA, Beck AT, Alford BA: Scientific Foundations of Cognitive Therapy and Therapy of Depression. New York, Wiley, 1999
- Butler AC, Beck JS: Cognitive therapy outcomes: a review of meta-analyses. Journal of the Norwegian Psychological Association 2000; 37:1-9
- Beck AT, Weishaar ME: Cognitive therapy, in Current Psychotherapies, 6th edition. Edited by Corsini RJ, Wedding D. Itasca, IL, Peacock, 2000, pp 241-272
- Beck AT, Rush AJ, Shaw BF, et al: Cognitive Therapy of Depression. New York, Guilford, 1979
- Beck JS: Cognitive Therapy: Basics and Beyond. New York, Guilford, 1995
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- Sharpe M: Cognitive behavior therapy for chronic fatigue syndrome. Am J Psychiatry 1998; 155:1461[Free Full Text]
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- Persons JB, Zalecki CA: ACT takes action in certifying cognitive therapists. The Behavior Therapist 2000; 23:102
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