Introductory Course To Psychiatric Interviewing and Supportive Psychotherapy Skills.

Integrating Practice-Based Learning And Neuroscience

Andres Sciolla, MD

Background

Research in the fields of child development, clinical neuropsychiatry, social cognition, experimental psychology of learning, neuroscience of memory and affect, and functional neuroimaging underlines the interplay between unconscious and automatic processes and conscious mental content and overt behavior. This course assumes that familiarity with the main results of this research may foster the learning of basic psychotherapeutic skills among psychiatry trainees. 

Significance

The consideration of the totality of a patient’s experience, including social context and psychological makeup, has been shown to improve health outcomes, patients’ satisfaction with care, and physician well-being. In addition, clinical response to psychological interventions in several mental disorders is comparable to biological interventions in terms of symptom reduction and functional neuroimaging correlates. Also, treatment response to the combination of psychological and biological interventions is greater, as compared to either modality delivered alone. Lastly, new accreditation requirements in postgraduate psychiatric training aim at the assessment of competence in interpersonal and communication skills as well as five psychotherapeutic modalities.

Method

Over the last three decades a body of data regarding the optimal conditions for adult learning has been gathered. Some of it has found specific applications in medical education at under and postgraduate levels of training. Scholars in philosophy of the mind have identified the conditions under which advanced skills are learned. Their recommendations are consistent with what is currently known of the neurobiological bases of memory and learning.  Thus, this course will emphasize problem-based, learner-centered, and experiential learning. 

The timeline of the course will be iterative and circular, rather than linear, because interns rotate through medicine and neurology services six months out of the year, during which they are not expected to attend psychiatry didactics. In other words, the course will revisit the same topics in three major cycles because the composition of attendees will change throughout the year. At each cycle, however, expectations for depth of knowledge and competence in skill will progressively increase.

 The course faculty will act as expert consultants, facilitating learning and discussion, and coaching interns to excel in skill acquisition. Interns will be encouraged to remain active, take risks, welcome challenge, provide input, help to set learning goals, and assume responsibility for the quality and extent of their learning throughout the course.

‘Theory’ sessions will entail interns’ discussion, facilitated by faculty, of selected papers previously sent to them and read in advance of the session. ‘Demonstration’ sessions will consist of experienced faculty interviewing patients in front of interns, followed by discussion of technique and behavior during interview.  Attempts will be made to focus faculty interviewing on a particular issue from the course’s list of learning goals. During each ‘Practice’ session two interns will conduct a 20-minute interview, which will be videotaped, followed by self-assessment of performance. On ‘Integration’ sessions, interns and faculty will review last session’s videotaped interviews, highlighting accomplishments and problems. Faculty will facilitate an integration of psychopathology, psychiatric diagnosis, neuroscience, and actual skills and attitudes observed during the interviews.

 Specific activities will include:

¨ individual and group readings;

¨ presentation of research data and critique of methodological limitations;

¨ live interviewing and feedback by facilitators and peers;

¨ videotaping and guided self-reflection; and

¨ presentation of inpatient cases or clinical dilemmas currently being faced by interns.

Assessment of learners will consist of unstructured self-evaluation by interns, periodic formative evaluations performed by faculty, and summative evaluation using a scale of adherence/competence of supportive psychotherapy to be completed by faculty. The latter will be administered by a faculty not involved in teaching the course to each intern at the beginning and at the end of the course. The assessment of interns’ competence in observing signs of and eliciting symptoms of psychopathology will derive from their performance in mock oral boards at the end of the academic year.  Assessment of the course itself will consist of a form to be filled out by the interns during the last session.

Learning goals

At the end of the course learners are expected to:

¨ be familiar with the main lines of evidence of unconscious mental processes relevant to psychiatric interviewing and supportive psychotherapy;

¨ increase their level of awareness of automatic mental processes that impact clinical reasoning;

¨ improve their capacity for self-reflection, as they pertain to interviewing and psychotherapeutic skills;

¨ understand the importance of personal therapy and other practices that enhance self-awareness;

¨ strive to reduce unconscious biases which shape the patient-psychiatrist relationship, and the diagnosis and therapy it informs;

¨ know and use judiciously appropriate means to observe and elicit signs and symptoms of psychopathology;

¨ pay attention to nuances and personal meaning of the above in the individual patient;

¨ know and use judiciously a variety of supportive psychotherapy techniques aimed at increasing the therapeutic alliance; patients’ self-efficacy, autonomy, and self-esteem; repertoire of coping skills; and decrease cognitive distortions and self-defeating or self-destructive behavior.

¨ improve their empathic and listening skills;

¨ increase the flexibility with which they switch from a medical to a therapeutic interviewing style;

¨ explore as a matter of course patients’ understanding of their problems, treatment expectations, and relevant medical knowledge;

¨ investigate childhood and earlier life relationship patterns and traumatic events that may bear on how patients cope with and experience their current difficulties;

¨ cultivate attitudes that convey respect, curiosity, and appreciation for patients’ backgrounds and life’s circumstances;

¨ be able to gather data from and educate family members and significant others effectively, while observing sensitivity to ethical, legal, and cultural contexts and constraints.