Psychotherapy | Psychiatry | School of Medicine

Psychotherapy therapy is a voyage of discovery. When spoken by the patient, and received without tumult by the therapist, isolating experiences and fears can be stripped of their power to limit and to harm. The patient’s need for symptoms and defenses must be explored, understood, and worked through before previously unknown aspects of the self can be integrated in a more stable and fulfilling life. Used creatively, talking is the channel through which a patient’s challenges and discoveries can be expressed and examined with the therapist and with other companions in the therapeutic enterprise, such as fellow members of a group or family. To be therapeutic, the process of understanding must be integrated with a process of change.

Psychotherapy Modalities

The psychotherapies are a variety of psychological treatments that help relieve symptoms and improve functioning in patients suffering from psychiatric disorders and psychological problems. Empirical evidence supports the use of a variety of psychotherapies as part of the treatment of patients with psychiatric disorders across the lifespan.

Training for Residents

Given the evidence for the effectiveness of psychotherapeutic treatment for a wide range of psychiatric conditions, graduating psychiatrists should be knowledgeable and sufficiently skilled to deliver some of these treatments to patients with psychiatric disorders.

Developmental Model

Fundamental skills focusing on alliance development should precede the learning of specific skills or therapies. Learning of individual therapies should precede the learning of systemic therapies.

Therapeutic Alliance

The therapeutic alliance is defined as the fundamental relationship between the therapist and the patient, which is made up of the following three components:

A bond (relational component)
Mutually agreed-upon goals
Tasks (means to attain goals)

Therapist Attributes

Warmth
Genuineness
Respectfulness
Capacity for Empathy

Basic Therapeutic Techniques

Empathic Reflection
Affective Exploration
Supportiveness
Facilitation of the expression of affect
Attention to the patient’s experience

Positive Outcome

Expression of positive therapist attributes and consistent and effective use of basic therapeutic techniques have an impact on positive therapeutic outcome. They are key capacities to learn and demonstrate in psychotherapy training.

Period of Training

Training in the evidence-based psychotherapies must involve no less than a full 32 weeks or eight months of the 60-month period of training (1200 hours). A period of 3 hours per week for PGY 2-5 residents is protected for Psychotherapy training.

Structured didactic learning
Patient treatment
Supervision

Levels of Knowledge

Proficiency: the resident is the primary therapist with one hour of weekly supervision

Working knowledge: participation as an observer or co-therapist

Basic or introductory knowledge: didactic seminars or structured learning activities

Proficiency

Cognitive Behavioural Therapy
Psychodynamic Psychotherapy
Supportive Therapy
Crisis Intervention

Working Knowledge

Behavioural Therapy
Dialectical Behavioural Therapy (DBT)
Family or Group Psychotherapy
Interpersonal Therapy (IPT)

Basic Knowledge

Brief Psychodynamic Psychotherapy
Mindfulness Training
Motivational Interviewing
Relaxation

Structure for Psychotherapy Training

Structure for Psychotherapy Training for Queen's Psychiatry Residents

Pre-requisites for Resident Psychotherapy Practice

1. Over the summer term, all PGY 2 residents will read the basic review of the fundamental principles
of psychotherapy, Introduction to Psychotherapy (Bateman, Brown, and Pedder).

2. The summer didactic sessions on Case Formulation and Psychotherapy Interviewing Skills are
also required before beginning psychotherapy practice.

3. In early September, all residents (who have not previously participated in this workshop) will
participate in the day-long workshop, Personal and Cultural Awareness.

PGY 2-5 Mandatory Didactic Training in Psychotherapy

The Basic and Intermediary CBT courses will be offered on alternative academic years and are mandatory for all residents. A workshop on Psychodynamic Psychotherapy will also be included in the curriculum, and completion will be mandatory for all residents. One full-day Introduction Workshop in Cultural Competency and follow-up seminars, expanding residents’ self-awareness, knowledge-base, and skills with regard to both professionals’ and patients’ cultural identities, including ethnicity, race, class, religious background, sexual orientation, gender identity, and others, will be offered to help psychotherapists improve service delivery by increasing their understanding of how cultural factors influence psychiatric treatment. Residents must demonstrate attendance at all seminars on Cultural Competency before graduation.

Schedule for Resident Psychotherapy Education and Practice

At the beginning of each psychotherapy module rotation, residents will be assigned appropriate readings related to that modality and will review the PTeR section that covers the modality. Residents will demonstrate to the supervisor that these materials have been understood and that the resident has basic knowledge about the modality.

1.   PGY 2 Residents will provide individual Supportive Psychotherapy to patients from an outpatient
      clinic at HDH at 2:30 PM on Fridays, and, directly after they treat their patients, they will participate
      in group supervision sessions from 3:30-5:00 p.m., each Friday for eight months. Fundamentals
      and common factors in all psychotherapy modalities will be learned during these group sessions in
      the context of case supervision. Minimum 20 patient sessions in Supportive Therapy.

2.    At the beginning of the PGY 3 year, residents will be assigned their long case supervisor,and they
will begin supervised practice in psychodynamic psychotherapy throughout their PGY 3 year.
       Minimum one year for long case in psychodynamic psychotherapy.

3.   Couple and Family Therapy will be practiced at both the working and proficiency level during the
      Child and Adolescent rotation in PGY 3. Residents who wish to enhance their Couple and Family
      Therapy practice may have the option of taking on additional cases supervised by an experienced
      Family Therapist outside the parameters of their Child and Adolescent rotation.

4. In the PGY 4 year, residents will be assigned supervisors for their CBT (Minimum 16 sessions) and
IPT training, and practice in these modalities will continue throughout their PGY 4 year.

5.   Crisis Intervention Psychotherapy will be practiced and supervision logged longitudinally
      throughout residency while residents are on call in the ER and during other rotations in which
      emergencies arise. Minimum 20 logged sessions in Crisis Intervention Psychotherapy.

6.   Other psychotherapy modalities, such as DBT, Group Psychotherapy, Motivational Interviewing,
      Mindfulness, and Relaxation, will be learned and practiced at the working and/or proficiency levels
      throughout the PGY 3, 4, and 5 years, depending on the individual schedules and interests of the
      residents. Residents who wish to enhance their working knowledge (and logged hours) of both
      DBT and Group Psychotherapy may do so during an elective at the Personality Disorders Service.
      If the elective is more than one block, proficiency in Group Psychotherapy can be achieved during
      this rotation.

7. Residents who wish to develop a higher level of proficiency in any psychotherapy modality may
see additional patients and/or increase the length of a psychotherapy modality rotation.

Elective Rotation

Personality Disorders Service: Elective Rotation

Personality Disorders constitute a challenging aspect of any psychiatric practice. The RCPSC recommends that the resident have exposure to all aspects of these disorders. Training Site: Personality Disorders Service, Providence Care - LaSalle Mews. A 3-block rotation at Personality Disorders Service is mandatory for PGY-4 psychiatry residents.

Medical Expert:

Take an appropriate history and conduct a mental status examination in order to diagnose personality disorders
Document treatment history and outcome
Conduct a thoughtful and reasonable diagnostic work up
Formulate a treatment plan based on the biopsychosocial approach
Observe a range of psychotherapeutic groups designed to treat patients with personality disorders
Become familiar with psychodynamic and dialectical behavioural therapy treatment approaches with patients suffering from personality disorders
Learn and observe common factors in the delivery of effective psychotherapy

Communicator:

Learn the elements necessary to establish therpeutic relationship with patient(s)
Demonstrate the ability to serve as a model for healthy interpersonal relating and to communicate deeply and creatively while at the same time maintaining appropriate professional boundaries
Communicate effectively with physician colleagues, psychologists, social workers, nurses, and all other professional colleagues, respecting the unique expertise of all

Collaborator:

Work constructively in a multidisciplinary team, acknowledge the special role of all health care professionals in care of patients
Collaborate with other specialists in the community involved in the care of patients
Collaborate with family members regarding the health of patient and family

Manager:

Understand the crucial importance of resource management and cross-discipline resource allocation and utilization

Health Advocate:

Be able to implement a model of care to provide a framework for improving quality of life for individuals suffering from personality disorders and their families

Scholar:

Become familiar with basic literature on common factors in psychotherapies and transference-based, mentalization, and dialectical behavioural therapies

Professional:

Develop awareness of biased attitudes often shown toward patients with personality disorders
Demonstrate sensitivity and awareness of differences and needs regarding patients from a range of cultures, races, religions, sexual orientations, and gender identities
Deliver highest quality care to this patient population with compassion, integrity and respect

This experience will enable a psychiatry resident to observe a wide range of psychotherapeutic groups focused on the four modalities of dialectical behavioural therapy including: Seeking Safety, Goals, People Skills, Mindfulness, Managing Powerful Emotions, Art, Values.