Professor Robert Feinstein
Department of Psychiatry
University of Colorado Anschutz Medical Campus
Psychotherapy Curriculum and Clinical Training
Introduction: In the last 20 years, there has been an explosion of new evidence-based
psychotherapies to treat a wide range of medical conditions, lifestyle issues, and psychiatric disorders. For most conditions, the average effectiveness of all psychotherapies shows a moderate to large effect size. Over this same time period, our psychiatric medications have been shown to be less effective than formerly believed many studies showing average effect sizes that are small to moderate. Psychotherapy training is again in a Renaissance. There are approximately 10 major different forms of evidence-based psychotherapy, and the list is growing. The prevalence of clinical conditions requiring some type of psychotherapy, and/or counseling, is high in all health care settings and needed across a wide range of health professionals.
The Problem: The problem for health educators and for psychotherapy teachers and students is the lack of consensus, based on clear evidence, regarding how to prioritize teaching the various psychotherapies, and matching which forms of psychotherapy work best for specific problems or patients. Currently, different forms of psychotherapy are being researched in head-to-head, comparative effectiveness trials, in an effort to see which ones may yield better outcomes for varying conditions and patients. Over a wide range of conditions, they all seem to be equally effective at about the same 70% rate of efficacy. As a result, psychotherapy curriculum is usually determined by external certification requirements, and local decisions regarding: 1) the specific faculty who will teach; 2) amount of training time allocated; and 3) the form of psychotherapy taught.
Proposed Solution: The basis of my Teacher’s Scholar project is to change the approach to teaching psychotherapy and counseling by cutting across all the major schools of thought, and focusing on teaching the common factors necessary for integrative psychotherapy. This proposed approach is consistent with emerging psychotherapy research which demonstrate that 30% of psychotherapy effectiveness is determined by common factors/processes; 40% client variables; 15% Expectancy/Hawthorne effect; and 15% related to specific schools of psychotherapy. Based on these emerging findings, I will design, implement, and test a new form of psychotherapy curriculum and training.
I. Needs Assessment will be conducted to determine the psychotherapy/counseling skills needed by each of the following groups: medical students, psychiatric and primary care residents, other mental health professionals, and primary care and psychiatric teaching faculty. The results will inform the development of the project.
II Goals and Objectives
Goal 1: Design a new progressive didactic curriculum, which can be integrated within the clinical program. The new curriculum teaches psychotherapy, with an emphasis on evidence supported common factors, processes, change strategies, and how they interface with client variables to optimize beneficial outcomes. The following are all taught didactically and experientially.
Objective 1: Teach common psychotherapy factors (e.g. listening, communication skills; the therapeutic alliance, psychological patterns or themes, resistance to change, transference, countertransference, instituting new adaptive patterns).
Objective 2: Teach core processes of psychotherapy (didactically, with video, and E-Resources) which includes: engagement, developing the working alliance, activating the patient observing self/ mentalization, search and change mal-adaptive patterns, and the termination of treatment.
Objective 3: Teach assessment of important patient variables, which can lead to better outcomes for successful treatment.
Objective 4: Teach utilization of extra-therapeutic change processes, e.g. use of patient’s family, friends, work, hobbies, readings, spiritual/religious beliefs etc.
Objective 5: Teach how to utilize the Hawthorne Effect (e.g. use of the expectancy of success), and the importance of hope.
Objective 6: Teach techniques/interventions from multiple theoretical approaches, and how these can be tailored toward individual patient needs.
Goal 2: Use experience-based learning in a clinical environment, working with patients, and
utilizing various forms of supervision to develop clinical skills and foster additional integration of didactic material within clinical practice.
Objective 1: Utilize and develop Psychotherapy-E training Resources (PTer-McMasters) for online learning, supporting the learning from all the other objectives. PTer includes: a) Review of key concepts and the literature b) Clinical psychotherapy vignettes, illustrating goals, objectives, and techniques; c) References and resources; d) Information on how to assess competence; e) Quizzes to assess knowledge; and f) Interactive "virtual therapist" to assess "virtual" clinical skills.
Objective 2: Develop a model of faculty–student collaborative treatment with a patient:
a) Faculty and a student will each conduct an independent intake, followed by a discussion and plan; b) The initial phase of treatment will be done by faculty with some student participation; c) The second phase will be done by the student, with some faculty participation; d) The final phase of treatment is done by just the student, with weekly faculty supervision.
Objective 3: Student sees the patient’s alone, with faculty supervision (via live observation, video, audio, process notes).
Objective 4: Students to learn 2 other forms of psychotherapy, which can be based on their primary needs, work environment, or interest.
Objective 5: Maintenance of psychotherapy skills. Students will have the option to set up peer supervision groups to maintain skills and/or utilize
other CME resources.
III. Teaching Methodologies: 1) Develop, teach, and design mini-didactic/small group
learning for each goal and objective; using adult learning principles, teach progressively and as is developmentally appropriate; 2) Use online psychotherapy E-Resources throughout the curriculum; 3) Faculty and student collaborative patient treatment; 4) Supervision of psychotherapy with multiple patients, using live observations, call-in interventions, video, audio, and process note supervision; 5) Group peer supervision for skill maintenance and CME resources.
As we develop explicit core competency objectives and/or other outcome measures, we will develop parallel assessment measures. Evaluations will include written and/or oral psychotherapeutic knowledge exams; formative and summative student-self assessments; supervisor completed formative and summative observation-based behavioral checklists, and narratives designed to assess clinical/psychotherapeutic skills development. We will also complete a program evaluation to assess the efficacy of teaching common factors necessary for integrative psychotherapy.