1	The Role of Personal Psychotherapy in Residency Education GAP Plenary Session November 1, 2002
2	Personal psychotherapy in residency education History Data Benefits Other Factors Barriers Solutions
3	A longstanding tradition… Recommended during psychiatry training since 1912. Continues to be required in postgraduate psychoanalytic training. Supported by GAP in 1987.
4	Freud’s support “It may be insisted, rather, that he should have undergone a psychoanalytic purification and have become aware of those complexes of his own which would be apt to interfere with his grasp of what the patient tells him.” “Recommendations to Physicians Practicing Psycho-analysis” Freud, 1924
5	Changing times Initial dominance of psychoanalytic traditions Emergence of the “medical model” Present emphasis on a balanced biopsychosocial approach
6	GAP speaks out in 1987 “…through experience as a patient in seeking and receiving help, the resident experiences first-hand what he or she is attempting to learn.” Personal psychotherapy may have negative short-term effects on training Resident’s own desire and motives regarding therapy must be considered Overall, personal psychotherapy should be a “useful adjunct, but not the focus of residency training” “Teaching Psychotherapy in Contemporary Psychiatric Residency Training” GAP Report #120, 1987, p. 39
7	A steady decline… Sources: Holt & Luborsky, 1958 Casariego & Greden, 1978 Weissman, 1994 Weintraub, Dixon, Kohlhepp & Woolery, 1999
8	What the numbers tell us Weintraub, et. al. surveyed 119 current residents at three training programs and 209 former residents at one of those programs. At the program for which both current and past residents were surveyed, 70% of past residents had personal psychotherapy in residency compared to 20% of current residents (P<0.0001) Comparing the three programs, bivariate analysis showed training program (P<0.0001) was associated with personal therapy participation.
9	Why such a decline? Environmental, systemwide changes Increased knowledge and focus on neurobiology Effect of reimbursement changes Rise of non-insight oriented therapies Use of medication Program-specific changes Trickle down of systemwide changes to faculty, curriculum, time and cost issues Lack of discussion regarding possible reasons / benefits of personal psychotherapy. Individual factors Stigma, cost, legal issues, licensure & insurability
10	Program attitudes about personal psychotherapy Daly (1998) surveyed 196 programs with replies from 86% and found: 42% of programs recommend personal psychotherapy Limited help provided in getting a psychotherapist: 6% from within program 24% from outside, listed by program, reduced fee 27% from outside, listed by program 24% no assistance from program 20% program assisted individually
11	Few residents in therapy…
12	Significant associations Program policy and increased percentage of residents in therapy (P<0.001) Program policy and better perceived outcome of therapy (P<0.001) Program orientation and percentage of residents in therapy (P=0.025)
13	Ginsburg Eli-Lilly Fellows survey Assessed current views of residency training directors towards personal psychotherapy and its role in residency education. 8 of 15 residency directors responded Responses given on a scale of 1 to 9 with 1 being “strongly agree” and 9 being “strongly disagree.”
14	Residency training directors were asked if… Personal psychotherapy should be part of a resident’s education. Range 2 to 9 Mean 4.375 Our program encourages residents to enter into personal psychotherapy. Range 2 to 5 Mean 2.125
15	When do training directors recommend psychotherapy? Personal difficulty Professional difficulty Least likely to recommend: Educational reasons
16	Resident attitudes Residents in therapy are more likely to believe that: Personal therapy helps a psychiatrist function professionally (P<0.001) Residents should be taught to deliver insight-oriented therapy (P<0.05) Weintraub, et. al. (1999) Residents in therapy found therapy: 85% find therapy at least somewhat helpful. 33% noted “an improvement in professional practice” 45% felt psychotherapy was “personally helpful” Daly (1998)
17	Statistics: residents in therapy Type of therapist: 23% analyst 41% psychiatrist 19% psychologist 7% LCSW Type of therapy 14% analytic 63% psychodynamic or interpersonal 10% CBT Payment source: 7% program 11% insurance 26% resident 49% multiple
18	Benefits of personal therapy Norcross, Strausser-Kirtland and Missar (1988) proposed “the goal of the psychotherapist’s personal treatment is to alter the nature of subsequent therapeutic work in ways that enhance its effectiveness.” Six main themes of clinical benefit: Improve emotional and mental functioning of psychotherapy Understand personal feelings and reduce countertransference Alleviating emotional stress Improve therapist’s internalized role as healer Increase empathy for clients Model technique for the therapist.
19	Studies showing benefits Personal psychotherapy: Causes therapists to become more responsive to therapeutic needs of patients. (Greenberg & Staller 1981, GAP 1987, Macran & Shapiro 1998) Benefits psychiatry residents with emotional and personal difficulties. (Russell et. al. 1975, Wallace & Tisdall 1991) Increases residents’ belief in efficacy of therapy. (Weintraub et. al. 1999)
20	Why are professional benefits hard to see? Macaskill (1988) suggested that benefits in therapy may only be visible intermittently, especially in challenging circumstances. If personal therapy contributes to procedural knowledge, it’s significantly harder to measure. Effect may be far removed from cause and confounded by other aspects of training
21	The case for personal psychotherapy Reduce stress in residency Understand countertransference issues Address personal and emotional issues for trainees
22	Consequences of psychiatric work… Vicarious Traumatization: “The endless stories of violence, cruelty, exploitation, and atrocity; the emotional impact of experiencing another’s terror, pain, and anguish; and the continual exposure to the darkest aspects of the human condition can produce symptoms strikingly similar to the post-traumatic symptoms of their patients.” Burnout: “A complex of psychological responses to the particular stresses of constant interaction with other people in need.” Blair & Ramones (1996)
23	Trauma counselor study Sept 8, 1994 - USAir Boeing 737 crashed outside Pittsburgh, PA 21 staff members of Staunton Clinic volunteered to provide emergency trauma counseling 20 remaining staff members were controls
24	Trauma study results Four weeks - at risk group reported significantly more PTSD and depressive symptoms emotional numbing being in a daze or a dream problems remembering important things difficulty sleeping poor concentration agitation restlessness decreased energy
25	Trauma study results (cont’d) Eight weeks - at risk group reported ongoing symptoms numbing being in a daze decreased energy Twelve weeks - at risk group reported avoidance of situations that aroused memories of the crash
26	Cognitive changes All therapists working with trauma victims may experience lasting alterations to basic cognitive systems that may have a significant impact on feelings, relationships and beliefs (McCann & Pearlman 1990). Trauma and working with survivors of trauma challenges several basic schemas: that the world is benign, the self is worthy, people are basically trustworthy, and the world is orderly and meaningful (Blair & Ramones 1996).
27	Risk factors for burnout Lack of observable clinical successes High rates of recidivism Interpersonal isolation of the professional Ambivalence concerning competence, adequacy or experience Having to be therapeutic with resistant, violent or confrontational patient populations
28	Countertransference Definitions range from the narrow (“therapist’s reaction to patient’s transference”) to the broad (“totality of the therapist’s reaction to the patient”). Rao, Meinzer and Berman (1997) describe three training modalities for addressing countertransference: Supervision T groups Personal psychotherapy
29	Supervision “The most common, most important, and probably the most important method of teaching psychotherapy is by means of supervision.” (GAP, 1987) Clarke (1987) notes that supervision is a focus of great ambivalence for trainees.
30	Problems with supervision Potentially harmful 40% - 60% of trainees report educational or emotional neglect, severe criticism or humiliation from their supervisors (Kozlowska, Nunn & Cousins, 1997) Poor modeling (at best) In a national survey of PGY-4 psychiatric residents, 4.9% of 548 respondents indicated that they had been sexually involved with psychiatric educators. (Gartrell 1988) 11 of 26 residents noted that contact began during working relationship.
31	Problems with supervision (cont’d) Impasses May be caused by interpersonal problems and/or unconscious issues within the supervisor, resident and patient. Lying Examples included a pattern of “editing everything”, writing “creative process notes” (“antiseptic, molded to the taste of the supervisor…this protected me from too much exposure”) omit from session “advice” given by therapist. “Almost all residents interviewed verbalized fears ranging from disappointment to frank retaliation in the form of rebuke or poor evaluations as a consequence either of challenging a supervisor’s suggestion or failing to meet his or her expectations.” (Hantoot, 2000)
32	Psychiatric residents & psychiatric disorders Limits of research Few studies Mostly survey-based Only some studies imply greater risks for psychiatrists and residents Despite these limits, it’s clear that psychiatric residents are: Not immune from psychiatric disorders Need treatment options
33	Specific mental health concerns Depression Higher rates of depression than community studies. Psychiatry with 2^nd highest rates (after ob-gyn) Suicide Psychiatrists suicide at about twice the expected rate. Substance Use Psychiatric residents had higher rates of substance use compared to other residents
34	Why not get psychotherapy? Resident concerns Stigma of treatment Time and cost Legal concerns Licensure issues Insurability after residency
35	Stigma of treatment
36	Time and cost Weintraub (1999) showed that the primary barrier to current residents not in therapy: Cost (45%) Lack of time (25%) Would not be helpful (16%) Other reasons (14%)
37	Legal concerns Mental illness or substance use, if affecting ability to function, may be basis for disciplinary action under most state laws, but “inability to function” not clearly defined. Unclear if colleague reporting applies to a physician’s therapist. Most states require physicians to report suspicion of a colleague’s impairment to state licensing boards.
38	Licensure issues Applications ask for (and even focus on) ANY past mental health treatment. Few state boards distinguish between treatment and impairment. State board actions on information provided could be discriminatory to physicians. Information regarding licensing is becoming increasing available to the public.
39	Licensing and ADA act Americans with Disabilities Act of 1990 may apply to licensing procedures. AMA position: “The AMA urges licensing boards, specialty boards, hospitals and their medical staffs and other organizations that evaluate physician competence to inquire only into conditions which impair a physician’s current ability to practice medicine” (AMA policy H-275.978) APA position: “It is not informative to ask about past psychiatric treatment except in the context of understanding current functioning…Applicants must be informed of the potential for public disclosure of any information they provide on applications.” (APA resource document 1997)
40	Insurability after residency Group policy Individual policy Supplemental
41	Insurance policy specifics Group disability policies offer 66% payout. Limitations: No coverage for 1 year of residency if any psychiatric treatment including psychotherapy or medication was received within the 90 days prior to issuing policy Limited 2 year benefit for psychiatric disability Individual policies can supplement coverage, but have their own drawbacks. Typically declined if any psychotherapy or psychiatric treatment in the last two years.
42	A tip to pass on to residents Residents should check for option of converting their group disability insurance policy to an individual policy when leaving residency.
43	What should be done? Influence public policy Change training programs Communicate with residents
44	Influence public policy Lobby state medical boards to change their statues so that the pursuit of psychotherapy is not regarded as physician impairment. Produce a convincing evidence base so that insurance companies will be persuaded to pay for more psychotherapy. Inform other physicians of the efficacy of psychotherapy.
45	Change training programs Add discussion of personal psychotherapy to the curriculum. Make personal psychotherapy logistically and financially feasible for residents. Offer process groups to residents.
46	Communicate with residents Make information about psychotherapy’s efficacy better known to residents. GAP Committees could disseminate information about personal psychotherapy. Risks Benefits
47	Special thanks to… The GAP Fellows Committee: Ed Foulks M.D. Stephen Shanfield M.D. Renato Alarcon M.D. Russell Gardner M.D. Leah Dickstein M.D. Consultant: Calvin Sumner M.D. And especially, Frances Roton & Deborah “Copa” Cabaniss M.D.
48	And also to… Our GAP Mentors: Dick Francis, M.D. Larry Gross M.D. Richard Hire M.D. Frances Levin M.D. Robert Larsen M.D. M.P.H. Mike Liptzin M.D.
49	GAP Fellows 2000 - 2002 Rob Andrews Jason Andrus Thomas Cobb Kay Cogbill Melita Daley Josh Gibson Jon Grant Stephanie Hall Gabrielle Marzani-Nissen Ben McCommon Jennifer Myer Linda Odom Jacob Roth John Tennison Liana Urfer