REGULAR
ARTICLES
Psychiatry Residency Programs: T r e n d s i n Psychotherapy Supervision PAUL RODENHAUSER, M . D . * Responses t o the 1989 survey of the A m e r i c a n A s s o c i a t i o n of D i r e c t o r s of P s y c h i a t r i c Residency T r a i n i n g characterize practices and problems i n teaching psychotherapy. C o n t e m p o r a r y i n s t r u c t i o n i n v o l v e s m a i n l y f u l l - t i m e f a c u l t y , case r e v i e w s , i n d i v i d u a l and g r o u p sessions, and emphasis on b r i e f and s h o r t - t e r m p s y c h o d y n a m i c psychotherapy. Supervisory problems include limits in faculty a v a i l a b i l i t y , s k i l l diversity, t h e o r e t i c a l f l e x i b i l i t y , competence, p r o g r a m structure, a t t i t u d e s , and a d m i n i s t r a t i v e s h o r t c o m i n g s . Controversy about the relative importance o f instruction i n psychotherapy for psychiatry residents gathered momentum i n the 1980s. Contributing factors included the increased emphasis o n cost o f psychiatric services, the difficulty i n demonstrating the effectiveness o f psychodynamic psychotherapy i n objective terms, resistance to efforts t o remedicalize psychiatry, and the refinements i n biological psychiatric treatments derived f r o m recent advances i n the neurosciences. The burgeoning neurobiological contributions to our understanding of behaviors has significantly enhanced the biological side o f the educational equation. Consequently, the wishes or fears o f many educators have turned psychotherapy into an endangered component o f residency education. Its diminished role has been reported and supported. Compromise seems t o have emerged the victor over displacement of training i n psychodynamic 1
2
1
3
4
'"Professor of Psychiatry, Director of Medical Student Education in Psychiatry, Department of Psychiatry and Neurology, Tulane University School of Medicine, 1430 Tulane Ave., New Orleans, L A 70112-2699. A M E R I C A N J O U R N A L O F P S Y C H O T H E R A P Y , Vol. X L V I , N o . 2 ,April 1 9 9 2
240
Trends i n Psychotherapy Supervision i n t e r v e n t i o n . Several developments are related to the status quo including discoveries of the superior treatment effectiveness of combined psychotherapy and pharmacotherapy ' and the broad implications of psychiatric interventions w i t h primary-care p a t i e n t s . Bridging the philosophy gap, learning the psychology of psychopharmacology, and practicing integrationist approaches to treatment are becoming vital characteristics of residency education programs. 15
6 7
8-10
11
12
Many residents and medical students who are interested i n psychiatry as a career want to be taught about, and have experience i n , psychodynamic treatment. These interests have implications for resident satisfaction and recruitment. Like the movement toward the remedicalization of psychiatry, continued inclusion of psychodynamic psychotherapy i n psychiatrists treatment inventory also has marketing and political implications. Fundamental and compelling reasons for continuing to teach psychodynamic psychotherapy are reported by a joint task force of the Association for Academic Psychiatry and the American Association of Directors of Psychiatric Residency Training. 13
14
>
1
Despite some resistance, contemporary approaches to research and treatment are more and more based on convergence of psychophysiological and psychological perspectives. Apropos this direction, L o e b e l refers to "the dynamic nature of cerebral cortical and mental activity" as a platform for investigation. Responses to the 1989 annual American Association of Directors of Psychiatric Residency Training (AADPRT) survey, the primary source of material for this article, reconfirm the shift from a predominance of psychodynamically oriented academic departments of psychiatry with secondary psychobiological emphasis to a predominance of biologically oriented departments w i t h secondary strengths i n psychodynamics. The gestalt of the survey responses implies progressive attempts at theoretical convergence or at least practical eclecticism, which would allow learner integration. 15
This article reviews the data f r o m the 1989 annual A A D P R T survey of residency education programs that pertain to psychosocial aspects of residency education. The focus of the selected survey data and, therefore, of this article is on resident instruction i n psychodynamic psychotherapy. METHODS The 1989 annual survey sponsored by the A A D P R T was developed, distributed, collected, and collated between mid-January and late September 1989. The thirty-three page questionnaire, a copy of which can be obtained f r o m me, was mailed coincident w i t h the 1989 annual A A D P R T meeting i n 241
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January to the directors of all accredited general psychiatry residency education programs (n = 215). One section of the questionnaire related specifically to psychotherapy supervision and resident experience w i t h psychotherapy. The following information was requested: the frequency and duration of meetings for psychotherapy supervision w i t h individual residents, groups of residents, and the supervisors (for their supervision); the numbers of full-time, paid part-time, and voluntary faculty members responsible for the supervision of individuals, groups, and supervisors at each postgraduate year level; the mechanics of psychotherapy supervision; and, the mean number of total cases per resident per total residency experience of the forms of psychotherapy offered i n each program. A final question directly related to this area of learning asked about major supervisory problems. I n addition, responses to one general interest question were explored for relevance: what topics are most difficult to teach, either because they are unpopular, discomforting, or met w i t h resistance? R E S U L T S
The number of completed questionnaires returned was 107, a return rate of 49.76 percent. PSYCHOBIOLOGICAL
AND PSYCHODYNAMIC
ORIENTATIONS
Respondents indicated that at present psychobiological orientations predominate i n approximately i n 51 (48%) o f their programs compared to 34 (32%) i n the past. A psychodynamic orientation was predominant i n the past in 56 (52%) of programs, but is predominant now i n approximately 43 (40%). A chi square analysis based on these data (chi square = 5.64, d f = 2, p = .0596) indicates that these changes are marginally statistically significant. This notable change is reflected i n the response to the questions about secondary departmental strengths. As a secondary strength currently, 43 (40%) of respondents listed biological and 43 (40%) listed psychodynamic orientations. A psychodynamic orientation as a secondary strength, historically, was listed as 26 (24%), and a biological one as 50 (47%). The psychodynamic orientation has increasingly been considered a secondary strength as a biological orientation has attained philosophical dominance. Other orientations, namely behavioral, cognitive, and eclectic, that used to be prominent i n 17 (16%) of the institutions, are now reduced to 13 (12%). PSYCHOTHERAPY
SUPERVISION
SESSIONS
Individual supervision for first-year residents occurred i n 76.6 percent (82/107) of programs. Whereas meetings for those individually supervised 242
Trends in Psychotherapy Supervision P G Y - I residents averaged about one per week and lasted approximately one and one-half hours, those for P G Y I I , H I , and I V residents were double or more i n frequency and equal or greater i n length. Meetings of P G Y I , I I , and I V residents supervised i n groups averaged, across programs, about one per week, while P G Y H I residents i n groups met more frequently. One hour was a typical session for all residents supervised i n groups. Supervisors met as a group most frequently and for longer periods of time i n relation to their work w i t h P G Y EH residents. A t that training level, supervisors met 1.4 times per week for 1.3 hours. Otherwise, on average, they reportedly met once weekly for an hour. MECHANICS OF PSYCHOTHERAPY
SUPERVISION
Case reviews, time-tested but not objectively confirmed to be advantageous, continue to be the predominant method for learning i n psychotherapy supervision. Case reviews are employed by 82 percent of programs. Explanatory comments accompanying responses to the question about case reviews frequently referred to use of process notes. Responses to inquiries about use of the other three methods for enabling supervision—videotaping, audiotaping, and direct observation—indicated that each is limited i n usage, on average, to approximately 10 percent of the supervisory sessions. The inquiry on direct observation d i d not distinguish between in-person and one-way mirror arrangements. DISTRIBUTION OF SUPERVISING
FACULTY
The questionnaire asked residency directors about the percentage of supervision provided by category of faculty for individual residents, groups of residents, and supervisors themselves for each postgraduate year. Supervision of residents i n groups and supervision of supervisors are not practices common to all programs. Supervision of supervisors was reported by 35-38/107 programs, varying w i t h postgraduate year. Supervision of residents i n groups was reported i n a range of 58 (PGY-I) to 85 (PGY-IH) programs. Full-time faculty were predominantly responsible for supervision i n the first postgraduate year (70% for individual supervision, 72% for group supervision, and 9 1 % for supervisor supervision). Distribution of supervision by full-time faculty across the remaining three postgraduate years remained relatively constant (52-60% for individual residents, 4 2 - 4 7 % for groups, and 82-84% for supervisors). Paid part-time faculty were utilized at a fairly steady rate during the four postgraduate years (13-19% for individuals, 17-27% for groups, and 4 - 1 3 % for supervisors). Utilization of voluntary faculty increased after the first postgraduate year to 24-31 percent for 243
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individuals and 16-21 percent for groups, but remained constant (4-5%) across all years for supervision of supervisors. I n sum, 75 percent of programs provided some individual psychotherapy supervision for first-year residents and all responding programs offered psychotherapy instruction i n the second, third, and fourth years. Two-thirds of the programs on the average offered supervision to residents i n groups and one-third provided supervisors w i t h supervision (mostly by full-time faculty). During the first residency year, full-time and some part-time faculty provide most of the psychotherapy supervision. Thereafter, part-time and voluntary faculty contribute a larger share of the supervision of individuals and groups. RESIDENT EXPERIENCE WITH FORMS OF PSYCHOTHERAPY
I n the course of their total residency experience, trainees are assigned and manage patients i n a variety of psychotherapeutic modalities, according to residency-director respondents. These include therapies defined i n part by therapeutic relationship, i.e., individual, group, family, and couples therapy, and those defined by theoretical approach, i.e., psychodynamic, cognitive and behavioral therapies. Based on the numbers of assigned patients, individual psychodynamic psychotherapy is the prevailing psychotherapeutic modality for residency education. The utilization of brief and short-term forms is almost three-fold that of long-term psychodynamic psychotherapy. Experiences w i t h cognitive and behavioral approaches are limited as are numbers of assigned families and couples for therapy. Information on resident experience w i t h group psychotherapy (an average of two exposures) does not address length or degree of involvement. Table I displays the complete data set for comparisons. SUPERVISORY
PROBLEMS
Although responses to the inquiry about problems w i t h supervision were numerous, they clustered into broad groups. Predominant problems were n u m b e r s (and availability) of faculty and s k i l l d i v e r s i t y among faculty. Related to diversity of skills is an individual supervisor's f l e x i b i l i t y i n approaches to treatment. Problems caused by lack of competence or experience were noted. Lack of interest and devotion and reluctance to supervise without pay might be considered a t t i t u d i n a l issues. Many responses related to problems w i t h program structure and s t a n d a r d i z a t i o n . These include inconsistency of evaluations, unevenness of goals and objectives i n supervision, communication and follow-through problems, quality control issues, and unwillingness of supervisors to be supervised. 244
Trends in Psychotherapy Supervision Table I
T O T A L P S Y C H O T H E R A P Y CASES PER R E S I D E N T RESIDENCY EXPERIENCE
PER
Modalities
Averages of Mean Numbers of Total Cases
Psychodynamic psychotherapy long-term ( > 12 months) short-term (3-12 months) brief ( < 3 months) Cognitive therapy Behavioral therapy Group psychotherapy Family therapy Couples therapy
6.0 15.2 17.4 3.6 2.7 2.0 (groups) 3.3 (families) 3.0 (couples)
DIFFICULT TOPICS TO TEACH
Residency directors were asked to list those topics that were most difficult to teach. The question suggested unpopularity, discomfort, and/or resistance as possible reasons. The rank order of all responses listed more than once is exhibited i n Table I I . I f biological psychiatry were subsumed into the category of neurosciences, that topic would be noticeably more "difficult"; likewise, if countertransference issues and psychoanalytic theories/ history were subsumed under psychodynamic theories/therapy, the result would be similar and the rank, the highest. Those very few reasons for difficulty offered were limited to psychodynamic theories/therapy (complexity plus resistance, strong resident biological bias), research design/ methodology (residents prefer clinically oriented material), neurosciences (too difficult), and homosexuality (discomforting). Videotaping the techniques of psychotherapy by residents was listed as one difficult topic. Table I I
D I F F I C U L T TOPICS T O T E A C H
Psychodynamic Theory/Therapy (10) Research Design/Methodology (7) Neurosciences (7) Biological Psychiatry (5) History of Psychiatry (5) Child Psychiatry (5) Community/Social Psychiatry (5) Psychoanalytic Theory/History (4) Family Theory/Therapy (4) Substance Abuse (4)
Administrative Psychiatry (3) Countertransference Issues (3) Geriatric Psychiatry (3) Mental Retardation (3) Non-Analytic Psychotherapy (3) Sexuality (3) Homosexuality (2) Consultation/Liaison Psychiatry (2) Suicide/Homicide/Violence (2) Transcultural Psychiatry (2) 245
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PSYCHOTHERAPY
DISCUSSION Although A A D P R T survey data may be of wide interest to psychiatric educators, residents are likely to be the primary beneficiaries of such information given the opportunity for programmatic responses to what is happening and what is working elsewhere. Most activities and trends i n education are not determined directly or governed exclusively by educators. The supremacy of the "Special Requirements for Residency Training i n Psychiatry" determined by the Accreditation Council for Graduate Medical Education's ( A C G M E ) Residency Review Committee for Psychiatry (RRC), must be factored into a discussion of influences i n the curriculum. The RRC, like the A C G M E , is heavily influenced by educators, however. Although the balance of power between psychodynamic and psychobiological influences has reversed, the psychodynamic orientation retains a substantial share of psychiatric education. The "Special Requirements for Residency Training i n Psychiatry" ensure resident experience i n the major modalities of psychotherapy. 16
16
I n that the results of this survey are based on a 50 percent response rate, the information reported should be interpreted w i t h caution. Degree of generalizability is arguable; however, the trends reported serve as a basis and a stimulus to compare future research relevant to this topic, which has become controversial i n psychiatric education. Data f r o m this survey suggest that residents are i n some fashion involved i n psychodynamic theory and practice. These data also indicate that many first-year residents take part i n instructional activities related to psychotherapy. Supervision of residents i n groups apparently enjoys some popularity as a medium for teaching and learning. Programs offer residents experimental learning i n the various conventional psychotherapeutic modalities—the extent of supervision depending, apparently, on the limit set by the number of faculty available. Supervision of psychotherapy consumes considerable faculty and resident time and energy. This is particularly apparent i n P G Y - I H when most programs provide outpatient clinical rotations. Perhaps the tendency to supervise residents i n groups is i n part related to the limited availability of well qualified supervisors (i.e., those w i t h experience, competence, and theoretical flexibility). Another tendency, the utilization of voluntary faculty for outpatient psychotherapy supervision, leads to questions i f and how this benefits to trainees. 1
Lack of theoretical diversity and flexibility among faculty is one of several problems associated with psychotherapy supervision. Workshops, courses, and conferences that address models for teaching and learning the psychol246
Trends in Psychotherapy Supervision ogy of psychopharmacology reflect current needs for faculty sophistication w i t h combined forms of treatment. Other problems w i t h supervisors seem related to program leadership and management and the relative importance of this mode of instruction. The literature addresses the characteristics of supervisors to a limited degrees; however, w i t h the exception of the beginning supervisor, little or no attention is paid to the needs of supervisors. The frequency and duration of meetings of supervisors at the P G Y - I I I stage but also throughout the span of training is noteworthy. Only one-third of the programs provide supervision for supervisors, however. This figure, high compared to anecdotal information, suggests that some respondents were including department- or program-management meetings i n their figures. Regular meetings of supervisors to discuss only psychotherapy supervision are supposedly u n c o m m o n . Participant responses f r o m courses and conference presentations on psychotherapy supervision conducted by me suggest that such regular meetings are only likely to occur i n very few programs. Assumed competence i n supervisory skills is generally unchallenged. 17
18
19
19
19
Arguments i n favor of using progress notes i n supervision suggest their usefulness for deeper reflection and increased opportunity for supervisee g r o w t h . ' The problems w i t h the other modes of access to information about supervisee-patient interaction are not limited to patient concerns. Supervisee concerns about their privacy might explain, i n part, why the technology of video- and audiotaping has not been utilized i n the process of supervision to a greater extent. Likewise, some of the difficulties i n teaching psychotherapy could be understood i n terms of issues about privacy. Program directors reported that psychodynamic theory/therapy and the neurosciences are b o t h difficult to teach. The literature reflects the observations of survey respondents w i t h regard to educational issues i n psychodynamic p s y c h i a t r y . Problems w i t h the counterpart, teaching and learning psychobiologic theory, are not being reported i n kind. The close competition for "most difficult to teach" between neurobiological and psychodynamic topics suggests that a persuasion of a third kind, i.e., an integrationist orientation, will result only from herculean educational efforts. Whether or not instruction i n psychotherapy should be included i n psychiatry residency education programs and i f so, to what extent, have been topics of debate. Furthermore, approaches to teaching and learning psychotherapy have been sources of controversy. Although advances i n the theory and practice i n psychotherapy depend significantly on clinical research, the art and science of psychiatric practice would undoubtedly benefit f r o m 20
21
22
23-25
1
26
27
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educational research to improve techniques and methods for instruction i n modes of psychotherapy. Psychobiology has deposed psychotherapy but delegated it a strong supportive role. The practice of psychiatry will continue to depend on skills and ability i n psychotherapeutic intervention. 28
SUMMARY The evolving dominance of psychobiologic over psychodynamic theoretical influences on education and practice presents new challenges for psychiatry. This article features selected data from the 1989 American Association of Directors of Psychiatric Residency Training annual survey (n = 215) that describe current teaching activities related to psychodynamic psychiatry, mainly psychotherapy. Results are based on a 50 percent return rate (107/215 questionnaires). Responses confirm the emergence of psychobiological (48%) over psychodynamic (40%) departmental orientations and report that the psychodynamic orientation has maintained strength as a secondary emphasis. Residents generally gain experience i n a range of psychotherapy theories and modalities, including psychodynamic, cognitive, behavioral, individual, couples, family, and group therapies. Training i n brief and short-term individual psychodynamic psychotherapy predominates, however. Use of video- and audiotaping i n supervision is limited. Full-time faculty provide the bulk of psychotherapy instruction. This is carried out i n both individual and group sessions, which are organized primarily around case reviews. Supervision-related problems include faculty availability, skill diversity, competence, theoretical flexibility, and attitudes, as well as program structure and standards. Acknowledgment:
The author thanks C. Theodore Reveley, M.D., for his critical suggestions.
REFERENCES 1. Mohl, P.C., Lomax, J., Tasman, A , et al. (1990). Psychotherapy training for psychiatrists of the future. A m e r i c a n j o u r n a l of P s y c h i a t r y , 147:7-13. 2 . Elkin, I . , Polkonis, P A . , Docherty, J.P., & Sotsky, S.M. (1988). Conceptual and methodological issues in comparative studies of psychotherapy and pharmacotherapy, I : active ingredients and mechanisms of change. A m e r i c a n J o u r n a l o f P s y c h i a t r y , 145:909-917. 3. Tasman, A , & Kay, J. (1987). Setting the stage: residency training in 1986. I n T r a i n i n g p s y c h i a t r i s t s f o r t h e 90's: Issues and r e c o m m e n d a t i o n s , Nadelson, C.C., & Robinowitz, C.B. Eds. Washington, D C : American Psychiatric Press. 4 . Langsley, D.G., & Yager, J. (1988). The definition of a psychiatrist: eight years later. A m e r i c a n J o u r n a l o f P s y c h i a t r y , 145:469-475. 5 . Verhulst, J., & Tucker, G.J. (1990). Issues for psychiatric education. P s y c h i a t r i c A n n a l s , 20:278-282. 6 . Meterissian, G.B., & Bradwejn, J. (1989). Comparative studies on the efficacy of psychotherapy, pharmacotherapy, and their combination in depression: was adequate pharmacotherapy provided? J o u r n a l o f C l i n i c a l P s y c h o p h a r m a c o l o g y , 9:334-339. 7 . Miller, I.W., Norman, W . H . , & Keitner, G . I . (1990). Treatment response of high cognitive dysfunction depressed inpatients. C o m p r e h e n s i v e P s y c h i a t r y , 31:62-71.
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Trends i n Psychotherapy Supervision 8 . Bonis, J.F., Olendzki, M.C., Kessler, L., et al. (1985). The "offset effect" of mental health treatment on ambulatory medical care utilization and charges. A r c h i v e s o f General P s y c h i a t r y , 42:573-580. 9 . Klerman, G.L., Budman, S., Berwick, D . , et al. (1987). Efficacy of a brief psychosocial intervention for symptoms of stress and distress among patients in primary care. M e d i c a l C a r e , 25:1078-1088. 1 0 . Katon, W., Von Korff, M . , Lin, E., et al. (1990). Distressed high utilizers of medical care: DSM-EI-R diagnoses and treatment needs. General H o s p i t a l P s y c h i a t r y , 12:355-362. 1 1 . Gutheil, T.G. (1982). The psychology of psychopharmacology. B u l l e t i n o f t h e M e n n i n g e r C l i n i c , 46:321-330. 1 2 . Karasu, T.B. (1982). Psychotherapy and pharmacotherapy: toward an integrative model. A m e r i c a n J o u r n a l o f P s y c h i a t r y , 139:1102-1113. 1 3 . Group for the Advancement of Psychiatry. (1987). Changes in methods of teaching. I n T e a c h i n g p s y c h o t h e r a p y i n c o n t e m p o r a r y p s y c h i a t r i c residency t r a i n i n g . New York: Brunner/Mazel. 1 4 . Rodenhauser, P., Moore, M.J., & Weissman, S. (1989). Influences on psychiatry residency program selection: faculty, resident and student perspectives. A c a d e m i c P s y c h i a t r y , 13:150-154. 1 5 . Loebel, J.P. (1990). Psychiatry in the '90s: time for convergence. P s y c h i a t r i c A n n a l s , 20:236-237. 1 6 . Special Requirements for Residency Education in Psychiatry. I n D i r e c t o r y o f g r a d u a t e medical e d u c a t i o n p r o g r a m s accredited by t h e a c c r e d i t a t i o n c o u n c i l f o r g r a d u a t e medical e d u c a t i o n . Croweley, A.E., Ed. Chicago: American Medical Association. 1 7 . Rodenhauser, P., Rudisill, J.R., & Painter, A F . (1989). Attributes conducive to learning in psychotherapy supervision. A m e r i c a n J o u r n a l of P s y c h o t h e r a p y , 43:368-377. 1 8 . Granet, R.B., Kalman, T.P., & Sacks, M . H . (1980). From supervisee to supervisor: an unexplored aspect of the psychiatrist's education. A m e r i c a n J o u r n a l o f P s y c h i a t r y , 137:1443-1446. 1 9 . Rodenhauser, P., Painter, A.F., & Rudisill, J.R. (1985). Supervising supervisors: a series of workshops. J o u r n a l o f P s y c h i a t r i c E d u c a t i o n , 9:217-224. 2 0 . Chevron, E.S., & Rounsaville, B.J. (1983). Evaluating the clinical skills of psychotherapists: a comparison of techniques. A r c h i v e s o f General P s y c h i a t r y , 40:1129-1132. 2 1 . Silberman, E.K., & Mazza, D . (1985). Supervision of the psychotherapeutic process. A r c h i v e s of General P s y c h i a t r y , 42:1J>9-14§. 2 2 . Betcher, R.W., & Zinber, N.E. (1988). Supervision and privacy in psychotherapy training. A m e r i c a n J o u r n a l o f P s y c h i a t r y , 145:796-803. 2 3 . Buckley, P., Conte, H.R., Plutchik, R., & Karasu, T.B. (1981). Psychotherapy skill profiles of psychiatric residents. The J o u r n a l o f N e r v o u s and M e n t a l D i s o r d e r s , 4:733-737. 2 4 . Buckley, P., Conte, H.R., Plutchik, R., & Karasu, T.B. (1982). Learning dynamic psychotherapy: a longitudinal study. A m e r i c a n J o u r n a l o f P s y c h i a t r y , 139:1607-1610. 2 5 . Book, H . E . (1987). The resident's countertransference: approaching an avoided topic. A m e r i c a n J o u r n a l o f P s y c h o t h e r a p y , 41:555-562. 2 6 . Yager, J. (1982). Supervising psychiatric residents for electic practice. I n T e a c h i n g P s y c h i a t r y and B e h a v i o r a l Sciences. Yager, J., Ed. New York: Grune and Stratton. 2 7 . Fava, G.A. (1986). Psychotherapy research: clinical trials versus clinical reality. P s y c h o t h e r a p y and Psychosomatics, 46:6-12. 2 8 . Maguire, G.P., Goldberg, D.P., Hobson, R.F., et al. (1984). Evaluating the teaching of a method of psychotherapy. B r i t i s h J o u r n a l of P s y c h i a t r y , 144:575-580.
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ARTICLES
Psychiatry Residency Programs: T r e n d s i n Psychotherapy Supervision PAUL RODENHAUSER, M . D . * Responses t o the 1989 survey of the A m e r i c a n A s s o c i a t i o n of D i r e c t o r s of P s y c h i a t r i c Residency T r a i n i n g characterize practices and problems i n teaching psychotherapy. C o n t e m p o r a r y i n s t r u c t i o n i n v o l v e s m a i n l y f u l l - t i m e f a c u l t y , case r e v i e w s , i n d i v i d u a l and g r o u p sessions, and emphasis on b r i e f and s h o r t - t e r m p s y c h o d y n a m i c psychotherapy. Supervisory problems include limits in faculty a v a i l a b i l i t y , s k i l l diversity, t h e o r e t i c a l f l e x i b i l i t y , competence, p r o g r a m structure, a t t i t u d e s , and a d m i n i s t r a t i v e s h o r t c o m i n g s . Controversy about the relative importance o f instruction i n psychotherapy for psychiatry residents gathered momentum i n the 1980s. Contributing factors included the increased emphasis o n cost o f psychiatric services, the difficulty i n demonstrating the effectiveness o f psychodynamic psychotherapy i n objective terms, resistance to efforts t o remedicalize psychiatry, and the refinements i n biological psychiatric treatments derived f r o m recent advances i n the neurosciences. The burgeoning neurobiological contributions to our understanding of behaviors has significantly enhanced the biological side o f the educational equation. Consequently, the wishes or fears o f many educators have turned psychotherapy into an endangered component o f residency education. Its diminished role has been reported and supported. Compromise seems t o have emerged the victor over displacement of training i n psychodynamic 1
2
1
3
4
'"Professor of Psychiatry, Director of Medical Student Education in Psychiatry, Department of Psychiatry and Neurology, Tulane University School of Medicine, 1430 Tulane Ave., New Orleans, L A 70112-2699. A M E R I C A N J O U R N A L O F P S Y C H O T H E R A P Y , Vol. X L V I , N o . 2 ,April 1 9 9 2
240
Trends i n Psychotherapy Supervision i n t e r v e n t i o n . Several developments are related to the status quo including discoveries of the superior treatment effectiveness of combined psychotherapy and pharmacotherapy ' and the broad implications of psychiatric interventions w i t h primary-care p a t i e n t s . Bridging the philosophy gap, learning the psychology of psychopharmacology, and practicing integrationist approaches to treatment are becoming vital characteristics of residency education programs. 15
6 7
8-10
11
12
Many residents and medical students who are interested i n psychiatry as a career want to be taught about, and have experience i n , psychodynamic treatment. These interests have implications for resident satisfaction and recruitment. Like the movement toward the remedicalization of psychiatry, continued inclusion of psychodynamic psychotherapy i n psychiatrists treatment inventory also has marketing and political implications. Fundamental and compelling reasons for continuing to teach psychodynamic psychotherapy are reported by a joint task force of the Association for Academic Psychiatry and the American Association of Directors of Psychiatric Residency Training. 13
14
>
1
Despite some resistance, contemporary approaches to research and treatment are more and more based on convergence of psychophysiological and psychological perspectives. Apropos this direction, L o e b e l refers to "the dynamic nature of cerebral cortical and mental activity" as a platform for investigation. Responses to the 1989 annual American Association of Directors of Psychiatric Residency Training (AADPRT) survey, the primary source of material for this article, reconfirm the shift from a predominance of psychodynamically oriented academic departments of psychiatry with secondary psychobiological emphasis to a predominance of biologically oriented departments w i t h secondary strengths i n psychodynamics. The gestalt of the survey responses implies progressive attempts at theoretical convergence or at least practical eclecticism, which would allow learner integration. 15
This article reviews the data f r o m the 1989 annual A A D P R T survey of residency education programs that pertain to psychosocial aspects of residency education. The focus of the selected survey data and, therefore, of this article is on resident instruction i n psychodynamic psychotherapy. METHODS The 1989 annual survey sponsored by the A A D P R T was developed, distributed, collected, and collated between mid-January and late September 1989. The thirty-three page questionnaire, a copy of which can be obtained f r o m me, was mailed coincident w i t h the 1989 annual A A D P R T meeting i n 241
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January to the directors of all accredited general psychiatry residency education programs (n = 215). One section of the questionnaire related specifically to psychotherapy supervision and resident experience w i t h psychotherapy. The following information was requested: the frequency and duration of meetings for psychotherapy supervision w i t h individual residents, groups of residents, and the supervisors (for their supervision); the numbers of full-time, paid part-time, and voluntary faculty members responsible for the supervision of individuals, groups, and supervisors at each postgraduate year level; the mechanics of psychotherapy supervision; and, the mean number of total cases per resident per total residency experience of the forms of psychotherapy offered i n each program. A final question directly related to this area of learning asked about major supervisory problems. I n addition, responses to one general interest question were explored for relevance: what topics are most difficult to teach, either because they are unpopular, discomforting, or met w i t h resistance? R E S U L T S
The number of completed questionnaires returned was 107, a return rate of 49.76 percent. PSYCHOBIOLOGICAL
AND PSYCHODYNAMIC
ORIENTATIONS
Respondents indicated that at present psychobiological orientations predominate i n approximately i n 51 (48%) o f their programs compared to 34 (32%) i n the past. A psychodynamic orientation was predominant i n the past in 56 (52%) of programs, but is predominant now i n approximately 43 (40%). A chi square analysis based on these data (chi square = 5.64, d f = 2, p = .0596) indicates that these changes are marginally statistically significant. This notable change is reflected i n the response to the questions about secondary departmental strengths. As a secondary strength currently, 43 (40%) of respondents listed biological and 43 (40%) listed psychodynamic orientations. A psychodynamic orientation as a secondary strength, historically, was listed as 26 (24%), and a biological one as 50 (47%). The psychodynamic orientation has increasingly been considered a secondary strength as a biological orientation has attained philosophical dominance. Other orientations, namely behavioral, cognitive, and eclectic, that used to be prominent i n 17 (16%) of the institutions, are now reduced to 13 (12%). PSYCHOTHERAPY
SUPERVISION
SESSIONS
Individual supervision for first-year residents occurred i n 76.6 percent (82/107) of programs. Whereas meetings for those individually supervised 242
Trends in Psychotherapy Supervision P G Y - I residents averaged about one per week and lasted approximately one and one-half hours, those for P G Y I I , H I , and I V residents were double or more i n frequency and equal or greater i n length. Meetings of P G Y I , I I , and I V residents supervised i n groups averaged, across programs, about one per week, while P G Y H I residents i n groups met more frequently. One hour was a typical session for all residents supervised i n groups. Supervisors met as a group most frequently and for longer periods of time i n relation to their work w i t h P G Y EH residents. A t that training level, supervisors met 1.4 times per week for 1.3 hours. Otherwise, on average, they reportedly met once weekly for an hour. MECHANICS OF PSYCHOTHERAPY
SUPERVISION
Case reviews, time-tested but not objectively confirmed to be advantageous, continue to be the predominant method for learning i n psychotherapy supervision. Case reviews are employed by 82 percent of programs. Explanatory comments accompanying responses to the question about case reviews frequently referred to use of process notes. Responses to inquiries about use of the other three methods for enabling supervision—videotaping, audiotaping, and direct observation—indicated that each is limited i n usage, on average, to approximately 10 percent of the supervisory sessions. The inquiry on direct observation d i d not distinguish between in-person and one-way mirror arrangements. DISTRIBUTION OF SUPERVISING
FACULTY
The questionnaire asked residency directors about the percentage of supervision provided by category of faculty for individual residents, groups of residents, and supervisors themselves for each postgraduate year. Supervision of residents i n groups and supervision of supervisors are not practices common to all programs. Supervision of supervisors was reported by 35-38/107 programs, varying w i t h postgraduate year. Supervision of residents i n groups was reported i n a range of 58 (PGY-I) to 85 (PGY-IH) programs. Full-time faculty were predominantly responsible for supervision i n the first postgraduate year (70% for individual supervision, 72% for group supervision, and 9 1 % for supervisor supervision). Distribution of supervision by full-time faculty across the remaining three postgraduate years remained relatively constant (52-60% for individual residents, 4 2 - 4 7 % for groups, and 82-84% for supervisors). Paid part-time faculty were utilized at a fairly steady rate during the four postgraduate years (13-19% for individuals, 17-27% for groups, and 4 - 1 3 % for supervisors). Utilization of voluntary faculty increased after the first postgraduate year to 24-31 percent for 243
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individuals and 16-21 percent for groups, but remained constant (4-5%) across all years for supervision of supervisors. I n sum, 75 percent of programs provided some individual psychotherapy supervision for first-year residents and all responding programs offered psychotherapy instruction i n the second, third, and fourth years. Two-thirds of the programs on the average offered supervision to residents i n groups and one-third provided supervisors w i t h supervision (mostly by full-time faculty). During the first residency year, full-time and some part-time faculty provide most of the psychotherapy supervision. Thereafter, part-time and voluntary faculty contribute a larger share of the supervision of individuals and groups. RESIDENT EXPERIENCE WITH FORMS OF PSYCHOTHERAPY
I n the course of their total residency experience, trainees are assigned and manage patients i n a variety of psychotherapeutic modalities, according to residency-director respondents. These include therapies defined i n part by therapeutic relationship, i.e., individual, group, family, and couples therapy, and those defined by theoretical approach, i.e., psychodynamic, cognitive and behavioral therapies. Based on the numbers of assigned patients, individual psychodynamic psychotherapy is the prevailing psychotherapeutic modality for residency education. The utilization of brief and short-term forms is almost three-fold that of long-term psychodynamic psychotherapy. Experiences w i t h cognitive and behavioral approaches are limited as are numbers of assigned families and couples for therapy. Information on resident experience w i t h group psychotherapy (an average of two exposures) does not address length or degree of involvement. Table I displays the complete data set for comparisons. SUPERVISORY
PROBLEMS
Although responses to the inquiry about problems w i t h supervision were numerous, they clustered into broad groups. Predominant problems were n u m b e r s (and availability) of faculty and s k i l l d i v e r s i t y among faculty. Related to diversity of skills is an individual supervisor's f l e x i b i l i t y i n approaches to treatment. Problems caused by lack of competence or experience were noted. Lack of interest and devotion and reluctance to supervise without pay might be considered a t t i t u d i n a l issues. Many responses related to problems w i t h program structure and s t a n d a r d i z a t i o n . These include inconsistency of evaluations, unevenness of goals and objectives i n supervision, communication and follow-through problems, quality control issues, and unwillingness of supervisors to be supervised. 244
Trends in Psychotherapy Supervision Table I
T O T A L P S Y C H O T H E R A P Y CASES PER R E S I D E N T RESIDENCY EXPERIENCE
PER
Modalities
Averages of Mean Numbers of Total Cases
Psychodynamic psychotherapy long-term ( > 12 months) short-term (3-12 months) brief ( < 3 months) Cognitive therapy Behavioral therapy Group psychotherapy Family therapy Couples therapy
6.0 15.2 17.4 3.6 2.7 2.0 (groups) 3.3 (families) 3.0 (couples)
DIFFICULT TOPICS TO TEACH
Residency directors were asked to list those topics that were most difficult to teach. The question suggested unpopularity, discomfort, and/or resistance as possible reasons. The rank order of all responses listed more than once is exhibited i n Table I I . I f biological psychiatry were subsumed into the category of neurosciences, that topic would be noticeably more "difficult"; likewise, if countertransference issues and psychoanalytic theories/ history were subsumed under psychodynamic theories/therapy, the result would be similar and the rank, the highest. Those very few reasons for difficulty offered were limited to psychodynamic theories/therapy (complexity plus resistance, strong resident biological bias), research design/ methodology (residents prefer clinically oriented material), neurosciences (too difficult), and homosexuality (discomforting). Videotaping the techniques of psychotherapy by residents was listed as one difficult topic. Table I I
D I F F I C U L T TOPICS T O T E A C H
Psychodynamic Theory/Therapy (10) Research Design/Methodology (7) Neurosciences (7) Biological Psychiatry (5) History of Psychiatry (5) Child Psychiatry (5) Community/Social Psychiatry (5) Psychoanalytic Theory/History (4) Family Theory/Therapy (4) Substance Abuse (4)
Administrative Psychiatry (3) Countertransference Issues (3) Geriatric Psychiatry (3) Mental Retardation (3) Non-Analytic Psychotherapy (3) Sexuality (3) Homosexuality (2) Consultation/Liaison Psychiatry (2) Suicide/Homicide/Violence (2) Transcultural Psychiatry (2) 245
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DISCUSSION Although A A D P R T survey data may be of wide interest to psychiatric educators, residents are likely to be the primary beneficiaries of such information given the opportunity for programmatic responses to what is happening and what is working elsewhere. Most activities and trends i n education are not determined directly or governed exclusively by educators. The supremacy of the "Special Requirements for Residency Training i n Psychiatry" determined by the Accreditation Council for Graduate Medical Education's ( A C G M E ) Residency Review Committee for Psychiatry (RRC), must be factored into a discussion of influences i n the curriculum. The RRC, like the A C G M E , is heavily influenced by educators, however. Although the balance of power between psychodynamic and psychobiological influences has reversed, the psychodynamic orientation retains a substantial share of psychiatric education. The "Special Requirements for Residency Training i n Psychiatry" ensure resident experience i n the major modalities of psychotherapy. 16
16
I n that the results of this survey are based on a 50 percent response rate, the information reported should be interpreted w i t h caution. Degree of generalizability is arguable; however, the trends reported serve as a basis and a stimulus to compare future research relevant to this topic, which has become controversial i n psychiatric education. Data f r o m this survey suggest that residents are i n some fashion involved i n psychodynamic theory and practice. These data also indicate that many first-year residents take part i n instructional activities related to psychotherapy. Supervision of residents i n groups apparently enjoys some popularity as a medium for teaching and learning. Programs offer residents experimental learning i n the various conventional psychotherapeutic modalities—the extent of supervision depending, apparently, on the limit set by the number of faculty available. Supervision of psychotherapy consumes considerable faculty and resident time and energy. This is particularly apparent i n P G Y - I H when most programs provide outpatient clinical rotations. Perhaps the tendency to supervise residents i n groups is i n part related to the limited availability of well qualified supervisors (i.e., those w i t h experience, competence, and theoretical flexibility). Another tendency, the utilization of voluntary faculty for outpatient psychotherapy supervision, leads to questions i f and how this benefits to trainees. 1
Lack of theoretical diversity and flexibility among faculty is one of several problems associated with psychotherapy supervision. Workshops, courses, and conferences that address models for teaching and learning the psychol246
Trends in Psychotherapy Supervision ogy of psychopharmacology reflect current needs for faculty sophistication w i t h combined forms of treatment. Other problems w i t h supervisors seem related to program leadership and management and the relative importance of this mode of instruction. The literature addresses the characteristics of supervisors to a limited degrees; however, w i t h the exception of the beginning supervisor, little or no attention is paid to the needs of supervisors. The frequency and duration of meetings of supervisors at the P G Y - I I I stage but also throughout the span of training is noteworthy. Only one-third of the programs provide supervision for supervisors, however. This figure, high compared to anecdotal information, suggests that some respondents were including department- or program-management meetings i n their figures. Regular meetings of supervisors to discuss only psychotherapy supervision are supposedly u n c o m m o n . Participant responses f r o m courses and conference presentations on psychotherapy supervision conducted by me suggest that such regular meetings are only likely to occur i n very few programs. Assumed competence i n supervisory skills is generally unchallenged. 17
18
19
19
19
Arguments i n favor of using progress notes i n supervision suggest their usefulness for deeper reflection and increased opportunity for supervisee g r o w t h . ' The problems w i t h the other modes of access to information about supervisee-patient interaction are not limited to patient concerns. Supervisee concerns about their privacy might explain, i n part, why the technology of video- and audiotaping has not been utilized i n the process of supervision to a greater extent. Likewise, some of the difficulties i n teaching psychotherapy could be understood i n terms of issues about privacy. Program directors reported that psychodynamic theory/therapy and the neurosciences are b o t h difficult to teach. The literature reflects the observations of survey respondents w i t h regard to educational issues i n psychodynamic p s y c h i a t r y . Problems w i t h the counterpart, teaching and learning psychobiologic theory, are not being reported i n kind. The close competition for "most difficult to teach" between neurobiological and psychodynamic topics suggests that a persuasion of a third kind, i.e., an integrationist orientation, will result only from herculean educational efforts. Whether or not instruction i n psychotherapy should be included i n psychiatry residency education programs and i f so, to what extent, have been topics of debate. Furthermore, approaches to teaching and learning psychotherapy have been sources of controversy. Although advances i n the theory and practice i n psychotherapy depend significantly on clinical research, the art and science of psychiatric practice would undoubtedly benefit f r o m 20
21
22
23-25
1
26
27
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educational research to improve techniques and methods for instruction i n modes of psychotherapy. Psychobiology has deposed psychotherapy but delegated it a strong supportive role. The practice of psychiatry will continue to depend on skills and ability i n psychotherapeutic intervention. 28
SUMMARY The evolving dominance of psychobiologic over psychodynamic theoretical influences on education and practice presents new challenges for psychiatry. This article features selected data from the 1989 American Association of Directors of Psychiatric Residency Training annual survey (n = 215) that describe current teaching activities related to psychodynamic psychiatry, mainly psychotherapy. Results are based on a 50 percent return rate (107/215 questionnaires). Responses confirm the emergence of psychobiological (48%) over psychodynamic (40%) departmental orientations and report that the psychodynamic orientation has maintained strength as a secondary emphasis. Residents generally gain experience i n a range of psychotherapy theories and modalities, including psychodynamic, cognitive, behavioral, individual, couples, family, and group therapies. Training i n brief and short-term individual psychodynamic psychotherapy predominates, however. Use of video- and audiotaping i n supervision is limited. Full-time faculty provide the bulk of psychotherapy instruction. This is carried out i n both individual and group sessions, which are organized primarily around case reviews. Supervision-related problems include faculty availability, skill diversity, competence, theoretical flexibility, and attitudes, as well as program structure and standards. Acknowledgment:
The author thanks C. Theodore Reveley, M.D., for his critical suggestions.
REFERENCES 1. Mohl, P.C., Lomax, J., Tasman, A , et al. (1990). Psychotherapy training for psychiatrists of the future. A m e r i c a n j o u r n a l of P s y c h i a t r y , 147:7-13. 2 . Elkin, I . , Polkonis, P A . , Docherty, J.P., & Sotsky, S.M. (1988). Conceptual and methodological issues in comparative studies of psychotherapy and pharmacotherapy, I : active ingredients and mechanisms of change. A m e r i c a n J o u r n a l o f P s y c h i a t r y , 145:909-917. 3. Tasman, A , & Kay, J. (1987). Setting the stage: residency training in 1986. I n T r a i n i n g p s y c h i a t r i s t s f o r t h e 90's: Issues and r e c o m m e n d a t i o n s , Nadelson, C.C., & Robinowitz, C.B. Eds. Washington, D C : American Psychiatric Press. 4 . Langsley, D.G., & Yager, J. (1988). The definition of a psychiatrist: eight years later. A m e r i c a n J o u r n a l o f P s y c h i a t r y , 145:469-475. 5 . Verhulst, J., & Tucker, G.J. (1990). Issues for psychiatric education. P s y c h i a t r i c A n n a l s , 20:278-282. 6 . Meterissian, G.B., & Bradwejn, J. (1989). Comparative studies on the efficacy of psychotherapy, pharmacotherapy, and their combination in depression: was adequate pharmacotherapy provided? J o u r n a l o f C l i n i c a l P s y c h o p h a r m a c o l o g y , 9:334-339. 7 . Miller, I.W., Norman, W . H . , & Keitner, G . I . (1990). Treatment response of high cognitive dysfunction depressed inpatients. C o m p r e h e n s i v e P s y c h i a t r y , 31:62-71.
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Trends i n Psychotherapy Supervision 8 . Bonis, J.F., Olendzki, M.C., Kessler, L., et al. (1985). The "offset effect" of mental health treatment on ambulatory medical care utilization and charges. A r c h i v e s o f General P s y c h i a t r y , 42:573-580. 9 . Klerman, G.L., Budman, S., Berwick, D . , et al. (1987). Efficacy of a brief psychosocial intervention for symptoms of stress and distress among patients in primary care. M e d i c a l C a r e , 25:1078-1088. 1 0 . Katon, W., Von Korff, M . , Lin, E., et al. (1990). Distressed high utilizers of medical care: DSM-EI-R diagnoses and treatment needs. General H o s p i t a l P s y c h i a t r y , 12:355-362. 1 1 . Gutheil, T.G. (1982). The psychology of psychopharmacology. B u l l e t i n o f t h e M e n n i n g e r C l i n i c , 46:321-330. 1 2 . Karasu, T.B. (1982). Psychotherapy and pharmacotherapy: toward an integrative model. A m e r i c a n J o u r n a l o f P s y c h i a t r y , 139:1102-1113. 1 3 . Group for the Advancement of Psychiatry. (1987). Changes in methods of teaching. I n T e a c h i n g p s y c h o t h e r a p y i n c o n t e m p o r a r y p s y c h i a t r i c residency t r a i n i n g . New York: Brunner/Mazel. 1 4 . Rodenhauser, P., Moore, M.J., & Weissman, S. (1989). Influences on psychiatry residency program selection: faculty, resident and student perspectives. A c a d e m i c P s y c h i a t r y , 13:150-154. 1 5 . Loebel, J.P. (1990). Psychiatry in the '90s: time for convergence. P s y c h i a t r i c A n n a l s , 20:236-237. 1 6 . Special Requirements for Residency Education in Psychiatry. I n D i r e c t o r y o f g r a d u a t e medical e d u c a t i o n p r o g r a m s accredited by t h e a c c r e d i t a t i o n c o u n c i l f o r g r a d u a t e medical e d u c a t i o n . Croweley, A.E., Ed. Chicago: American Medical Association. 1 7 . Rodenhauser, P., Rudisill, J.R., & Painter, A F . (1989). Attributes conducive to learning in psychotherapy supervision. A m e r i c a n J o u r n a l of P s y c h o t h e r a p y , 43:368-377. 1 8 . Granet, R.B., Kalman, T.P., & Sacks, M . H . (1980). From supervisee to supervisor: an unexplored aspect of the psychiatrist's education. A m e r i c a n J o u r n a l o f P s y c h i a t r y , 137:1443-1446. 1 9 . Rodenhauser, P., Painter, A.F., & Rudisill, J.R. (1985). Supervising supervisors: a series of workshops. J o u r n a l o f P s y c h i a t r i c E d u c a t i o n , 9:217-224. 2 0 . Chevron, E.S., & Rounsaville, B.J. (1983). Evaluating the clinical skills of psychotherapists: a comparison of techniques. A r c h i v e s o f General P s y c h i a t r y , 40:1129-1132. 2 1 . Silberman, E.K., & Mazza, D . (1985). Supervision of the psychotherapeutic process. A r c h i v e s of General P s y c h i a t r y , 42:1J>9-14§. 2 2 . Betcher, R.W., & Zinber, N.E. (1988). Supervision and privacy in psychotherapy training. A m e r i c a n J o u r n a l o f P s y c h i a t r y , 145:796-803. 2 3 . Buckley, P., Conte, H.R., Plutchik, R., & Karasu, T.B. (1981). Psychotherapy skill profiles of psychiatric residents. The J o u r n a l o f N e r v o u s and M e n t a l D i s o r d e r s , 4:733-737. 2 4 . Buckley, P., Conte, H.R., Plutchik, R., & Karasu, T.B. (1982). Learning dynamic psychotherapy: a longitudinal study. A m e r i c a n J o u r n a l o f P s y c h i a t r y , 139:1607-1610. 2 5 . Book, H . E . (1987). The resident's countertransference: approaching an avoided topic. A m e r i c a n J o u r n a l o f P s y c h o t h e r a p y , 41:555-562. 2 6 . Yager, J. (1982). Supervising psychiatric residents for electic practice. I n T e a c h i n g P s y c h i a t r y and B e h a v i o r a l Sciences. Yager, J., Ed. New York: Grune and Stratton. 2 7 . Fava, G.A. (1986). Psychotherapy research: clinical trials versus clinical reality. P s y c h o t h e r a p y and Psychosomatics, 46:6-12. 2 8 . Maguire, G.P., Goldberg, D.P., Hobson, R.F., et al. (1984). Evaluating the teaching of a method of psychotherapy. B r i t i s h J o u r n a l of P s y c h i a t r y , 144:575-580.
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