PGY4 Outpatient Psychotherapy

Rotation Director: Brian Sparks, MD

Location: Community Memorial Health Center Midtown Medical Behavioral Health Clinic

Educational Purpose

The Outpatient Psychotherapy rotation in the PGY4 year offers an opportunity for residents to advance theory and skills developed in the PGY3 outpatient year. The residents will learn to deepen psychotherapeutic formulations beyond fundamentals, apply in a flexible manner concepts and interventions skillfully from a broad array of psychotherapy modalities, and develop a growing capacity to manage boundaries in psychotherapy. This is meant to prepare them for independent practice as a licensed psychiatrist upon graduation, where psychotherapy knowledge, skills, and recognition of patient needs will help direct the psychiatrist towards appropriate management and collaborative care.

Teaching Methods

The principle teaching and learning activities are centered on direct patient care and supervision. The learning experience will include review of history, mental status examination, inter-session developments, differentiating appropriate interventions from a broad swath of psychotherapy modalities, capacities and limitations of different interventions, resident reactions to patients as a means of informing assessment and future interventions, boundary management, emphasis on holistic considerations (lifestyle, interpersonal and social dynamics), as well as collaboration with other treatment providers as necessary.

Psychotherapy Supervision

For the PGY4 year, residents will have an increase in their psychotherapy supervision, each resident meeting individually and weekly to discuss at least 3 cases in detail. This continues throughout the entirety of the academic year. Supervision is centered around two principle factors: History review and intervention. Review involves discussion of case material, session management, between-session management, case formulation, and efficacy of interventions to date. Intervention involves discussing case-by-case rapport building, discerning patient capacities, the resident’s own evolving capacities, targeted interventions, intersections with psychiatric care, collaboration with other treatment providers, boundary management, and appropriate retention/discharge.

Overall Education Goals and Objectives

To learn how to incorporate psychotherapy theory and technique into the care of psychiatric patients, towards competent application of non-pharmacological interventions and management in an outpatient clinic setting.

Core Competencies:

1. Establish and maintain a therapeutic alliance with patients, towards increasing capacity to anticipate and manage boundary crossings and violations.
2. Using select psychotherapeutic techniques (supportive, cognitive-behavioral, psychodynamic, mindfulness-based, positive psychology), collaborating on goal setting, and integrating techniques across modalities as appropriate, towards a more tailored application based on case formulations.
3. Be able to identify, reflect, and collaborate on management of core feelings, anxiety pathways, and key issues of the patient within a session, working towards holistic linking and value across sessions.

Medical Knowledge

1. Be able to identify, increasingly explain, and incorporate theoretical principles across core psychotherapeutic modalities (supportive, psychodynamic, and cognitive-behavioral).
2. Identify and use techniques from supportive, cognitive-behavioral, and psychodynamic psychotherapies, while working towards comparative intervention selection regarding potential risks and benefits.
3. Summarize and increasingly demonstrate a capacity to analyze, the evidence base for combining psychotherapy with pharmacotherapy.

Systems Based Practice

1. When appropriate and only with written consent from the patient, the resident will become proficient in communicating with ancillary medical providers, mental health providers, and other relevant sources of information or providers of education, structure and/or care to the patient, to establish and maintain an optimal treatment plan. In this rotation, this often involves collaboration with primary care providers and psychiatric practitioners towards clarification of diagnostics and goals of care.

Practice Based Learning

1. The resident will utilize the best available evidence towards the care of the patients, prioritizing acute matters while learning how to critically appraise and navigate conflicting information and/or uncertainty across sessions to help guide the overall recovery of the patient.
2. Deliberate practice informs the resident in the psychotherapy rotation. A receptive openness predicated on humility and motivation to learn will serve as the foundational impetus for analyzing, reflecting, and instituting changes in knowledge and skill towards a greater fusion of these qualities. This will be measured through progressive tracking with the supervisor of both resident and their patient’s goals, against ongoing areas of potential improvement.

Professionalism

1. Growth in the domains of professional behavior and practical application of ethical principles in the psychotherapy rotation is achieved largely through the growing capacity of the residents to effectively manage the therapeutic frame and boundaries.
2. The above will supplement the core expectations of any psychiatric rotation that includes professionalism in complex and stressful situations. Emphasis is placed on knowing when to seek help should professional lapses occur. This is towards the goals of addressing and improving reporting, and utilizing consultation when necessary, for improvement of outcomes.

Interpersonal and Communication Skills

1. The PGY-4 psychotherapy rotation is uniquely positioned to significantly increase the resident’s rapport-building capacities, comfort with transference/counter-transference related assessment and skills building, and skill in addressing bias at both the macro-and-microscopic levels.
2. Residents in this rotation find their ability to identify and align treatment goals, negotiate preferences, assess and motivate zones of proximal development, and navigate uncertainty and conflicts of interest with patients is much stronger by the end of the psychotherapy rotation.
3. The supervisory role on this rotation encourages the principles of parallel processing, where proactive feedback and constructive criticism as seen as growth and alliance building opportunities. This is done in an environment of compassion and mutual respect. When appropriate, these qualities are escalated to the system with mindfulness towards respect, compassion, alliance building, and quality improvement.