Academic Psychiatry 28:251-253, September 2004
© 2004 Academic Psychiatry
Assessing Psychotherapy Competence
Paul C. Mohl, M.D.
Professor and Vice Chair for Education, General Residency Training Director, University of Texas Southwestern Medical Center at Dallas
To the Editor: Once again, Academic Psychiatry is to be congratulated for an excellent special issue on Assessing Psychotherapy Competence (1). These papers will be a fine resource for me as a training director and, I assume, to many others as well. I would like to add some thoughts and observations in four areas from my vantage point of being heavily involved in the input process that led to the current Psychiatry Residency Review Committee (RRC) requirements: 1) psychiatry as the only specialty that has its own unique competency requirements; 2) the way competency was redefined in the RRC process; 3) how the particular forms of psychotherapy were selected; and 4) how the field has gone about defining and, by implication, measuring competency in psychotherapy.
I could find no comment in any of the papers of this special issue on the fact that psychiatry appears to be the only specialty that has added specialty-specific competency requirements. Quite apart from the excellent points raised by Yager and Bienenfeld (2), does this put psychiatry ahead of the field or out in left field? In my opinion, the effort to tighten the psychotherapy training requirements so they could not be easily finessed was necessary. But the interaction of the RRC process with that of the Accreditation Council on Medical Education (ACGME) process involving the general competencies for all specialties produced an excessive response. Some in-between position is out there, though I have some criticisms of Yager and Bienenfeld's proposals, primarily along the lines of the political uses to which the term "evidence based medicine" has been put. Evidence-based medicine is a bit like motherhood and apple pie, but, as always, the devil is in the details of application. Many would disagree about which therapies have "enough" empirical evidence (does clinical evidence count at all?) to be required.
In my role as president of the American Association of Directors of Psychiatry Residency Training (AADPRT), I coordinated the input of training directors to the RRC during the Spring, Summer and Fall of 1998. Following a briefing of the entire AADPRT Executive Council of the issues on the table by Dr. Sheldon Miller in May 1998, I designed a questionnaire that would elicit opinions in all of the areas. This questionnaire was shared with Drs. Jerry Kay and Gene Beresin to coordinate coherent input (i.e., comparable responses to identical questions) from a wide array of stakeholders in the process. Dr. Kay coordinated soliciting responses from the American Association of Chairs of Departments of Psychiatry (AACDP), and Dr. Beresin coordinated input from the American Association of Child and Adolescent Psychiatrists (AACAP). I organized the responses from AADPRT and the Association for Academic Psychiatry (AAP). A long letter summarizing the data was sent to the RRC after being reviewed by the AADPRT Executive Council Steering Committee.
There was overwhelming consensus that the psychotherapy requirements needed to be more specific and that we should train to competence, though none of us knew at the time how the use of the term "competence" would interact with other forces at work in the ACGME. Interestingly, this was one of the few areas where chairs and training directors disagreed, with the chairs more comfortable with what then were more general and vague requirements. Of perhaps even greater importance is the definition of competence that was included in the questionnaire and in the letter to the RRC. Reflecting a typical, long-term developmental, educational perspective, both documents defined competence as achieving a level of skill in a given form of psychotherapy such that the graduating residents would be in a position to assume full responsibility for their continued growth and development as psychotherapists. All of the respondents to the questionnaire (chairpersons, training directors, child and adolescent psychiatrists, and other psychiatric educators) were endorsing "competence" based on the above definition. In my opinion, much of the angst of the last several years has been caused by a shift from the above developmental definition to what might be termed a "hard" definition of competence (i.e., absolute in some fashion). Careful reading of the ACGME requirements makes it clear that this shift in definition is not explicit nor necessarily implicit in the RRC's wording, though, as always, it is the interpretation through site visits and accreditation decisions that create the ultimate reality. In addition, the geographic juxtaposition of the psychotherapy competencies next to the general competencies in the final version of the requirements invariably tied the two together in a manner that the respondents never had in mind and that the RRC itself may not have intended. After all, the psychiatry requirements were the very first to include the new general competencies, and no one may have had any idea how the RRC's meaning would evolve.
I believe, though can't be certain, that the unpublished data that Miller, Scully, and Winstead (3) mention in their article refers to Dr. Kay's feedback of the AACDP responses of the shared questionnaire to the RRC.
The data from all four organizations, though never published, have been presented publicly in a number of fora by all three of us who solicited input. The response rate was very high from all organizations (70+% in all cases), and the similarity of the responses was quite striking. I want to focus on the question of how we arrived at five therapies and which ones were selected. Although I have partial data sets from the chairpersons and AAP, I will only mention those from AADPRT, with which I am most familiar.
In response to the question about how many forms of psychotherapy in which residents needed to be competent, one of the most pure Gaussian distributions I have ever seen in a data set emerged, with the peak clearly at three (Figure 1).
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FIGURE 1. Training Directors’ Responses, "In How Many Forms of Psychotherapy Should Residents be Trained to Competence?"
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The questions about which forms of psychotherapy should be taught to competence were posed in a closed-ended fashion and repeated in an open-ended fashion (i.e., "list all forms of psychotherapy..."). In the closed-ended, forced-choice question, three forms were endorsed by more than 60% of training director respondents: supportive, cognitive, and psychodynamic, respectively. Family and group therapies were endorsed by more than 50% of training directors, and brief dynamic therapy came in sixth at 45% (Figure 2).
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FIGURE 2. Training Directors’ Responses to Forced Choice Questions, "In Which Forms of Psychotherapy Should Residents be Trained to Competence?"
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The responses to the open-ended, spontaneous response question were much more dramatic. Cognitive, supportive, and dynamic therapies, respectively, were listed by more than 55% of all training directors. No other form of psychotherapy was mentioned by more than 25% of respondents. Brief dynamic therapy came in seventh and was endorsed by only about 15% of training directors (Figure 3).
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FIGURE 3. Training Directors’ Responses to Opened Ended Question, "List all Forms of Psychotherapy to Which Residents Should be Trained to Competence."
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I was delighted to see the Summers and Barber article (4). Though a member of the task force described in the Mellman and Beresin paper (5), I have always had my doubts about the process of creating a long list of subcompetencies and advocated that this is an area where the psychotherapy research literature, especially in the area of the helping alliance, could produce reliable, valid, outcome-oriented instruments for assessing competence. While still holding this opinion, I believe the process that Drs. Beresin and Mellman led us through was truly useful in demonstrating, to many training directors, that we can begin to define what we mean by psychotherapy competence and readily reach beyond global impressions.
In summary, I thought there was great wisdom in the collective responses of the AADPRT membership of 1998, though my individual responses were not totally consonant with them. The definition of competence was education oriented. The three identified therapies made sense, and the RRC's addition stating that graduates should be competent to handle medications for patients for whom they were also performing one of the three therapies was well thought out.
REFERENCES
- Yager J, Kay J, Mellman L (eds): Assessing psychotherapy competence. Acad Psychiatry 2003; 27:125–181[Free Full Text]
- Yager J, Bienenfeld D: How competent are we to assess psychotherapeutic competence in psychiatric residents? Acad Psychiatry 2003; 27:174–181[Abstract/Free Full Text]
- Miller SI, Scully JH, Winstead DK: The evolution of core competencies in psychiatry. Acad Psychiatry 2003; 27:128–130[Abstract/Free Full Text]
- Summers RF, Barber JP: Therapeutic alliance as a measurable psychotherapy skill. Acad Psychiatry 2003; 27:160–165[Abstract/Free Full Text]
- Mellman LA, Beresin E: Psychotherapy competencies: development and implementation. Acad Psychiatry 2003; 27:149–153[Abstract/Free Full Text]
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